Magdalena Harris* and Tim Rhodes
* Corresponding author: Magdalena Harris firstname.lastname@example.org
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H9SH, UK
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Harm Reduction Journal 2013, 10:7 doi:10.1186/1477-7517-10-7
The electronic version of this article is the complete one and can be found online at: http://www.harmreductionjournal.com/content/10/1/7
Received: 6 August 2012, Accepted: 13 April 2013, Published: 7 May 2013
© 2012 Harris and Rhodes; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Evidence documents successful hepatitis C virus (HCV) treatment outcomes for people who inject drugs (PWID) and interest in HCV treatment among this population. Maximising HCV treatment for PWID can be an effective HCV preventative measure. Yet HCV treatment among PWID remains suboptimal. This review seeks to map social factors mediating HCV treatment access.
We undertook a review of the social science and public health literature pertaining to HCV treatment for PWID, with a focus on barriers to treatment access, uptake and completion. Medline and Scopus databases were searched, supplemented by manual and grey literature searches. A two step search was taken, with the first step pertaining to literature on HCV treatment for PWID and the second focusing on social structural factors. In total, 596 references were screened, with 165 articles and reports selected to inform the review.
Clinical and individual level barriers to HCV treatment among PWID are well evidenced. These include patient and provider concerns regarding co-morbidities, adherence, and side effect management. Social factors affecting treatment access are less well evidenced. In attempting to map these, key barriers fall into the following domains: social stigma, housing, criminalisation, health care systems, and gender. Key facilitating factors to treatment access include: combination intervention approaches encompassing social as well as biomedical interventions, low threshold access to opiate substitution therapy, and integrated delivery of multidisciplinary care.
Combination intervention approaches need to encompass social interventions in relation to housing, stigma reduction and systemic changes in policy and health care delivery. Future research needs to better delineate social factors affecting treatment access.
Keywords: Hepatitis C; Antiviral treatment; Treatment access; People who inject drugs; Social factors
Worldwide 170 million people are estimated to live with chronic HCV , with annual mortality rates due to HCV-related liver diseases estimated at over 350 000 . Global HCV antibody prevalence among people who inject drugs (PWID) is high. A recent systematic review, for instance, identified 24 countries where HCV antibody prevalence in PWID ranged from 40–60% (such as Australia, UK, Greece), 25 countries with a range of 60-80% (USA, Canada, Germany) and 12 (Mexico, Thailand, Russia, the Netherlands) where prevalence was 80% or higher . The World Health Organisation identifies PWID as a key target group for HCV prevention and treatment .
HCV antiviral treatment with peginterferon alfa and ribavirin is the standard of care for chronic HCV, with a 50-85% cure rate depending on genotype . Modelling studies indicate that scaling-up HCV treatment access to PWID, specifically current injectors, has the potential to reduce the pool of communicable disease in the population, acting as an effective preventative measure [5,6]. Qualitative [7,8] and quantitative research [9-12] shows that PWID are interested in assessing and commencing HCV treatment. PWID have rates of HCV treatment adherence and successful completion comparable to other populations [13-16]. Clinical guidelines in a number of countries (such as the UK, Australia, US, Canada, France) have been modified to remove current injecting drug use as HCV treatment exclusion criteria [17-20]. Yet HCV treatment uptake among PWID is suboptimal, and estimated to be in the order of 2-4% of those eligible [5,17,21,22]. Why might this be so? What interplay of factors mediate HCV treatment access for PWID? And what specifically, might be the role of social and structural factors?
Drawing upon published literature pertaining to HCV treatment as well as HCV among PWID, we seek to map the social factors potentially mediating HCV treatment access and uptake for PWID. This will assist in developing a descriptive typology of social factors and how they function potentially as ‘barriers’ and ‘facilitators’ to treatment access. This is necessary because there is a dearth of pooled evidence investigating the role of social factors affecting HCV treatment. We therefore draw upon previous work on the conditionality of HIV treatment access for PWID as a way of conceptualising ‘social factors’ and their relevance [23-25]. This work on HIV treatment maps the treatment access environment as a product of interplay between macro-level factors (such as the adverse impacts of criminalisation, social and material inequality, and health policy) and meso-level factors (such as related to systems of service administration, management and delivery) . Given the absence of previous review on social factors affecting HCV treatment, this review takes a two step approach to two different literatures in an attempt to map the field. First, we draw upon literature specific to HCV treatment for PWID, generated through a Medline and Scopus search of published papers since the year 2000, selected for their relevance to barriers and facilitators to treatment access. Second, we draw upon literature specific to HCV among PWID, generated through a Medline and Scopus search of published papers since the year 2000, and selected for their relevance regarding ‘social factors’ linked to HCV risk, prevention or treatment. The first of these literatures (HCV treatment) focuses predominantly on clinical and individual level factors, and the second (HCV among PWID) focuses on social and system level factors with a heavier focus on qualitative studies.