Health service utilisation and access for people who inject drugs during COVID-19.

INTRODUCTION: The wide-spread implementation of interventions to limit transmission and public health consequences of COVID-19 in the Australian state of Victoria had flow-on consequences for people who use and inject drugs. Consequences included the interruption of illicit drug supply and drug procurement, and the disruption to the delivery of health services. To inform strategies that can minimise the adverse outcomes of similar future disruptive events, this study explored how COVID-19 restrictions impacted access to harm reduction and drug treatment services for people who inject drugs in Melbourne, Victoria. METHODS: Qualitative semi-structured interviews were conducted via an online calling app, with 11 participants of a broader cohort study (the SuperMIX study) in April 2020. Interviews were focused on participants experiences of accessing and using harm reduction and drug treatment services. Data were thematically analysed using a process of blended coding. RESULTS: Findings revealed how disruptions in the delivery of harm reduction and drug treatment services-in response to COVID-19 restrictions-created barriers accessing sterile injecting equipment, increased risk of arrest by police and exacerbated social isolation. Participants reported difficulties adapting to changes in services access, with some increases in injecting risk behaviours. However, improvements in opioid agonist therapy prescriptions were noted as a beneficial outcome. DISCUSSION: By examining the impacts of COVID-19 and the resultant restrictions on people who inject drugs' access to health services in Melbourne, Victoria, findings provide guidance for future responses to the unanticipated large-scale effects of the COVID-19 pandemic, and similar disruptive events.

Decentralised hepatitis C testing and treatment in rural Cambodia: evaluation of a simplified service model integrated in an existing public health system.

BACKGROUND: Direct-acting antiviral treatment for hepatitis C virus (HCV) has provided the opportunity for simplified models of care delivered in decentralised settings by non-specialist clinical personnel. However, in low-income and middle-income countries, increasing overall access to HCV care remains an ongoing issue, particularly for populations outside of urban centres. We therefore aimed to implement a simplified model of HCV care via decentralised health services within a rural health operational district in Battambang province, Cambodia. METHODS: The study cohort included adult residents (≥18 years) of the health operational district of Moung Russei who were voluntarily screened at 13 local health centres. Serology testing was done by a rapid diagnostic test using SD Bioline HCV (SD Bioline HCV, Standard Diagnostics, South Korea) with capillary blood. HCV viral load testing was done by GeneXpert (Cepheid, Sunnyvale, CA, USA). Viraemic patients (HCV viral load ≥10 IU/mL) received pretreatment assessment by a general physician and minimal treatment evaluation tests at the health operational district referral hospital. Viraemic patients who did not have additional complications received all HCV care follow-up at the local health centres, provided by nursing staff, and patients who had decompensated cirrhosis, previously treated with a direct-acting antiviral, HBV co-infection, or other comorbidities requiring observation continued receiving care at the referral hospital with a general physician. Patients deemed eligible for treatment were prescribed oral sofosbuvir (400 mg) and daclatasvir (60 mg) once a day for 12 weeks, or 24 weeks for patients with decompensated cirrhosis or those previously treated with a direct-acting antiviral. HCV cure was defined as sustained virological response at 12 weeks after treatment (HCV viral load <10 IU/mL). Patients were assessed for serious and non-serious adverse events at any time between treatment initiation and 12 weeks post-treatment testing. FINDINGS: Between March 12, 2018, and Jan 18, 2019, 10 425 residents (ie, 7·6% of the estimated 136 571 adults in the health operational district of Moung Russei) were screened. Of those patients screened, the median age was 44 years (IQR 31-55) and 778 (7·5%) were HCV-antibody positive. 761 (97·8%) of 778 antibody-positive patients received HCV viral load testing, and 540 (71·0%) of those tested were HCV viraemic. Among these 540 patients, linkage to treatment and follow-up care was high, with 533 (98·7%) attending a baseline consultation at the HCV clinic, of whom 530 (99·4%) initiated treatment. 485 (91·5%) of 530 patients who initiated treatment received follow-up at a health centre and 45 (8·5%) were followed up at the referral hospital. Of the 530 patients who initiated direct-acting antiviral therapy, 515 (97·2%) completed treatment. Subsequently, 466 (90·5%) of 515 patients completed follow-up, and 459 (98·5%) of 466 achieved a sustained virological response at 12 weeks after treatment. Two (0·4%) adverse events (fatigue [n=1] and stomach upset [n=1]) and five (0·9%) serious adverse events (infection [n=2], cardiovascular disease [n=1], and panic attack [n=1], with data missing for one of the causes of serious adverse events) were reported among patients who initiated treatment. All serious adverse events were deemed to be unrelated to therapy. INTERPRETATION: This pilot project showed that a highly simplified, decentralised model of HCV care can be integrated within a rural public health system in a low-income or middle-income country, while maintaining high patient retention, treatment efficacy, and safety. The project delivered care via accessible, decentralised primary health centres, using non-specialist clinical staff, thereby enhancing the efficient use of limited resources and maximising the potential to test and treat individuals living with HCV infection. FUNDING: Médecins Sans Frontières.

Are there differences in individual-level needle and syringe coverage across Australian jurisdictions related to program policy? A preliminary analysis.

INTRODUCTION AND AIMS: Services provided by needle and syringe programs (NSP) within Australia are easily accessible by international standards. However, important variation in NSP policy remains across Australian jurisdictions. The potential impacts of these variations on program operation for clients have not been systematically analysed in Australia. In this paper we conduct a preliminary examination to compare individual-level syringe coverage between and within Australian capital cities. DESIGN AND METHODS: Participants were 2498 people who inject drugs (PWID) recruited from all Australian capital cities as part of the annual Illicit Drug Reporting System PWID survey over the period 2014-2016. Insufficient coverage was defined when <100% of a participant's injecting episodes were 'covered' by sterile needles and syringes. We report the percentage of insufficient coverage for each capital city for each year, and present descriptive statistics for coverage parameters, and an alternative measure for insufficient coverage, as Supporting Information. RESULTS: Differences in behaviours that have the potential to impact syringe coverage were highly variable over time and place leading to variations in levels of insufficient coverage between and within all cities. Overall, insufficient coverage was most evident in larger cities where insufficient coverage varied between 19% and 23% (Sydney) over time, compared to smaller cities with variation from 9% to 12% (Adelaide). DISCUSSION AND CONCLUSIONS: We found no consistent pattern of differences in individual-level needle and syringe coverage between and within Australian capital cities. Further work is needed to fully evaluate whether policy variation between Australian jurisdictions impacts on NSP coverage.

Putting the "M" back in maternal-fetal medicine.

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Formal and informal maternal health care: comparing the service provision of health facilities and village health volunteers in East Sepik Province.

Maternal health across Papua New Guinea (PNG) is of extreme public health concern. In response, the National Department of Health explicitly prioritized improving maternal, neonatal and child health services, envisaging increased collaboration between the formal health system and community-based initiatives as one method for achieving this. This study examined the patterns of formal and non-formal service utilization during pregnancy and childbirth in one province. We analysed the activity database of the East Sepik Women and Children's Health Project's Village Health Volunteer (VHV) program, an informal health service in East Sepik Province of PNG, estimating VHV activity and coverage for two maternal health care services (first antenatal care visit and VHV-attended deliveries) and comparing these to the volume and estimated coverage of these services delivered by the formal health system in East Sepik over the years 2007 to 2010. We found a significant increase in women's utilization of VHVs for first antenatal care and for an attended delivery. Reported coverage of these services delivered by the formal health service declined or at best remained static over the same time period. Our data cannot illuminate the causes of an apparent and highly concerning decline in health facility usage for assisted delivery, nor the reasons for increased usage of VHVs. The factors contributing to these trends in service provision require urgent study, to improve our understanding of the drivers of utilization of critical maternal health services. Our study demonstrates that VHVs deliver a substantial proportion of maternal health services in East Sepik. This finding alone highlights the importance of considering this cadre when planning health service improvements and suggests that a national VHV policy that builds on the work of the National Health Plan in defining the most appropriate role for VHVs in maternal health care is long overdue.