"I want to get better, but ": identifying the perceptions and experiences of people who inject drugs with respect to evolving hepatitis C virus treatments.

BACKGROUND: The advent of highly tolerable and efficacious direct-acting antiviral (DAA) medications has transformed the hepatitis C virus (HCV) treatment landscape. Yet, people who inject drugs (PWID) - a population with inequitably high rates of HCV and who face significant socio-structural barriers to healthcare access - continue to have disproportionately low rates of DAA uptake. The objective of this study is to explore how PWID with lived experience of HCV perceive and experience DAA treatment, in a setting with universal coverage of these medications since 2018. METHODS: Informed by a critical interpretive framework, we thematically analyze data from in-depth, semi-structured interviews conducted between January and June 2018 in Vancouver, Canada, with a purposive sample (n = 56) of PWID at various stages (e.g., pre, peri, post) of DAA treatment. RESULTS: The analysis yielded three key themes: (i) life with HCV, (ii) experiences with and perceptions of evolving HCV treatments, and (iii) substance use and the uptake of DAA treatments. First, participants described how health and healthcare conditions, such as the deprioritizing of HCV (e.g., due to: being asymptomatic, healthcare provider inaction, gatekeeping) and catalysts to care (e.g., symptom onset, treatment for co-morbidities) shaped DAA treatment motivation and access. Second, participants described how individual and community-level accounts of evolving HCV treatments, including skepticism following negative experiences with Interferon-based treatment and uncertainty regarding treatment eligibility, negatively influenced willingness and opportunities to access DAAs. Concurrently, participants described how peer and community endorsement of DAAs was positively associated with treatment uptake. Third, participants favoured HCV care that was grounded in harm reduction, which included the integration of DAAs with other substance use-related services (e.g., opioid agonist therapy, HIV care), and which was often contrasted against abstinence-focused care wherein substance use is framed as a contraindication to HCV treatment access. CONCLUSIONS: These findings underscore several equity-oriented healthcare service delivery and clinician adaptations that are required to scale up DAAs among PWID living with HCV, including the provision of harm reduction-focused, non-stigmatizing, integrated, and peer-led care that responds to power differentials.

"I want to feel young again": experiences and perspectives of young people who inject drugs living with hepatitis C in Vancouver, Canada.

OBJECTIVES: People who inject drugs (PWID) are disproportionately impacted by hepatitis C virus (HCV). Despite the availability and efficacy of direct-acting antiviral (DAA) HCV therapies, treatment rates remain low among PWID. Among PWID, those who are young (under age 30) experience high rates of HCV and also face distinct barriers to care. The objective of this study is to identify facilitators and barriers to navigating various facets of the HCV cascade of care, including DAA treatment access, among young PWID. METHODS: We draw on data from in-depth, semi-structured interviews conducted between May and November 2019 with a sample of 11 young, street-involved PWID who have lived experience of HCV and who live in Metro Vancouver, Canada. Informed by a social constructivist epistemology, data were thematically analyzed using an equity-oriented theoretical framework. RESULTS: Our analysis yielded two key themes. First, participants described facilitators to HCV care access, including individual factors (e.g., desire to be cured, knowledge of side effects) and healthcare and socio-contextual factors (e.g., peer supports, supportive youth-specific services). Second, participants described a contrasting set of barriers to HCV care access, including concerns over treatment side effects and (in)eligibility, complex healthcare system navigation, substance use- and housing-related stigma, and clinician gatekeeping of DAAs. CONCLUSION: Findings from this study underscore the need for HCV-related knowledge-building efforts among young PWID and clinicians. Also needed are structural policy interventions to facilitate access to DAAs, including anti-stigma efforts, access to safe housing, and the scale-up of low-barrier youth-specific services and decentralized HCV care.

RéSUMé: OBJECTIFS: Les personnes qui font usage de drogues par injection (PUDI) sont démesurément touchées par le virus de l'hépatite C (VHC). Malgré la disponibilité et l'efficacité potentielle des traitements antiviraux à action directe (AAD) contre le VHC, les taux de traitement demeurent faibles chez les PUDI. Les jeunes PUDI (moins de 30 ans) présentent des taux élevés de VHC tout en faisant face à des obstacles distincts pour se faire soigner. Notre étude vise à cerner les éléments qui favorisent ou qui entravent la négociation des divers aspects de la cascade des soins du VHC, dont l'accès aux traitements par AAD, chez les jeunes PUDI. MéTHODE: Nos données proviennent d'entretiens semi-directifs approfondis menés entre mai et novembre 2019 auprès d'un échantillon de 11 jeunes PUDI de la rue ayant une expérience vécue du VHC et vivant dans le District régional du Grand Vancouver, au Canada. Éclairées par une épistémologie constructiviste sociale, les données ont été analysées thématiquement à l'aide d'un cadre théorique orienté sur l'équité. RéSULTATS: Deux grands thèmes se sont dégagés de notre analyse. Premièrement, les participants ont décrit les éléments qui favorisent l'accès aux soins du VHC, dont les facteurs individuels (p. ex. le désir de guérir, la connaissance des effets secondaires) et les facteurs socio-contextuels et liés aux soins de santé (p. ex. l'entraide des pairs, les services de soutien pour les jeunes). Deuxièmement, les participants ont décrit un ensemble opposé d'obstacles à l'accès aux soins du VHC, dont les craintes par rapport aux effets secondaires des traitements et à l'(in)admissibilité aux traitements, le parcours complexe du système de soins de santé, la stigmatisation associée à l'usage de substances et au logement, ainsi que la protection de l'accès aux AAD par les cliniciens. CONCLUSION: Les constatations de l'étude confirment la nécessité de renforcer les connaissances sur le VHC, tant chez les jeunes PUDI que chez les cliniciens. Sont aussi nécessaires des interventions stratégiques structurelles pour faciliter l'accès aux AAD, dont la lutte contre la stigmatisation, la sécurité du logement, l'augmentation des services jeunesse « à bas seuil ¼ et la décentralisation des soins du VHC.

"Stigma is where the harm comes from": Exploring expectations and lived experiences of hepatitis C virus post-treatment trajectories among people who inject drugs.

BACKGROUND: The advent of direct-acting antiviral (DAA) medications has facilitated opportunities to treat hepatitis C virus (HCV) among people who inject drugs (PWID). However, there remains a need for data about how to optimally support PWID throughout DAA post-treatment trajectories, including with regard to re-infection prevention. The objective of this study is therefore to identify how PWID with lived experience of HCV describe their expectations and experiences related to health and social outcomes, contexts, and substance use practices following completion of DAA treatment. METHODS: We thematically analyzed data from in-depth, semi-structured interviews, conducted between January and June 2018, in Vancouver, Canada, with a purposive sample (n = 50) of PWID at various stages of DAA treatment (e.g., pre, peri, post). RESULTS: Our analysis yielded three themes. First, while participants had hoped to experience holistic enhancements in wellbeing following HCV cure, discussions of actual post-treatment experiences tended to be located in physical health (e.g., increased energy). Second, participants often pointed to the ways in which HCV-related and other stigmas had restricted opportunities for health and healthcare access. Participants therefore identified stigma-reduction as a key motivator of HCV cure, and while reductions in internalized stigma were sometimes achieved, participants underscored that other forms of enacted stigma (e.g., related to: substance use, HIV, poverty) had continued to feature prominently in their post-treatment lives. Third, participants described considerable knowledge about how to prevent HCV re-infection following cure, but they also expressed apprehensiveness about how socio-structural barriers, including stigma and criminalization, could interfere with harm reduction and re-infection prevention efforts. CONCLUSIONS: DAAs are transforming the health and wellbeing of some PWID. Yet, HCV-related policy must extend beyond the scale-up of DAAs to include concerted public health investments, including anti-stigma efforts and improvements to the social welfare system, to meaningfully advance equity in PWID's post-treatment trajectories and outcomes.

Where is the Science? A Critical Interrogation of How Sex and Gender are Used to Inform Low-Risk Alcohol Use Guidelines.

: Across the globe, many countries publish low-risk alcohol guidelines which outline the recommended best practices for drinking limits to reduce the health risks and harms associated with excessive alcohol use. Frequently, low-risk drinking guidelines include different recommendations for cisgender men and women. As researchers working in the area of trans-inclusive substance use treatment and care, we are interested in the rationale for how gender-based low-risk drinking guidelines are determined, including the role of evidence and science. We argue that low-risk drinking guidelines based on sex and/or gender are highly insufficient and not engaging with a robust evidence base, and we further argue that it is important that we attend to these concepts correctly as we develop clinical and public health guidelines, which will undeniably have an impact on the individuals and societies who rely on them.

Stigma associated with mental illness among Asian men in Vancouver, Canada.

BACKGROUND:: Due to racism, xenophobic nationalism, acculturation pressures and patriarchal social relations, Asian men in Western societies may be particularly susceptible to negative experiences and beliefs regarding mental illness and treatment services. AIMS:: We examine factors associated with stigma toward mental illness among Asian men in Canada. METHODS:: Between 2013 and 2017, 428 self-identified Asian men living in proximity to Vancouver, Canada, were recruited and completed self-administered questionnaires assessing social stigma and self-stigma. The degree to which these variables were associated with the men's sociodemographic characteristics was analyzed. RESULTS:: Multivariable regression revealed that social stigma was significantly predicted by age, immigration, employment status and experience with mental illness. Together, these variables accounted for 12.36% of variance in social stigma. Interaction terms were added to the regression models to examine whether the effects of immigration on social stigma varied by age and experience with mental illness, but none of the interaction terms were statistically significant. Among the 94 Asian men identified as living with mental illness, self-stigma was predicted by age, immigration and employment status, which together accounted for 14.97% of variance in self-stigma. CONCLUSION:: These results offer new knowledge about the factors predicting stigma toward mental illness among Asian men in Western societies.