"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.

Integrated models of care for people who inject drugs and live with hepatitis C virus: A systematic review.

BACKGROUND: Despite the key role that people who inject drugs (PWID) play in the hepatitis C virus (HCV) epidemic, HCV treatment rates among this population have been historically low. Integrated models of HCV and substance use care have the potential to overcome some barriers to access; however, the evidence base is uncertain. This systematic review assesses the impacts of integrated HCV and substance use services on engagement in HCV care among PWID. METHODS: We searched five databases up to December 2018 to identify original quantitative studies evaluating the impacts of co-location of HCV and substance use services on engagement in the HCV cascade of care among adult PWID. We conducted a narrative synthesis, categorizing models based on patient entry point (a: HCV facility, b: substance use disorder (SUD) facility, and c: other facilities), and levels of integrated services offered (a: HCV/substance use testing only, b: HCV/substance use treatment, and c: testing/treatment + other services). RESULTS: A total of 46 articles corresponding to 44 original studies were included. Almost all studies (n = 42) were conducted in high-income countries and only six studies in the Direct-Acting Antiviral (DAA) era. Twenty-six studies discussed the integration of services at SUD facilities, one at HCV facilities, and seventeen at other facilities. Analysis of included studies indicated that overall integrated care resulted in improved engagement in HCV care (e.g., testing, treatment uptake and cure). However, the quality of evidence was predominantly low to moderate. CONCLUSIONS: Available evidence suggests that integration of HCV and substance use services may improve engagement along the continuum of HCV care among PWID. Given limitations in data quality, and very few studies conducted in the DAA era and in low- and middle-income settings, further research is urgently needed to inform strategies to optimize HCV care access and outcomes among PWID globally.

Integrating hepatitis C and addiction care for people who inject drugs in the era of direct-acting antiviral therapy.

As new, more tolerable and effective hepatitis C virus (HCV) treatments are available, there is a global need to consider how to maximize treatment access for groups who are most affected by HCV. A substantial number of people who inject drugs (PWID) are living with HCV, yet only a minority have received treatment. HCV treatment programs that are integrated into community-based addiction care may be a successful way to overcome barriers and increase access and uptake of HCV treatment for this population. Examples of successful HCV and addiction care integration in the community have been documented. However, potential challenges to integration exist and include changing healthcare provider roles, lack of stimulant use research and restrictive drug policies. Successful engagement of PWID in HCV care is critical step towards the elimination of HCV infection. Further research and efforts are needed in order to reach this goal.

The impact of an HIV/AIDS adult integrated health program on leaving hospital against medical advice among HIV-positive people who use illicit drugs.

Background: Leaving hospital against medical advice (AMA) is a major source of avoidable morbidity, mortality and healthcare expenditure. The objective of this study was to assess the impact of an innovative HIV/AIDS adult integrated health program on leaving hospital AMA among HIV-positive people who use illicit drugs (PWUD). Methods: Using generalized estimating equations, we examined the relationship between being a participant of the Dr. Peter Centre (DPC), a specialty HIV/AIDS-focused adult integrated health program, and leaving hospital AMA among a cohort of HIV-positive PWUD patients. Results: Between July 2005 and July 2011, 181 HIV-positive PWUD who experienced ≥1 hospitalization were recruited into the study. Of the 406 hospital admissions among these individuals, 73 (39.9%) participants left the hospital AMA. In a multivariable model adjusted for confounders, being a participant of the DPC was independently associated with lower odds of leaving hospital AMA (adjusted odds ratio = 0.42; 95% confidence interval: 0.19-0.89). Conclusions: Our findings suggest that the provision of a broad range of clinical, harm reduction and support services through an innovative HIV/AIDS-focused adult integrated health program operating in proximity to a hospital may curb the rate at which individuals leave hospital prematurely.

Dietary supplementation with an extract of North American ginseng in adult and juvenile mice increases natural killer cells.

Cells belonging to the innate immune system are referred to as natural killer (NK) cells. We recently demonstrated that normal, pre-weaned infant mice, injected with a proprietary extract of ginseng (CVT-E002) had augmented NK cell numbers vs. sham-injected mice. In the present study, we extended these observations into juvenile and adult mice. Thus, young adult (age: 8-9 wk) C3H mice were given daily dietary CVT-E002 for 4 wk followed by untreated chow for the following 2 months, then euthanized (age: 20-21 wk). Other C3H mice (juvenile: 4-wk-old) were given CVT-E002 under the same protocol and sampled at 18 wk of age. In spite of withdrawing the extract 2 months earlier, the absolute numbers of NK cells in the young adults, remained significantly (p < 0.01), and slightly, elevated in the spleen and bone marrow (BM), respectively. The relative numbers (%) of NK cells in the blood also remained elevated (p < 0.05). In juvenile mice fed CVT-E002, the absolute numbers (spleen, BM) and % (blood) of NK cells were all elevated (p<0.01 - p<0.05). The mechanisms responsible for these super-normal numbers of NK cells long after withdrawal of CVT-E002, is as yet unknown.

The sustained influence of short term exposure to a proprietary extract of North American ginseng on the hemopoietic cells of the bone marrow, spleen and blood of adult and juvenile mice.

This study assessed the influences of CVT-E002, a proprietary extract of North American ginseng, Panax quinquefolius (Afexa Life Sciences, Inc., Edmonton, AB, Canada), in vivo, on murine hemopoietic and immune cells when administered as a dietary additive. The extract was given daily to young, adult mice for a period of 4 weeks, immediately following which one group was euthanized and the hemopoietic and immune cells of their bone marrow, spleen and blood were assayed for CVT-E002-mediated alterations in any of five cell lineages (lymphocytes, nucleated erythroid cells, granulocytes, immature granuloid precursors and monocytes). Another group of these mice was left for a subsequent 8 weeks on control diet, following which the same organs and cell lineages were analysed. In another study, juvenile mice immediately upon weaning (age: 4 weeks), were subjected to the above protocol, and their organs/cell lineages assayed. The results revealed that CVT-E002 had a long-lasting, positive quantitative effect on the lymphocytes and monocytes, regardless of age at commencement of daily, dietary CVT-E002. CVT-E002 may therefore have a prophylactic disease defense, immunostimulatory role, or potentially, even a therapeutic role.