Barriers associated with the treatment of hepatitis C virus infection among illicit drug users.

BACKGROUND: Illicit drug users account for the majority of cases of HCV infection in the developed world, but few have received treatment. METHODS: We evaluated barriers to initiating HCV treatment -- including general treatment willingness -- and factors associated with these among HCV infected illicit drug users. Participants were recruited via convenience sampling from two community clinics in Canada. Individuals age >18 years with a history of illicit drug use completed interviewer-administered surveys. Those reporting positive HCV testing underwent additional questioning on willingness, uptake and barriers to treatment for HCV. RESULTS: Of 188 HCV positive illicit drug users, 16% (n=30) had received treatment for HCV. Factors associated with a decreased treatment uptake included current heroin use and HIV/HCV co-infection. Among those not having received therapy, 77% (117/153) indicated a willingness to receive HCV treatment. Factors associated with treatment willingness included not being infected with HIV, having not recently used drugs by injection and having reported physical health problems. Among those not having sought HCV treatment (n=107), the major reasons for not doing so were: lack of information about HCV or knowledge that treatment was available (23%), the absence of symptoms (20%) and the perceived side effects of treatment (14%). CONCLUSIONS: Among illicit drug users attending inner city clinics, we have observed a low uptake of HCV treatment, but a high willingness to receive therapy. An increased focus on improving education about the long-term consequences of HCV and the availability of effective treatment are important components for expanding HCV treatment among illicit drug users.

Public opinion towards supervised injection facilities and heroin-assisted treatment in Ontario, Canada.

In recent years, controversial interventions such as 'heroin-assisted treatment' (HAT) and 'supervised injection facilities' (SIFs) have been established in attempts to minimise the high morbidity and mortality consequences of illicit drug use. This paper examines public opinion towards HAT and SIF using data from the 2003 Centre for Addiction and Mental Health (CAMH) Monitor, a representative population survey conducted among adults residing in Ontario, Canada. Data relating specifically to SIFs and HAT were isolated from the main database (n=885); agreement scores were collapsed to create a scale and analysed using independent sample t-tests and ANOVAs. Results revealed that 60 percent (n=530) of the sample agreed that SIFs should be made available to injection drug users, while 40 percent (n=355) disagreed. When asked about the provision of HAT, a similar pattern emerged. Variables significantly associated with positive opinions toward SIFs and HAT were: income; higher education; the use of cocaine or cannabis within the last 12 months; being in favour of cannabis decriminalisation; support of needle exchange in prison; view of illicit drug users as ill people; and agreement that drug users are in need of public support. Given the current political climate and the tentative position of SIFs and HAT in Canada, understanding the public's opinion is crucial for the feasibility and long-term sustainability of these interventions.

Prevalence and associated factors of hepatitis C infection (HCV) in a multi-site Canadian population of illicit opioid and other drug users (OPICAN).

BACKGROUND: Hepatitis C virus (HCV) infection is highly prevalent in illicit drug user populations, with three in four new HCV infections related to this risk behaviour and a growing HCV disease burden in Canada. Using data from a multi-site cohort study of illicit opioid users in five Canadian cities (OPICAN), this paper explores the prevalence and predictors of HCV status in this high-risk population. METHODS: HCV status of cohort participants was assessed by salivary antibody test. Univariate relationships of HCV status with select variables were examined on the basis of cohort baseline data, and subsequently multivariate models using logistic regression to determine independent predictors of HCV status were generated. RESULTS: 54.6% of the analysis sample (n=482) was HCV positive. Significant differences in terms of HCV prevalence existed across the sites. Significant variables in the final stepwise logistic regression model included age, site (Toronto), unprotected sex, injecting drug use, drug treatment and incarceration in past year, in addition to opioid use in combination with non-opioids. DISCUSSION: Besides drug injecting, various other socio-behavioural factors were associated with HCV status in our cohort. On this basis, interventions focusing solely on injection risks are overly limited in scope to prevent HCV transmission in the high-risk population of illicit drug users and need to be broadened. Prevention efforts should also target young injectors as a priority.

Crack across Canada: Comparing crack users and crack non-users in a Canadian multi-city cohort of illicit opioid users.

AIMS: To examine possible differences between crack users and crack non-users across Canada. DESIGN: Cohort study of illicit opioid and other drug users in five cities across Canada. SETTING: Vancouver, Edmonton, Toronto, Montreal and Quebec City, Canada. PARTICIPANTS: Regular illicit opioid and other street drug users not in treatment at time of assessment. MEASUREMENTS: Participants (n = 677) were assessed at baseline (2002) by way of an interviewer-administered questionnaire, a psychiatric diagnostic instrument (Composite International Diagnostic Interview), and salivary antibody tests for infectious disease. FINDINGS: Approximately half the sample had used crack in the past 30 days, although prevalence rates differed strongly between study sites. When examined by discriminant analysis, crack users in the study population were more likely to have: no permanent housing, have illegal and sex work income, indicate physical health problems and hepatitis C virus (HCV) antibodies, use walk-in clinics, use heroin and to have been arrested and in detention (in past year). They were less likely to report depressive symptoms, and use Dilaudid (hydromorphone) and alcohol. CONCLUSION: These results illustrate crack users' pronounced social marginalization (as expressed by homelessness and high involvement in illegal activities) as well as extensive health problems compared to non-crack users in the Canadian context. The development of targeted interventions-addressing the dynamics of social marginalization-of this population is urgently needed.

Treatment for hepatitis C virus and cannabis use in illicit drug user patients: implications and questions.

Illicit drug users are the primary risk group for HCV transmission, and will form the largest HCV treatment population for years to come. Sylvestre et al.'s study suggests that cannabis use may benefit treatment retention and outcomes in illicit drug users undergoing HCV treatment. In fact, there is substantial evidence that cannabis use may help address key challenges faced by drug users in HCV treatment (e.g., nausea, depression), especially when such treatment occurs in the context of methadone maintenance treatment which may amplify these consequences. While further research is required on the biological and clinical aspects of the benefits of cannabis use for HCV treatment, and the effectiveness of cannabis use for HCV treatment needs to be explored in larger study populations, we advocate that in the interim existing barriers to cannabis use are removed for drug users undergoing HCV treatment until the conclusive empirical basis for evidence-based guidance is available.

Hepatitis C, illicit drug use and public health: does Canada really have a viable plan?

Some 300,000 individuals are infected with the hepatitis C virus (HCV) in Canada. HCV infection is associated with major morbidity, mortality and health care costs; these indicators are projected to rise over the next decade. The vast majority of prevalent and incident HCV infections in Canada are illicit drug use-related; thus, the HCV disease burden can only be addressed through interventions targeting this primary risk factor. Both preventive (e.g., needle exchange, methadone treatment) and therapeutic (e.g., the accessibility of HCV treatment for illicit drug users) interventions aimed at HCV in illicit drug users have been broadly expanded in Canada in recent years. However, evidence suggests that existing preventive measures only offer limited effectiveness in reducing HCV risk exposure. Also, due to restricted resources, treatment for HCV currently only reaches an extremely small proportion (i.e., <5%) of HCV-infected drug users. Thus, on the basis of current HCV incidence as well as given interventions and their impact, Canada is not achieving a net reduction in the prevalence of HCV-related to illicit drug use. In order to reduce the HCV disease burden, Canada needs to reconsider the scope, delivery and resourcing of both preventive and treatment interventions targeting the primary risk population of illicit drug users.