Showing posts with label IV drug use. Show all posts
Showing posts with label IV drug use. Show all posts

Friday, August 17, 2018

HCV elimination among people who inject drugs. Modelling pre- and post–WHO elimination era

Research Article
HCV elimination among people who inject drugs. Modelling pre- and post–WHO elimination era 
Ilias Gountas , Vana Sypsa, Sarah Blach, Homie Razavi, Angelos Hatzakis
Published: August 16, 2018

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Elimination of hepatitis C virus (HCV) among people who inject drugs (PWID) is a costly investment, so strategies should not only focus on eliminating the disease, but also on preventing disease resurgence. The aims of this study are to compute the minimum necessary antiviral therapies to achieve elimination with and without the additional expansion of harm reduction (HR) programs and to examine the sustainability of HCV elimination after 2030 if treatment is discontinued.

We considered two types of epidemic (with low (30%) and high (50%) proportion of PWID who engage in sharing equipment (sharers)) within three baseline chronic HCV (CHC) prevalence settings (30%, 45% and 60%), assuming a baseline HR coverage of 40%. We define sustainable elimination strategies, those that could maintain eliminations results for a decade (2031–2040), in the absence of additional treatment.

The model shows that the optimum elimination strategy is dependent on risk sharing behavior of the examined population. The necessary annual treatment coverage to achieve HCV elimination under 45% baseline CHC prevalence, without the simultaneous expansion of HR programs, ranges between 4.7–5.1%. Similarly, under 60% baseline CHC prevalence the needed treatment coverage varies from 9.0–10.5%. Increasing HR coverage from 40% to 75%, reduces the required treatment coverage by 6.5–9.8% and 11.0–15.0% under 45% or 60% CHC prevalence, respectively. In settings with ≤45% baseline CHC prevalence, expanding HR to 75% could prevent the disease from rebounding after elimination, irrespective of the type of the epidemic. In high chronic HCV prevalence, counseling interventions to reduce sharing are also needed to maintain the HCV incident cases in low levels.

Harm reduction strategies have a vital role in HCV elimination strategy, as they reduce the required number of treatments to eliminate HCV and they provide sustainability after the elimination. The above underlines that HCV elimination strategies should be built upon the existing HR services, and argue for HR expansion in countries without services.

Friday, May 11, 2018

MMWR: Access to Syringe Services Programs — Kentucky, North Carolina, and West Virginia, 2013–2017

Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report (MMWR)
Weekly / May 11, 2018 / 67(18);529–532

Access to Syringe Services Programs — Kentucky, North Carolina, and West Virginia, 2013–2017
Danae Bixler, MD1; Greg Corby-Lee2; Scott Proescholdbell, MPH3; Tina Ramirez4; Michael E. Kilkenny, MD5; Matt LaRocco6; Robert Childs, MPH7; Michael R. Brumage, MD4; Angela D. Settle, DNP8; Eyasu H. Teshale, MD1; Alice Asher, PhD

The Appalachian region of the United States is experiencing a large increase in hepatitis C virus (HCV) infections related to injection drug use (IDU) (1). Syringe services programs (SSPs) providing sufficient access to safe injection equipment can reduce hepatitis C transmission by 56%; combined SSPs and medication-assisted treatment can reduce transmission by 74% (2). However, access to SSPs has been limited in the United States, especially in rural areas and southern and midwestern states (3). This report describes the expansion of SSPs in Kentucky, North Carolina, and West Virginia during 2013-August 1, 2017. State-level data on the number of SSPs, client visits, and services offered were collected by each state through surveys of SSPs and aggregated in a standard format for this report. In 2013, one SSP operated in a free clinic in West Virginia, and SSPs were illegal in Kentucky and North Carolina; by August 2017, SSPs had been legalized in Kentucky and North Carolina, and 53 SSPs operated in the three states. In many cases, SSPs provide integrated services to address hepatitis and human immunodeficiency virus (HIV) infection, overdose, addiction, unintended pregnancy, neonatal abstinence syndrome, and other complications of IDU. Prioritizing development of SSPs with sufficient capacity, particularly in states with counties vulnerable to epidemics of hepatitis and HIV infection related to IDU, can expand access to care for populations at risk.

During 2013–2017, the number of operational SSPs increased from one to approximately 50 in Kentucky, North Carolina, and West Virginia. Visits to SSPs by clients who inject drugs also increased. In Kentucky and North Carolina, this increase followed changes in laws permitting access to sterile injecting supplies; in West Virginia, SSPs were never prohibited under state law. In North Carolina, any group can start an SSP after notifying the state health department; Kentucky requires a lengthy approval process for local health departments before offering syringe services. This paper demonstrates that increasing access to SSPs is possible with community support using a variety of models if SSPs are not prohibited by law.

The increase in client visits to SSPs by persons who inject drugs represents an unprecedented opportunity to improve access to care for this highly stigmatized population. In addition to increased access to sterile needles, syringes, and injection paraphernalia (5), comprehensive syringe services programs should also improve access to medication-assisted treatment, counseling, and social support to address substance use disorder (6); naloxone and lay naloxone training to prevent fatal overdose (7); the full range of contraceptives, including long acting reversible contraceptives to prevent unintended opioid-exposed pregnancy; prenatal care and medication-assisted treatment to reduce harm from substance use disorder in pregnant women and their infants (8); vaccination; and HCV, HIV, and hepatitis B virus (HBV) screening and treatment (5). State and local health departments that are actively addressing the health effects of the opioid crisis might consider a formal evaluation process to improve service quality and access for persons who inject drugs, including those attending SSPs. Process evaluation indicators for SSPs should include number of clients, number of syringes distributed, number of syringes returned, availability of services in hours per week, summary statistics on HIV, HBV, and HCV testing, and number and type of services (e.g., patient-centered family planning services and naloxone) and referrals provided (e.g., medication assisted treatment, prenatal care, HIV, and hepatitis treatment) (9). Evaluation should also include health indicators such as rates of hepatitis, HIV, fatal and nonfatal overdose, unintended pregnancy and neonatal abstinence syndrome, and initiation and retention in drug treatment. CDC has published a framework to guide evaluation of public health programs (10), which might be useful for evaluating access to essential services at the community level for persons who inject drugs.

The findings in this report are subject to at least six limitations. First, data were self-reported from SSPs and are therefore subject to bias. Second, because some programs do not collect identifying information, the total numbers of clients served is estimated. Third, at the time of this analysis, North Carolina was in its first year of implementation, and limited data are available. Fourth, no data were obtained for SSPs operating underground (i.e., outside the legal framework). Fifth, growth of SSPs and service integration in these states is rapid, and the most recent data on SSPs should be sought through the state or local health department or harm reduction coalition. Finally, these data cannot be used to evaluate quality of service delivery and whether service delivery is adequate to meet the needs of the population.

SSPs can be implemented through a variety of models and by a variety of agencies and organizations including those in rural areas. Demand for syringe services is growing rapidly in these three states with underserved populations of persons who inject drugs, representing an opportunity to implement, evaluate, and improve access to evidence-based services known to reduce the considerable morbidity and mortality associated with injection drug use.

Full report -

Thursday, April 26, 2018

Strategies for Reducing Opioid-Overdose Deaths — Lessons from Canada

April 26, 2018
N Engl J Med 2018; 378:1565-1567
DOI: 10.1056/NEJMp1800216

Strategies for Reducing Opioid-Overdose Deaths — Lessons from Canada
Evan Wood, M.D., Ph.D.

Audio Interview with Dr. Evan Wood on actions taken by Canada to reduce opioid-overdose deaths.
Listen Here.....

As the United States faces this unprecedented epidemic, there are lessons to be learned from Canada, which has taken bold action on a number of fronts with the aim of reducing deaths related to fentanyl, fentanyl analogues, and other opioids. For instance, in March 2016, the Canadian government made the overdose-reversal drug naloxone available without a prescription. Although naloxone is also increasingly available in many regions of the United States, laws in 14 states provide no immunity from criminal prosecution for health care providers who prescribe or distribute it to laypersons. Furthermore, in 36 states, existing laws make possession of naloxone without a prescription illegal.

The Canadian government has also passed legislation aimed at facilitating the development of medically supervised injection facilities, where people who use drugs can inject opioids they buy on the street under the supervision of health care staff. Although research has found that supervised injection facilities can reduce rates of fatal overdoses by more than 30% in communities with high rates of drug use1 and can help facilitate greater uptake of addiction treatment, there are few, if any, such programs in the United States. In recent months, however, public health officials in several U.S. cities, including San Francisco, Seattle, and Philadelphia, have endorsed plans to open pilot supervised injection programs to address increasing rates of overdose deaths.

Thursday, April 12, 2018

#ILC2018 Testing & Treatment of HCV infection for people who use drugs: Where To Next?

The International Liver Congress 2018 
If you are interested in updates from The International Liver Congress 2018,
I highly suggest you follow Henry E. Chang on Twitter.

Following presentation shared today by @HenryEChang.

Linkage to care specialist facilitates access to HCV treatment for people who inject drugs

Linkage to care specialist facilitates access to hepatitis C treatment for people who inject drugs

European Association for the Study of the Liver

12 April 2018, Paris, France: A prospective, longitudinal study involving more than 1,000 people who inject drugs has identified a promising role for linkage to care specialists in facilitating rapid access to hepatitis C treatment. The study, which was conducted in Texas, USA, ensured that individuals newly diagnosed with hepatitis C were contacted by a linkage to care specialist within 48 hours of being referred to the service, thereby ensuring that almost 50% of patients referred to a medical practitioner made it to their first appointment and that 60% of those seen were initiated on treatment.

'We have a major problem with injection drug use in the USA', explained Zohha Alam from the Austin Hepatitis Center in Texas, USA. 'At least 75% of new hepatitis C virus (HCV) infections result from injection drug use, and it is often difficult to engage with the users and ensure that HCV infection is both diagnosed and treated'.

The prospective study, which was presented today at The International Liver Congress™ 2018 in Paris, France, evaluated 1,038 patients who were screened and entered into an electronic database in Austin between January and October 2017. A total of 503 individuals were found to be HCV RNA positive and were referred to the linkage to care service. Of those referred, 398 (79%) were contacted within 48 hours by a linkage to care specialist who provided education and linked the individual to a care provider. Of the 249 individuals referred to a medical practitioner, 116 (47%) attended their first appointment, and 69 (59%) had initiated HCV therapy at the time of the analysis.

'Linkage to care is the missing link in the treatment of chronic HCV infection', said Zohha Alam. 'Our study demonstrates a promising role for linkage to care specialists in engaging with people who inject drugs and, importantly, connecting those individuals with HCV care providers'.

The importance of increasing the number of HCV-infected individuals screened and linked to care was highlighted in another study presented at The International Liver Congress™ 2018. The study by a team from the CDA Foundation's Polaris Observatory in Lafayette, Colorado, USA, used data from 53 countries in Europe to forecast the current and future burden of HCV in the region and to estimate the levels of HCV diagnosis and treatment required to achieve World Health Organization (WHO) Global Health Sector Strategy Goals for Hepatitis by 2030.1

'Based on our analysis', said Sarah Robbins from the Polaris Observatory, 'we predict that given the current standard of care for the next 15 years, the total HCV-infected population in Europe would increase by an estimated 1% by 2030 and that, in order to meet WHO goals, the number of individuals diagnosed annually would need to increase to at least 800,000 by 2022, with 900,000 being treated each year by 2025. Improving linkage to care coupled with increased access to DAA therapy is needed to achieve such goals'.

Unfortunately, progress towards establishing national policies to support the necessary scale-up of HCV diagnosis and treatment to achieve these goals remains slow, according to the results of a third study presented in Paris. The 2017 Hep-CORE study, which was conducted in 25 European countries, found that an approved national hepatitis C strategy and/or action plan was in place in just 12 (48%) of those countries. Hepatitis C treatment was reported to be available in non-specialist settings in five (20%) countries, although treatment was available in prisons in 18 (72%) countries. Although an improvement from 2016, 52% and 32% of countries in the 2017 Hep-CORE study still restrict access to direct-acting antiviral agents based on the degree of fibrosis and/or current injecting drug use, respectively.

'HCV can be cured in more than 95% of patients', said Prof. Markus Cornberg from the Hannover Medical School, Germany, and EASL Governing Board Member. 'However, in order to prevent complications such as HCC, patients first need to be identified and treated accordingly. Screening and linkage to care are fundamental if WHO elimination targets are to be achieved, and the data presented here are important in improving these measures'.

1. World Health Organization. Global Health Sector Strategy on Viral Hepatitis 2016-2012. June 2016. Available from: Last accessed: February 2018.

Wednesday, April 4, 2018

Experiences of liver health related uncertainty among people who inject drugs living with hepatitis C

Experiences of liver health related uncertainty and self-reported stress among people who inject drugs living with hepatitis C virus: a qualitative study
Stelliana Goutzamanis, Joseph S. Doyle, Alexander Thompson, Paul Dietze, Margaret Hellard,
Peter Higgs and on behalf of the TAP study group

BMC Infectious Diseases
Received: 4 August 2017
Accepted: 21 March 2018
Published: 2 April 2018

People who inject drugs (PWID) are most at risk of hepatitis C virus infection in Australia. The introduction of transient elastography (TE) (measuring hepatitis fibrosis) and direct acting antiviral medications will likely alter the experience of living with hepatitis C. We aimed to explore positive and negative influences on wellbeing and stress among PWID with hepatitis C.

The Treatment and Prevention (TAP) study examines the feasibility of treating hepatitis C mono-infected PWID in community settings. Semi-structured interviews were conducted with 16 purposively recruited TAP participants. Participants were aware of their hepatitis C seropositive status and had received fibrosis assessment (measured by TE) prior to interview. Questions were open-ended, focusing on the impact of health status on wellbeing and self-reported stress. Interviews were voice recorded, transcribed verbatim and thematically analysed, guided by Mishel’s (1988) theory of Uncertainty in Illness.

In line with Mishel’s theory of Uncertainty in Illness all participants reported hepatitis C-related uncertainty, particularly mis-information or a lack of knowledge surrounding liver health and the meaning of TE results. Those with greater fibrosis experienced an extra layer of prognostic uncertainty. Experiences of uncertainty were a key motivation to seek treatment, which was seen as a way to regain some stability in life. Treatment completion alleviated hepatitis C-related stress, and promoted feelings of empowerment and confidence in addressing other life challenges.

TE scores seemingly provide some certainty. However, when paired with limited knowledge, particularly among people with severe fibrosis, TE may be a source of uncertainty and increased personal stress. This suggests the need for simple education programs and resources on liver health to minimise stress.

--Noninvasive tests for fibrosis
Recently, the therapeutic landscape of hepatitis C has drastically changed. Non-invasive fibrosis assessment tools, such as transient elastography (TE) (an ultrasound like device which determines liver stiffness by measuring wave velocity [9]) and highly effective interferon-free direct acting antiviral (DAA) medications are now considered standard of care [10, 11]. These advances have made the elimination of hepatitis C as a public health threat a real possibility, particularly in Australia, where DAAs are widely accessible and heavily subsidised [12, 13]. However, such advances may also alter the individual experience of living with hepatitis C....

-Throughout the trial, research nurses experienced in hepatitis C and working with PWID provided participants with information and explanation of TE results.
Most participants had been diagnosed with hepatitis C many years prior to interview as having “non A, non B” hepatitis or when “Hep C wasn’t even invented”, but had only recently been told their level of fibrosis through the TAP study. Throughout the trial, research nurses experienced in hepatitis C and working with PWID provided participants with information and explanation of TE results. Many participants also received consultation regarding their hepatitis C from other healthcare providers, outside of the TAP study. Despite the consultation with research nurses following their liver assessment; most participants either did not understand or missed key information regarding their TE results, which ignited feelings of stress.

I didn’t know anything about it, [doctors] were like: ‘liver cancer and liver all these things’ and I got really freaked out. (Score: P15, low-level fibrosis)

Approximately half the participants were unclear about the true meaning of TE results, implications of the result and how to manage their fibrosis. Participants were often left feeling frustrated or perplexed when their perceptions of liver health or treatment options did not align with their doctors’, particularly with their liver specialists:

What I understood from [the liver specialist] is that a third is damaged. Well I’m like; ‘can’t you cut a third off?’ Just get rid of that broken bit, it’s simple for me! Then I don’t need to live with the stress. And they’re like; ‘it doesn’t work like that’. That doesn’t make sense to me. (Score: P1, high-level fibrosis)

Read the full article:

Friday, March 30, 2018

Potential geographic "hotspots" for drug-injection related transmission of HIV and HCV and for initiation into injecting drug use in New York City, 2011-2015, with implications for the current opioid epidemic in the US

Potential geographic "hotspots" for drug-injection related transmission of HIV and HCV and for initiation into injecting drug use in New York City, 2011-2015, with implications for the current opioid epidemic in the US
D. C. Des Jarlais , H. L. F. Cooper, K. Arasteh, J. Feelemyer, C. McKnight, Z. Ross

For HIV, the lack of potential hotspots is further validation of widespread effectiveness of efforts to reduce injecting-related HIV transmission. Injecting-related HIV transmission is likely to be a rare, random event. HCV prevention efforts should include focus on potential hotspots for transmission and on hotspots for initiation into injecting drug use. We consider application of methods for the current opioid epidemic in the US.
Published: March 29, 2018

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We identified potential geographic “hotspots” for drug-injecting transmission of HIV and hepatitis C virus (HCV) among persons who inject drugs (PWID) in New York City. The HIV epidemic among PWID is currently in an “end of the epidemic” stage, while HCV is in a continuing, high prevalence (> 50%) stage.

We recruited 910 PWID entering Mount Sinai Beth Israel substance use treatment programs from 2011–2015. Structured interviews and HIV/ HCV testing were conducted. Residential ZIP codes were used as geographic units of analysis. Potential “hotspots” for HIV and HCV transmission were defined as 1) having relatively large numbers of PWID 2) having 2 or more HIV (or HCV) seropositive PWID reporting transmission risk—passing on used syringes to others, and 3) having 2 or more HIV (or HCV) seronegative PWID reporting acquisition risk—injecting with previously used needles/syringes. Hotspots for injecting drug use initiation were defined as ZIP codes with 5 or more persons who began injecting within the previous 6 years.

Among PWID, 96% injected heroin, 81% male, 34% White, 15% African-American, 47% Latinx, mean age 40 (SD = 10), 7% HIV seropositive, 62% HCV seropositive. Participants resided in 234 ZIP codes. No ZIP codes were identified as potential hotspots due to small numbers of HIV seropositive PWID reporting transmission risk. Four ZIP codes were identified as potential hotspots for HCV transmission. 12 ZIP codes identified as hotspots for injecting drug use initiation.

Thursday, March 29, 2018

Harm reduction, screening and treatment would save money and lives in Eastern European, Central Asian countries where injecting drug use drives rising rates of HIV, HCV

Science Speaks: Global ID News
Harm reduction, screening and treatment would save money and lives in Eastern European, Central Asian countries where injecting drug use drives rising rates of HIV, HCV
By Antigone Barton on March 28, 2018
Increasing access to sterile needles and syringes and to opioid substitution therapy, as well as to HIV and hepatitis C screening services and effective treatment would lower new infection rates by double digit percentages, save money and lives, and contain the spread of the viruses in Eastern European and Central Asian countries where people who inject drugs currently have limited access to proven interventions, a study reported in the March Open Forum Infectious Diseases says.

Intervention Packages to Reduce the Impact of HIV and HCV Infections Among People Who Inject Drugs in Eastern Europe and Central Asia: A Modeling and Cost-effectiveness Study

Tuesday, March 27, 2018

Methadone maintenance therapy and having access to regular physician care regarding HCV among people who inject drugs

The impact of methadone maintenance therapy on access to regular physician care regarding hepatitis C among people who inject drugs
Lianping Ti, María Eugenia Socías, Evan Wood, M-J Milloy, Ekaterina Nosova, Kora DeBeck, Thomas Kerr, Kanna Hayashi

Published: March 26, 2018

Background & aims
People who inject drugs (PWID) living with hepatitis C virus (HCV) infection often experience barriers to accessing HCV treatment and care. New, safer and more effective direct-acting antiviral-based therapies offer an opportunity to scale-up HCV-related services. Methadone maintenance therapy (MMT) programs have been shown to be effective in linking PWID to health and support services, largely in the context of HIV. The objective of the study was to examine the relationship between being enrolled in MMT and having access to regular physician care regarding HCV among HCV antibody-positive PWID in Vancouver, Canada.

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Tuesday, January 9, 2018


American Journal of Public Health Podcast
Jan 9, 2018
Hello and welcome to AJPH February 2018 podcast. This month we will be discussing the very worrisome epidemic of hepatitis C occurring in the United States. I first review with Professor Kimberly Page from the University of New Mexico how likely it is that, in a foreseeable future, the epidemic of hepatitis C could be controlled by a vaccine. Then the CDC epidemiologist Alice Asher explains why the epidemic is exacerbated by another epidemic of injection drug use, in particular of opioids, and why it is affecting young, non Hispanic white populations in the Appalachian region. And with Dr John Wong, clinical decision maker from Tufts University, we discuss how the availability of effective treatments may have transformed the prognosis of newly infected persons.

Listen Online

Monday, January 8, 2018

Epclusa - Study Backs Hepatitis C Treatment in Injection Drug Users

Study Backs Hepatitis C Treatment in Injection Drug Users
By Amy Orciari Herman
Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

Use of sofosbuvir-velpatasvir to treat hepatitis C virus (HCV) infection in injection drug users usually leads to a sustained virologic response at 12 weeks, according to an industry-supported study in the Lancet Gastroenterology & Hepatology.

Thursday, January 4, 2018

How Injection Drug Use Affects HCV Treatment

Clinical Care Options
How Injection Drug Use Affects HCV Treatment
Norah Terrault MD, MPH - 1/3/2018
Here’s my take on why colocalization of HCV treatment with other medical and social services may be ideal for persons who inject drugs.

In this viral hepatitis case series, we highlight common patient case scenarios and the critical decision making that informs selection of optimal patient management strategies. This commentary features a young woman recently diagnosed with HCV infection after initiating medication-assisted treatment for heroin use. Key considerations for her care are discussed, including how former injection drug use affects her candidacy for HCV treatment.
Free registration required

Friday, October 27, 2017

Endocarditis - SPECIAL REPORT: London doctors’ simple strategy may stem a deadly toll

London doctors’ simple strategy may stem a deadly toll
By Randy Richmond, The London Free Press
Friday, October 27, 2017 11:30:42 EDT AM

At University Hospital, Koivu started to notice more and more endocarditis deaths. When she asked her dying patients what they were using, almost all those who injected drugs said they were using HydromorphContin capsules.

To inject the drug, you first have to crush the capsules in a tiny container, usually a little pan called a cooker – the kind seen in movies and on television used to melt crack cocaine or crystal meth.

Cooking doesn’t dissolve the capsules, so you have to crush them as best as you can in a bit of water.

Then you place a tiny filter, sometimes called a sponge, over the hydro-laced mixture and draw liquid up with your needle.

Koivu theorized that when people drew up the crushed capsules in a syringe, even through a properly used filter, some particles were being drawn up as well.
Those particles scratch the heart valves...

Read the article here......

Of Interest
HIV and Hepatitis C Are No Longer the Most Serious Infectious Threats to People Who Inject Drugs
For whatever reason, endocarditis and other invasive bacterial infections are not nearly as feared as HIV and HCV, despite the fact that the former are far more immediately life threatening and way more difficult to treat.

Thursday, May 25, 2017

Safe space for illegal drug consumption in Baltimore would save $6 million a year

Safe space for illegal drug consumption in Baltimore would save $6 million a year

Supervised facilities would also save lives, prevent infections and hospitalizations

Johns Hopkins University Bloomberg School of Public Health

A new cost-benefit analysis conducted by the Johns Hopkins Bloomberg School of Public Health and others suggests that $6 million in costs related to the opioid epidemic could be saved each year if a single "safe consumption" space for illicit drug users were opened in Baltimore.

It would also reduce overdose deaths, HIV and hepatitis C infections, overdose-related ambulance calls and hospitalizations - and bring scores of people into treatment, they found.

Carefully monitored "safe consumption" spaces, which are not legal in the United States but have been used in dozens of cities around the world, provide a clean indoor environment in which people can use their own drugs with medical personnel on hand to reverse overdoses should they occur. These facilities serve as access points to substance use disorder treatment and other vital social services for drug users, such as medical care and housing.

The authors of the study, published this month in the Harm Reduction Journal, say that the findings add economic evidence to the body of research that already links such spaces to a reduction in fatal drug overdoses and an increase in people seeking treatment. "Safe consumption" spaces are especially critical right now: Last year, the United States hit a record for the number of people who have died from drug overdose, and fentanyl, a more dangerous and powerful drug than heroin, is increasingly being added to heroin in places like Baltimore.

"No one has ever died from an overdose in a safe consumption space," says the study's senior author, Susan G. Sherman, PhD, MPH, a professor in the Department of Health, Behavior and Society at the Bloomberg School. "Thousands of lives have been saved. There are lots of doors people can walk through when they are addicted to drugs. We want them to walk through a door that may eventually lead to successful treatment - and keep them alive until they are ready for that."

Says Amos Irwin, MA, the study's lead author and program director at the Law Enforcement Action Partnership in Washington, D.C.: "Today, thousands of Baltimoreans are risking their lives to inject drugs instead of seeking treatment. We estimate that more than 100 new people would enter treatment every year if the city had a supervised injection facility. Bringing these people into a safe space actually helps reduce drug use, not increase it."

For their study, the researchers looked at the costs of operating a safe consumption space in Vancouver, the only one in North America. Then they estimated the impact on several health outcomes, based on Baltimore data.

They determined that running a 1,000-square-foot, 13-booth space in Baltimore for 18 hours a day would cost $1.8 million a year. Insite, the Vancouver facility, serves about 2,100 unique individuals a month, who perform roughly 180,000 injections per year in a space the same size.

Based on research done at Insite, they estimate that a Baltimore facility would generate $7.8 million in annual savings, preventing four HIV infections, 21 hepatitis C infections, 374 days in the hospital for skin and soft-tissue infections, six overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits and 27 overdose-related hospitalizations.

At the same time, an estimated 121 additional people would enter treatment.

"Six million dollars is a lot of money for one facility to save," Irwin says. "It is almost a third of Baltimore City's entire budget for HIV, sexually-transmitted infections and substance abuse treatment and prevention."

A bill allowing safe consumption spaces failed in the Maryland General Assembly this year. Last month, the Massachusetts Medical Society recommended opening safe consumption spaces in that state. These supervised injection facilities are a widely used public health intervention in 11 countries, mostly in Europe.

Sherman says many drug users in Baltimore are injecting on the streets or in abandoned houses, exposing them to possible violence, arrest and overdose death. Safe consumption spaces would provide clinical supervision and a clean environment, and they allow health professionals to connect drug users to critical health services. Such spaces maintain a strict prohibition on drug sharing or selling. These programs are not condoning illicit behavior, she says. They are meeting people where they are and connecting them with lifesaving resources.

The researchers did not estimate how many safe consumption spaces would be needed to service Baltimore's drug using population.

"We know what doesn't work when it comes to the so-called 'War on Drugs' in the United States because we have an opioid epidemic that is only getting worse," Sherman says. "The stakes are even higher now with so much heroin and other drugs adulterated with fentanyl. You can keep doing what you are doing or you can try something that has been proven by evidence and is considered usual care in a dozen nations."

"Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility" was written by Amos Irwin, Ehsan Jozaghi, Brian W. Weir, Sean T. Allen, Andrew Lindsay and Susan G. Sherman. Other collaborating institutions include the Criminal Justice Policy Foundation and the University of British Columbia.

The research was supported by grants from the National Institutes of Health's National Institute of Allergy and Infectious Diseases (P30AI094189) and the National Institute on Drug Abuse (T32DA007292) as well as Amherst College, the Criminal Justice Policy Foundation, the Law Enforcement Action Partnership and the Canadian Institutes of Health Research Postdoctoral Fellowship.

Thursday, March 16, 2017

Hepatitis C among young people - Prescription medication misuse

TYSA Feb 2017
Recently, there has been a rise in Hepatitis C among young people. There is reason to believe that the use of injected drugs is directly linked.

The NYC Hep C Task Force Hep C Prevention in Youth Initiative, in partnership with Tackling Youth Substance Abuse, received a grant from Birds Nest Foundation to create a video highlighting how prescription medication misuse can lead to intranasal or injection drug use, which can lead to Hep C infection. Watch and share this important and compelling video.

The video will initially be presented at schools and other forums on Staten Island, which has been particularly hard hit by the current opiod/heroin epidemic.  A guidance document for facilitated discussion is being created to accompany the video as a tool for educators. Keep an eye out for the official launch date.  While the content is tailored to Staten Island, educators may find it useful for other areas of NYC. And HepFreeNYC will look, based on success of this video, towards the feasibility of extensions to this project.

HHS Background: Opiods and Hepatitis C

Friday, February 21, 2014

Researchers Look to Reduce Hep C Infections with 'Staying Safe' Intervention for Injecting Drug Users

Researchers Look to Reduce Hep C Infections with 'Staying Safe' Intervention for Injecting Drug Users

Despite a number of social/behavioral intervention and educational programs, the spread of hepatitis C (HCV) in people who inject drugs (PWIDs) remains a chronic problem. Now, researchers affiliated with New York University’s Center for Drug Use and HIV Research (CDUHR) are focusing on intervention strategies that highlight the lesser-known dangers of HCV transmission through the sharing of other injection equipment such as cookers, filters, drug-dilution water and water containers.

Their article, “The Staying Safe Intervention: Training People Who Inject Drugs in Strategies to Avoid Injection-Related HCV and HIV Infection,” published in AIDS Education and Prevention (Vol. 26:2, April 15, 2014), explores the feasibility and efficacy of their “Staying Safe Intervention,” a strengths-based social/behavioral intervention conducted with small groups of PWID, designed to facilitate long-term prevention of HIV and HCV.

“The Staying Safe Intervention seeks to reduce injection risk by intervening upstream in the causal chain of risk behaviors by modeling, training in, and motivating the use of strategies and practices of long-term risk-avoidance,” says Dr. Pedro Mateu-Gelabert, the study’s Principal Investigator, at the NYC-based National Development Research Institutes.

Mateu-Gelabert and his NDRI-CDUHR team evaluated 68 street-recruited injectors from the Lower East Side of Manhattan; the objective was to reduce participants’ injection risk behaviors, empower and motivate behavioral change, and teach tactics to help reduce drug intake. The current program was built upon findings of their 2005 study, “Staying Safe,” which looked at the behaviors and strategies of individuals who had injected drugs for long periods of time (8-15 years) but had not contracted HIV or HCV.

“The Staying Safe Intervention does not focus exclusively on the moment of injection,” explains Mateu-Gelabert, “but on the upstream determinants of risk behavior, such as stigma, risk networks, social support and income, while encouraging injectors to plan ahead in order to better manage the drug-related risk contexts they are likely to face.”

The social/behavioral intervention showed substantial improvement in motivation and planning to avoid injection-related risks, increased use of stigma management strategies, and decreases in drug withdrawal episodes (known to reduce safe injection practices) and number of weekly injections. The research team also noted that participants in the study have been spreading the word on safer drug use within their communities.

The Centers for Disease Control and Prevention (CDC) estimates that not only do nine percent of new HIV infections originate from drug use, but 18 percent of PWID are HIV positive and up to 70-77 percent of PWIDs have HCV.

“Given the substantial reductions observed among Staying Safe participants in key injection-related risk behaviors associated with HCV transmission, the Staying Safe Intervention may have the potential to contribute to sufficient additional risk reduction to help address the seemingly intractable rates of HCV transmission among PWID,” says Mateu-Gelabert.

Currently, Mateu-Gelabert’s team is researching HCV and HIV risk associated with nonmedical prescription opioid use. Future research will evaluate the effectiveness of the Staying Safe Intervention in preventing HIV and hepatitis C infection among young prescription opioid users who have transitioned to heroin injection.

The project described was supported by Award Numbers R21DA026328, R01DA019383, R01DA031597, and R01DA035146 from the National Institute on Drug Abuse.

Source: New York University College of Nursing

Wednesday, September 18, 2013

Don’t Marginalize Your HCV-Infected PWID—Treat Them

CCO - Clinical Thought

Don’t Marginalize Your HCV-Infected PWID—Treat Them

Jason Grebely, BSc, PhD - 9/16/2013  More from this author

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In many ways, people who inject drugs (PWID) represent a “forgotten” group of patients eligible for hepatitis C virus (HCV) treatment. Generally, they have been excluded from clinical trials and HCV treatment guidelines. When they have approached clinicians for treatment, they have been told that once they stop using drugs for more than 6 months, they can think about treatment. Preconceptions about low rates of adherence, inability to attend appointments, increased susceptibility to adverse effects, and the potential for high rates of reinfection have limited providers’ willingness to reach out to and treat this at-risk population. Concerns about HIV coinfection, interactions between drugs—both prescribed and illicit—and liver damage due to heroin or methadone have further limited interest in treating PWID.

Recently published international recommendations from the International Network on Hepatitis in Substance Users, of which I am a coauthor, are intended to supplement existing guidelines and address many of these issues. To implement these recommendations, we have to address obstacles that may interfere with the initiation of treatment.

Breaking Down the Barriers
PWID continue to experience high rates of HCV infection in developed countries. The damage associated with HCV infection is known to be accelerated by factors such as age, ongoing moderate or heavy alcohol use, HIV coinfection, obesity, and insulin resistance. However, there is no evidence that fibrosis is accelerated by methadone or heroin use and little is known about the effect of methamphetamine. Similarly, whereas active PWID were excluded from the pivotal trials of the currently available direct-acting antivirals, results from separate trials indicate that methadone/buprenorphine can be coadministered with direct-acting antivirals. Finally, treatment for HCV should not significantly affect treatment for drug dependency nor lead to an increase in drug use.

If the decision is made to treat PWID for HCV, will they adhere to therapy or will they fail to complete their course of treatment? The few studies addressing HCV treatment in a setting of active drug use indicate that PWID can be treated successfully. My experience is similar to that described by Graham Foster: When PWID are carefully identified and counseled, they stay with therapy almost as readily as any other population.

What about reinfection? Many providers believe that PWID actively using drugs, even intermittent users, are just going to get reinfected, negating previously successful treatment efforts. As it happens, this does not appear to be the case. Actively using PWID certainly should be counseled about the risks associated with certain behaviors and the potential for reinfection, but the reinfection rates associated with active drug use may actually be quite low based on a recent review of available studies. These data suggest that there is no need to avoid treating HCV in PWID for fear that it will be necessary to repeat the process.

Some providers have raised concerns about the possibility of poor adherence among this patient population. Taking into consideration the high costs of HCV therapy and the potential for transmitted resistance by nonadherent patients, many providers may be reluctant to initiate therapy in this population. However, this perception is not borne out by the evidence that indicates PWID are no less likely to adhere to therapy than other patients. Furthermore, in the era of direct-acting antivirals, resistance may be a less of a concern due to their higher barrier to resistance.

Overcoming Our Own Preconceptions
There are numerous strategies we can employ to improve outcomes for PWID. First, we have to decide to treat these patients, and to make that decision, we need to recognize that what appear to be barriers are not necessarily so. There is no denying that there are challenges to the treatment of HCV in this population. However, when barriers are systematically identified and addressed within a supportive, multidisciplinary environment, PWID can be successfully treated for HCV infection. Also, reinfection is lower than one might expect. This is not to deny that challenges do exist, but they are not insurmountable. We can begin by overcoming our own preconceptions, which will allow us to implement appropriate strategies and successfully treat these patients.

Your Thoughts?
I am keen to hear your thoughts and experiences in treating HCV in PWID. Do you treat actively using PWID or ask them to cease drug use? How have you approached the treatment of PWID? Is there a particular strategy that has been successful for you in treating PWID?

 Topics: HCV - Treatment 

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