Search

Objectives: There is limited research on health-related quality of life (HRQoL) among people who inject drugs (PWID). We evaluated the HRQoL and associated factors among a cohort of PWID in Australia., Methods: Participants were enrolled in an observational cohort study (the Enhancing Treatment of Hepatitis C in Opioid Substitution Settings Engage Study) from May 2018 to September 2019 (wave 1) and November 2019 to June 2021 (wave 2). Participants completed the EQ-5D-5L survey at enrolment. Two-part models were used to assess the association of clinical and socioeconomic characteristics with EQ-5D-5L scores., Results: Among 2395 participants (median age, 43 years; 66% male), 65% reported injecting drug use in the past month, 20% had current hepatitis C virus (HCV) infection, and 68% had no/mild liver fibrosis (F0/F1). Overall, the mean EQ-5D-5L and EQ-visual analog scale scores were 0.78 and 57, respectively. In adjusted analysis, factors associated with significantly lower EQ-5D-5L scores include older ages, female (marginal effect = -0.03, P = .014), being homeless (marginal effect = -0.04, P = .040), and polysubstance use (marginal effect = -0.05, P < .001). Factors associated with significantly higher EQ-5D-5L scores were being Aboriginal/Torres Strait Islander (marginal effect = 0.03, P = .021) and recent injecting drug use in the past 12 months. Current HCV infection and liver fibrosis stage were not associated with reduced HRQoL among the study participants., Conclusions: PWID experienced a lower HRQoL compared with the general population. Further research is needed to understand HRQoL in this population to facilitate the development of multifaceted care models for PWID beyond HCV cure and inform health economic analyses for identifying optimal health strategies for PWID., Competing Interests: Author Disclosures Links to the individual disclosure forms provided by the authors are available here., (Copyright © 2023 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: People who inject drugs (PWID) are at a high risk of hepatitis C virus (HCV) infection. HCV cure is associated with improved patient-reported outcomes (PROs), but there are little data among PWID. This study aimed to assess the change in PROs during and after HCV direct-acting antiviral (DAA) treatment., Methods: This analysis used data from 2 clinical trials of DAA treatment in PWID. PROs assessed included health-related quality of life, social functioning, psychological distress, housing, and employment. Generalized estimating equations and group-based trajectory modeling were used to assess changes in PROs over time., Results: No significant changes in the 3-level version of EQ-5D scores, EQ visual analogue scale scores, social functioning, psychological distress, and housing were observed over the 108-week study period. There was a significant increase in the proportion of participants employed (18% [95% confidence interval (CI) 12%-23%] at baseline to 28% [95% CI 19%-36%] at the end of the study). Participants were more likely to be employed at 24 weeks and 108 weeks after commencing treatment. Having stable housing increased the odds of being employed (odds ratio 1.70; 95% CI 1.00-2.90). The group-based trajectory modeling demonstrated that most outcomes remained stable during and after DAA treatment., Conclusions: Although no significant improvement was identified in health-related quality of life after HCV DAA treatment, there was a modest but significant increase in employment during study follow-up. The study findings support the need for multifaceted models of HCV care for PWID addressing a range of issues beyond HCV treatment to improve quality of life., (Copyright © 2023. Published by Elsevier Inc.)

Background: People who inject drugs are exposed to various and changing risk environments and are at risk of multiple harms related to injecting drug use (IDU). We aimed to undertake a global systematic review of the prevalence of IDU, key IDU-related harms (including HIV, hepatitis C virus [HCV], and hepatitis B virus [HBV] infection and overdose), and key sociodemographic characteristics and risk exposures for people who inject drugs., Methods: We systematically searched for data published between Jan 1, 2017, and March 31, 2022, in databases of peer-reviewed literature (MEDLINE, Embase, and PsycINFO) and grey literature as well as various agency or organisational websites, and disseminated data requests to international experts and agencies. We searched for data on the prevalence, characteristics, and risks of people who inject drugs, including gender, age, sexuality, drug-use patterns, HIV, HCV, and HBV infections, non-fatal overdose, depression, anxiety, and injecting-related disease. Additional data were extracted from studies identified in our previous review. Meta-analyses were used to pool the data where multiple estimates were available for a country. We present country, regional, and global estimates for each variable examined., Findings: We screened 40 427 reports published between 2017 and 2022, and the 871 eligible reports identified were added to the 1147 documents from the previous review. Evidence of IDU was documented in 190 of 207 countries and territories, and 14·8 million people (95% uncertainty interval [UI] 10·0-21·7) aged 15-64 years globally were estimated to inject drugs. Existing evidence suggests that there might be 2·8 million (95% UI 2·4-3·2) women and 12·1 million (95% UI 11·0-13·3) men who inject drugs globally, and that 0·4% (95% CI 0·3-1·3) of people who inject drugs identify as transgender. The amount of available data on key health and social risks among people who inject drugs varied widely across countries and regions. We estimated that 24·8% (95% CI 19·5-31·6) of people who inject drugs globally had experienced recent homelessness or unstable housing, 58·4% (95% CI 52·0-64·8) had a lifetime history of incarceration, and 14·9% (95% CI 8·1-24·3) had recently engaged in sex work, with substantial geographical variation. Injecting and sexual risk behaviour varied considerably geographically, as did risks of harms. Globally, we estimated that 15·2% (95% CI 10·3-20·9) of people who inject drugs are living with HIV, 38·8% (95% CI 31·4-46·9) have current HCV infection, 18·5% (95% CI 13·9-24·1) have recently overdosed, and 31·7% (95% CI 23·6-40·5) have had a recent skin or soft tissue infection., Interpretation: IDU is being identified in a growing number of countries and territories that comprise more than 99% of the global population. IDU-related health harms are common, and people who inject drugs continue to be exposed to multiple adverse risk environments. However, quantification of many of these exposure and harms is inadequate and must be improved to allow for better targeting of harm-reduction interventions for these risks., Funding: Australian National Health and Medical Research Council., Competing Interests: Declaration of interests In the past 3 years, LD and MF have received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior and Seqirus. AP has received investigator-initiated untied educational grants from Seqirus. JG is a consultant or advisor and has received research grants from AbbVie, bioLytical, Camurus, Cepheid, Gilead Sciences, Hologic, Indivior, and Merck or MSD. GJD has received research grants from AbbVie, Gilead Sciences, and Merck or MSD. EBC has received funding from the Canadian Network on Hepatitis C. These companies and organisations had no knowledge of or role in the design, conduct, interpretation, or publication of these findings. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Harm reduction and treatment programmes are essential for reducing harms for people who inject drugs (PWID). We aimed to update estimates from a 2017 review of global coverage of needle and syringe exchange programmes (NSPs), opioid agonist treatment (OAT), and other harm reduction services that target PWID (eg, take-home naloxone [THN] programmes, supervised consumption facilities, and drug checking services)., Methods: We did a systematic review of available evidence from peer-reviewed and grey literature databases for studies published between Jan 1, 2017, and May 31, 2022. Programmatic data were collected on the availability of services, the number of sites, people accessing services, and equipment distributed in countries where there is evidence of injecting drug use. National estimates of coverage of OAT (ie, number of people accessing OAT per 100 PWID) and NSPs (ie, number of needles and syringes distributed per PWID per year) were generated where available using the most recent data. Regional and global estimates were derived and compared with WHO indicators. The study was registered with PROSPERO (CRD42020173974)., Findings: We included 195 studies and found there were 90 countries implementing OAT (75% of the PWID population) and 94 countries implementing NSPs (88% of the global PWID population). Only five countries (2% of the global PWID population) are providing high coverage of both services. Far fewer countries were implementing THN programmes (n=43), supervised consumption facilities (n=17), and drug checking services (n=26), with nine countries implementing all five services. Globally, we estimated there were 18 (95% uncertainty interval [UI] 12-27) people accessing OAT per 100 PWID, and 35 (95% UI 24-52) needles and syringes being distributed per person who injects drugs per year. More countries reported high (OAT 24; NSPs 10), moderate (OAT 8; NSPs 15), and low (OAT 38; NSPs 47) coverage of services compared with the previous review., Interpretation: Global coverage of OAT and NSPs has increased modestly in the past 5 years but remains low for most countries. Programmatic data on other key harm reduction interventions are scarce., Funding: Australian National Health and Medical Research Council., Competing Interests: Declaration of interests LD and MF have received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior and Seqirus in the past 3 years. AP has received investigator-initiated untied educational grants from Seqirus. JG is a consultant and adviser and has received research grants from AbbVie, Camurus, Cepheid, Gilead Sciences, Hologic, Indivior, and Merck. GJD has received research grants from Abbvie, Gilead Sciences, and Merck. EBC has received funding from the Canadian Network on hepatitis C. These companies or organisations had no knowledge of or role in the design, conduct, interpretation, or publication of these findings. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: With the advent of direct acting antiviral (DAA) therapies for the treatment of hepatitis C virus (HCV), the World Health Organization recommended a goal to eliminate HCV as a public health threat globally by 2030. With the majority of new and existing infections in high income countries occurring among people who inject drugs, achieving this goal will require the design and implementation of interventions which address the unique barriers to HCV care faced by this population., Methods: In this systematic review and meta-analysis, we searched bibliographic databases and conference abstracts to July 21, 2020 for studies assessing interventions to improve the following study outcomes: HCV antibody testing, HCV RNA testing, linkage to care, and treatment initiation. We included both randomised and non-randomised studies which included a comparator arm. We excluded studies which enrolled only paediatric populations (<18 years old) and studies where the intervention was conducted in a different healthcare setting than the control or comparator. This analysis was restricted to studies conducted among people who inject drugs. Data were extracted from the identified records and meta-analysis was used to pool the effect of interventions on study outcomes. This study was registered in PROSPERO (CRD42020178035)., Findings: Of 15,342 unique records, 45 studies described the implementation of an intervention to improve HCV testing, linkage to care and treatment initiation among people who inject drugs. These included 27 randomised trials and 18 non-randomised studies with the risk of bias rated as "critical" for most non-randomised studies. Patient education and patient navigation to address patient-level barriers to HCV care were shown to improve antibody testing uptake and linkage to HCV care respectively although patient education did not improve antibody testing when restricted to randomised studies. Provider care coordination to address provider level barriers to HCV care was effective at improving antibody testing uptake. Three different interventions to address systems-level barriers to HCV care were effective across different stages of HCV care: point-of-care antibody testing (linkage to care); dried blood-spot testing (antibody testing uptake); and integrated care (linkage to care and treatment initiation)., Interpretation: Multiple interventions are available that can address the barriers to HCV care for people who inject drugs at the patient-, provider-, and systems-level. The design of models of care to improve HCV testing and treatment among people who inject drugs must consider the unique barriers to care that this population faces. Further research, including high-quality randomised controlled trials, are needed to robustly assess the impact these interventions can have in varied populations and settings., Competing Interests: Declarations of Interest JG is a consultant/advisor and has received research grants from AbbVie, Biolytical, Camurus, Cepheid, Gilead Sciences, Hologic, Indivor, and Merck/MSD and has received honoraria from AbbVie, Cepheid, Gilead Sciences, and Merck. GJD is a consultant/advisor and has received research grants from Abbvie, Abbot Diagnostics, Gilead Sciences, Bristol Myers Squibb, Cepheid, GlaxoSmithKline, Merck, Janssen and Roche. JWW is supported by The Task Force for Global Health which receives funds for the general support of the Coalition for Global Hepatitis Elimination from Abbott, Gilead, AbbVie, Merck, Siemens, Cepheid, Roche, Pharco, Zydus-Cadila, governmental agencies and philanthropic organizations. MH has received unrestricted honoraria and travel expenses from MSD and Gilead unrelated to this project. PV has received research grants from Gilead Sciences and is in receipt of grants from the UK National Institute of Health Research. AC, ADM, AW, BMV, BH, CEF, EBC, GF, JP, LD, RR, and SB had no conflict of interest to declare. No input into this work was provided by any of the above listed organisations or institutions., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Background: Injecting-related skin and soft tissue infections (SSTIs) are a preventable cause of inpatient hospitalisation among people who inject drugs (PWID). This study aimed to determine the prevalence of hospitalisation for SSTIs among PWID, and identify similarities and differences in factors associated with hospitalisation for SSTIs versus non-bacterial harms related to injecting drug use., Methods: We performed cross-sectional analyses of baseline data from an observational cohort study of PWID attending drug treatment clinics and needle and syringe programs in Australia. Logistic regression models were used to identify factors associated with self-reported hospitalisation for (1) SSTIs (abscess and/or cellulitis), and (2) non-bacterial harms related to injecting drug use (e.g., non-fatal overdose; hereafter referred to as non-bacterial harms), both together and separately., Results: 1851 participants who injected drugs in the previous six months were enrolled (67% male; 85% injected in the past month; 42% receiving opioid agonist treatment [OAT]). In the previous year, 40% (n = 737) had been hospitalised for drug-related causes: 20% (n = 377) and 29% (n = 528) of participants were admitted to hospital for an SSTI and non-bacterial harm, respectively. Participants who were female (adjusted odds ratio [aOR]: 1.53, 95% CI: 1.19-1.97) or homeless (aOR: 1.59, 95% CI: 1.16-2.19) were more likely to be hospitalised for an SSTI, but not a non-bacterial harm. Both types of hospitalisation were more likely among people recently released from prison., Conclusions: Hospitalisation for SSTIs is common among PWID. Community-based interventions to prevent SSTIs and subsequent hospitalisation among PWID will require targeting of at-risk groups, including women, people experiencing homelessness, and incarcerated people upon prison release., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Evidence regarding the acceptability of contingency management is limited. We investigated the willingness of people who inject drugs to participate in a randomised controlled trial (RCT) involving financial incentives to initiate HCV treatment., Methods: ETHOS Engage is an observational cohort study of people with a history of injecting drug use who either injected in the past six months or receive opioid agonist therapy (OAT) in Australia. We assessed willingness to participate in a RCT with financial incentives and factors associated with preference for entire incentive ($60) at first clinic visit versus delayed incentive with logistic regression., Results: 93% (593/635) of eligible participants agreed to participate in an RCT with financial incentives of which 24% were Aboriginal or Torres Strait Islander, 84% had completed secondary school, and 59% injected drugs in the prior month. Willingness to participate in an RCT increased by amount offered: unspecified (72%), $20 (75%), $60 (80%), and $100 (85%). The preferred incentive distribution method over three clinical visits was entire incentive at first clinical visit (32%). Among those with a preferred distribution method (n = 369), factors associated with entire incentive at first clinic visit were being Aboriginal or Torres Strait Islander (aOR 1.75; 95% CI 1.05-2.94), completion of secondary school (aOR 0.46; 95% CI 0.26-0.83) and mainly injected heroin in month prior (aOR 1.82; 95% CI 1.03-3.20)., Conclusion: Most participants were willing to participate in an RCT involving financial incentives to initiate treatment but differed regarding distribution. Study findings inform implementation of incentives in clinical practice., (Copyright © 2022 Elsevier B.V. All rights reserved.)

A community-based public health facility in Sydney, Australia, the Kirketon Road Centre (KRC), provides health care to people who inject drugs (PWID), homeless and other marginalized people. Since March 2016, KRC has provided treatment for chronic hepatitis C virus (HCV) with direct-acting antivirals (DAAs). We aimed to evaluate treatment adherence amongst clients taking DAAs in a highly marginalized population. All clients who commenced DAA therapy prior to March 2018 at KRC were included in this observational cohort with a subset of clients attending daily or weekly for enhanced adherence support and dosing. Demographic, behavioural, clinical measures and medication dosing were recorded, and adherence was calculated as the proportion of doses taken during the expected treatment duration. Factors associated with adherence were examined using logistic regression. A total of 242 individuals commenced DAA therapy, of whom 79 (32%) received enhanced adherence support. Enhanced support was associated with homelessness, daily injecting, Aboriginality, mental health co-morbidity and poly-drug use (all P < .001). Overall adherence was 86%, and 92% of patients missed one or more doses (median 10, IQR 4-24). At least 90% adherence during planned duration was seen in 38%, but increased to 66% by continuing therapy beyond planned duration. Intention-to-treat SVR12 was 68% and 66% in the enhanced adherence support sub-population, with 29% lost to follow-up by SVR12 testing. There were only 2 (0.8%) documented virological failures. Per-protocol SVR12 was 99% and 96% in the enhanced adherence support sub-population. In conclusion, adherence support may benefit those with multiple markers of marginalization. Extension of therapy beyond planned duration is a pragmatic strategy to enhance completion. Strategies to improve follow-up, particularly post-treatment are required., (© 2019 John Wiley & Sons Ltd.)