Setting foot in private spaces: extending the hepatitis C cascade of care to automatic needle/syringe dispensing machines, a mixed methods study.

BACKGROUND: Global commitment to achieving hepatitis C virus (HCV) elimination has enhanced efforts in improving access to direct-acting antiviral (DAA) treatments for people who inject drugs (PWID). Scale-up of efforts to engage hard-to-reach groups of PWID in HCV testing and treatment is crucial to success. Automatic needle/syringe dispensing machines (ADMs) have been used internationally to distribute sterile injecting equipment. ADMs are a unique harm reduction service, affording maximum anonymity to service users. This paper explores the feasibility and acceptability of extending the HCV cascade of care to sites where ADMs are located. METHODS: The ADM users into Treatment (ADMiT) study was undertaken in a metropolitan region in Sydney, Australia. This mixed methods study involved analysis of closed-circuit television footage, ethnographic methods (fieldwork observation and in-depth interviews) and structured surveys. Researchers and peers conducted fieldwork and data collection over 10 weeks at one ADM site, including offering access to HCV testing and treatment. RESULTS: Findings from 10 weeks of fieldwork observations, 70 survey participants and 15 interviews highlighted that there is scope for engaging with this population at the time they use the ADM, and enhanced linkage to HCV testing and treatment may be warranted. Most survey participants reported prior HCV testing, 61% in the last 12 months and 38% had received HCV treatment. However, fieldwork revealed that most people observed using the ADM were not willing to engage with the researchers. Field work data and interviews suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement. DISCUSSION: Enhanced linkage to HCV testing and treatment for people who use ADMs may be warranted. However, data suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement. The current study raises important public health questions about the need to ensure interventions reflect the needs of affected communities, including their right to remain anonymous.

Client resistance to hepatitis C treatment initiation in opioid agonist treatment clinics in Sydney, Australia: A qualitative study.

INTRODUCTION: Opioid agonist treatment (OAT) clinics play a key role in achieving elimination of hepatitis C virus (HCV) globally. Previous research has identified barriers to HCV treatment uptake in OAT clinics; however, most studies were conducted prior to the introduction of direct-acting antiviral treatments (DAA). It remains unclear whether progress has been made in responding to barriers and what challenges persist in this setting. METHODS: Semi-structured in-depth interviews were conducted with staff (n = 20) and clients (n = 15) in two OAT clinics in Sydney, Australia. Interviews were transcribed verbatim and analysed using constant comparative methods. RESULTS: Despite progress in integrating hepatitis C care in the clinics, competing priorities, concerns about side-effects, distrust of staff, health problems and difficulties accessing testing and medication persisted as key reasons why clients had not initiated treatment. Most clients preferred to postpone treatment and focus on other priorities and some highlighted lack of medical evidence for urgent treatment. Pressure on services to achieve elimination targets within set time frames was a primary driver of repeated offers of treatment by staff and the framing of clients' preferences for postponing treatment, as a barrier. DISCUSSION AND CONCLUSION: Current timelines for HCV elimination targets may have galvanised services into action but may have also created tensions at the coalface due to disparities between staff and clients' priorities. The involvement of peer workers and mechanisms to ensure continued follow up with clients about DAA treatments is required. Public health timelines for HCV elimination need to be informed by affected communities' priorities.

Developing a model of care for substance use in pregnancy and parenting services, Sydney, Australia: Service provider perspectives.

INTRODUCTION: The absence of a clear model of care for services supporting pregnant women and mothers with substance use disorders has impeded opportunities to build an evidence base for the effectiveness of these services. Previous research has typically focused on the needs of pregnant women or mothers, as two distinct groups. This paper explores service providers' perceptions of key components of a model of care, extending from perinatal care to community-based support for up to 17 years post-delivery. A model of care is outlined and feasibility factors affecting implementation are highlighted. METHODS: Qualitative methods were adopted as a first step to informing development of the model of care. Semi-structured in-depth interviews were conducted with thirty-eight staff providing a range of substance use in pregnancy and parenting services (SUPPS) in hospital and community-based agencies, in a metropolitan health district in Sydney, Australia. Interview data was entered into NVivo and analysed using constant comparative methods. RESULTS: Guiding principles for the model of care included integrated care, harm reduction and person-centredness. Practice approaches integral to the model of care were promoting engagement with women, flexible service provision, trauma-informed care, and continuity of care. Feasibility factors influencing implementation of the model of care included fragmentation or siloing of the service network and workforce sustainability. CONCLUSIONS: A harm reduction approach was crucial for promoting engagement of women with SUPPS, particularly child protection services. A greater focus on providing ongoing community-based support for mothers also has the potential to achieve sustainable positive outcomes for women and children. Implementation of the SUPPS model of care could be undermined by threats to integration of service delivery and continuity of care. Further research is needed to explore consumer perspectives and inform the model of care as a framework for evaluation.

Refining Program Theory for a Place-Based Integrated Care Initiative in Sydney, Australia.

INTRODUCTION: The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family engagement with health and social services through a care coordination model. Besides servicing families in Sydney, HHAN has also established place-based initiatives (PBIs) in areas of disadvantage such as Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, and financial and legal services. This integration aims to facilitate service access and multi-agency support for vulnerable families in Redfern. Hence, this study aims to evaluate for whom, when and why HHAN's PBI at Redfern works, or not, and what are its outcomes. METHODS: The project utilises critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and the community. Purposive sampling was used to identify 21 participants including HHAN clients, HHAN staff and stakeholders (HHAN partners). In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using a context (C), intervention (I), mechanism (M) outcome (O) (CIMO) approach to abductive analysis. RESULTS: Five key CIMO configurations of the Redfern PBI emerged - whole-of-family involvement, flexibility, trust, building connections and co-location. Whilst each theory had specific outcomes, overall client outcomes included improved access to services, better outlook, empowerment and engagement with services. Service outcomes included increased collaboration and foundation for integration between HHAN and other services. Negative outcomes included lack of full integration, the risk associated with integration and difficulty evaluating impact. CONCLUSION: This study successfully refined the program theory for subsequent use in later implementation of critical realist evaluation studies.

Engaging people who inject drugs in hepatitis C virus testing and prevention through community-based outreach, in Sydney, Australia.

INTRODUCTION AND AIMS: Increasing treatment uptake among people who inject drugs (PWID) with chronic hepatitis C virus (HCV) infection is integral to eliminating viral hepatitis. This study explored the role of community-based outreach in engaging and retaining Australian PWID in the testing component of the HCV care cascade. DESIGN AND METHODS: Semi-structured interviews were conducted with 28 PWID, including new initiates to injecting and those from culturally and linguistically diverse (CALD) backgrounds, who acquired HCV infection while enrolled in a community-based prospective observational study of hepatitis C vaccine preparedness in Sydney. Participants were interviewed at diagnosis and 12 months later. Transcripts were thematically analysed using constant comparative techniques. RESULTS: Community-based outreach was effective in engaging newly infected participants in HCV monitoring and decision-making about seeking interferon-based treatment. Key factors in the acceptability of outreach were privacy and discretion, and opportunities to build trust with non-judgmental staff. Retaining participants in the HCV cascade of care required more than a one-off session of post-test counselling. Ongoing discussions with staff enabled paced and tailored delivery of information about HCV prevention, testing and treatment. Increased understanding of the role of HCV ribonucleic acid viremia in determining the need for treatment, and access to this testing, was pivotal in making HCV monitoring salient for participants. DISCUSSION AND CONCLUSIONS: Outreach is an effective strategy for engaging new initiates to injecting and CALD PWID in HCV testing and decision-making about treatment. Findings highlight the need to increase availability and access to HCV ribonucleic acid testing for PWID.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia.

BACKGROUND: In Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination. METHODS: Semi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory. RESULTS: In addition to increasing occupational functionality, ATS were used to control pervasive feelings of 'sadness' in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use. CONCLUSION: In addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.

Promoting equitable access to hepatitis C treatment for Indo-Chinese injecting drug users.

ISSUE ADDRESSED: Increasing the uptake of hepatitis C treatment by injecting drug users (IDUs) is a key strategy in addressing the escalating disease burden of chronic hepatitis C virus (HCV) infection in Australia. Little is known about barriers to treatment uptake among culturally diverse groups of IDUs. Indo-Chinese IDUs represent a marginalised group with high rates of incident and prevalent HCV infection. METHODS: An ethnographic study was conducted to explore barriers to HCV treatment uptake experienced by Indo-Chinese IDUs and inform the development of policies and practices that promote access to treatment. Following a baseline interview, participants (n=23) received a brief intervention about HCV treatment and an offer of facilitated referral to a tertiary liver clinic. Follow-up interviews were conducted three and six months post intervention, to explore decision-making about treatment-seeking and experiences accessing the clinic. RESULTS: While 'getting rid of' HCV was regarded as highly desirable, only three participants were assessed for treatment. For most participants, seeking treatment was not seen as feasible given social and structural barriers related to their drug use, lack of resources and support. Institutional barriers included the clinic's administrative procedures, limited flexibility and apparent reluctance to consider current IDUs suitable candidates for treatment. CONCLUSIONS: Resources and support, fexible, low threshold approaches to assessment and a willingness to provide treatment to current IDUs, would promote equitable access to treatment among these groups.

Scaling up HIV treatment, care and support for injecting drug users in Vietnam.

BACKGROUND: People living with HIV/AIDS (PLWHA) in developing countries are rarely consulted about ways to promote their health and well-being. This study sought to identify and understand, from the perspective of PLWHA, challenges and opportunities for improving access to HIV treatment, care and support in Vietnam, a resource-limited setting with an epidemic driven by injecting drug use. METHODS: PLWHA trained in participatory research methods completed fieldwork and data collection and co-facilitated focus groups with injecting drug users (IDUs) in Ho Chi Minh City. Qualitative data were analysed in Vietnamese and English using an inductive approach to code and compare content and identify key themes. RESULTS: Results suggest considerable barriers to scaling up in this setting. Against a backdrop of punitive government policies, including mandatory detention of IDUs and sex workers, and widespread stigma and discrimination, many PLWHA lived with the fear of discovery and the threat of abandonment. Lack of confidentiality, limited financial resources and restricted access to essential medications provided powerful disincentives to health service utilisation. CONCLUSIONS: Opportunities for scaling up lie firstly in expanding access to confidential HIV counselling and testing. However, in the absence of affordable, quality care and access to anti-retroviral therapy, IDUs are unlikely to see testing as worthwhile. Efforts to scale up also need to address structural barriers including stigma and discrimination, poverty and institutional capacity. Finally, PLWHA in Vietnam are a significant but underutilised resource and consideration should be given to overcoming barriers to building confidence and capacity within affected communities.