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Aim: Peer support services have been shown to be beneficial in increasing uptake and adherence to treatment in other areas but few examples of these services exist in hepatitis C (HCV) care. This study examined the performance of two community-controlled peer support services operating within a larger study aimed at increasing access to HCV care and treatment for opiate substitution treatment (OST) clients, ETHOS.Methods: Semi-structured interviews were conducted in two clinics with three groups of participants: clients (n=31), staff (n=8) and peer workers (n=3) and examined the operation of the service in relation to process, outputs and impacts.Results: There was a very strong positive response to the peer worker services reported by staff and clients who had and had not interacted with a peer worker. A number of changes were reported that were not explicit goals of the service including providing access to additional services for clients and staff, peer workers acting as mediators between clients and staff and a less tangible notion of a changing "feel" of the clinic to a more positive and client-friendly social and physical space. Explicit goals of the service were also reported in peer workers supporting clients to consider and prepare for treatment (via blood tests and other assessments) as well as provide information and support about treatment.Conclusions: The peer support service was acceptable to clients and clinic staff. All groups of participants noted that the service met its goals of engaging clients, building trusting relationships and providing instrumental support for clients to access HCV treatment. Peer workers may also contribute to more effective deployment of health resources by preparing clients for clinical engagement with HCV health workers. [ABSTRACT FROM AUTHOR]

Aims To explore identity transformation among service users attending opiate substitution therapy ( OST) clinics following the introduction of hepatitis C ( HCV) care and treatment. Design An interview-based substudy of the Australian ETHOS (Enhancing Treatment for Hepatitis C in Opiate Substitution Settings) project. Setting Three OST clinics and one community health centre (operating a public OST) in New South Wales, Australia. Participants were interviewed at the recruitment sites. Participants The sample consisted of 57 OST service users concurrently living with HCV, 16 staff, including specialist HCV clinicians, and three peer-support workers, employed on the ETHOS project. Measurements Semi-structured interviews. Findings Service-user participants largely welcomed the introduction of HCV treatment as a practical, clinical intervention that also intimated a more comprehensive, holistic form of care. Negative stereotypes characteristic of OST settings-of limited, routinized clinical exchanges and minimal social-care interaction-were unsettled, opening up the possibility of new relations between staff and service users. The shift in the dynamic of the clinical encounter to address health in addition to dependence appeared to catalyse transformative possibilities not only for the therapeutic alliance but also for service-user understandings of self and identity. Conclusion Trial introduction of HCV care and treatment in selected Australian opiate substitution therapy (OST) clinics may have facilitated alternative, 'non-addict' identities to emerge from a clinical setting where the stigmatizing figure of 'the drug user' has traditionally prevailed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Internationally, there are ongoing efforts to increase access to hepatitis C (HCV) assessment and treatment to counter a generally low uptake of treatment among people with a history of injecting drug use. The aim of this qualitative study was to examine client and staff attitudes towards and experience of co-location of HCV and opioid substitution treatment (OST) services. Methods: In-depth interviews were conducted with 57 clients and 19 staff from four NSW clinics participating in the Australian ETHOS study. Results: Client and staff participants typically welcomed integrated treatment, citing issues of convenience, reduced travel time and costs, persistent cues to engagement and immediacy of access to care. Positive attitudes towards the initiative were expressed even by clients who had not engaged with HCV care. Providing co-located care largely avoided the negative, stigmatising or discriminatory experiences that participants reported encountering in settings less familiar with people who use drugs. A minority of client participants expressed concerns about the lack of privacy and/or confidentiality available in the co-located model, preferring to seek HCV care elsewhere. Conclusions: The co-location of HCV care in OST clinics was welcomed by the large majority of participants in this study. Besides issues of convenience, the appeal of the co-located service centred on the familiarity of existing relationships between clients and staff in the OST setting. While some clients remained distrustful of OST and chose not to take up HCV care in this setting, the co-located treatment model was overwhelmingly successful amongst both client and staff participants. [Copyright &y& Elsevier]

Abstract: Background: Assessment and uptake of treatment for hepatitis C among people who inject drugs (PWID) is low and strategies to enhance hepatitis C care in this group are needed. Knowledge of hepatitis C and its treatment is one precursor to decisions about treatment. Methods: We conducted a cross-section study designed to evaluate treatment considerations in participants with self-reported hepatitis C infection in New South Wales, Australia. Participants were recruited from needle and syringe programs, opiate substitution clinics, pharmacies that dispensed opiate substitution treatment and from the mailing list of a community-based hepatitis C organisation and completed a self-administered survey. Knowledge of hepatitis C was assessed by a 48-item scale addressing the natural history and treatment of hepatitis C. Factors associated with knowledge were assessed by ordinal regression. Results: Among the 997 participants recruited, 407 self-reported acquiring hepatitis C through injecting drug use and had never received hepatitis C treatment. Knowledge about hepatitis C was overall poor and the effects of the long term consequences of hepatitis C were over-estimated. Higher knowledge scores were associated with recruitment site, higher education levels and recent contact with a general practitioner. One-third of participants indicated that they did not intend to have treatment and one-fifth did not answer this question. Conclusion: Knowledge is a precursor to informed decisions about hepatitis C treatment. These results indicate that efforts to support those less engaged with hepatitis C care (and specifically those on opiate substitution treatment) and those with lower literacy are required. [Copyright &y& Elsevier]

Issues. In an effort to increase the number of people undergoing hepatitis C treatment, a range of initiatives are planned or underway to provide treatment in non-specialist services, such as opioid pharmacotherapy treatment (OPT) clinics. Approach. This commentary considers the implications of this new approach to treatment delivery, taking account of individual-level issues generally discussed in the literature, such as knowledge of treatment and concerns about side effects. In addition, because less visible organisational and structural factors would equally influence the successful implementation of hepatitis C treatment in OPT services, these are also explored. Key Findings. Provision of hepatitis C treatment in OPT services raises a broad range of pressing questions, from individual knowledge and concern about treatment, to workforce issues, such as discrimination, and tensions between the need for supportive care during hepatitis C treatment and the surveillant, regulatory nature of OPT clinic operations. Implications. A thorough critical examination of the structure and delivery of all services involved is necessary. Social research can play a unique role in this assessment because of its ability to generate detailed insights into lived experience and make use of social theories that allow previously invisible operations of power to become visible. Conclusion. The success of hepatitis C treatment in new sectors, such as OPT clinics, is not a given. Close attention needs to be paid to the context and culture in which OPT is delivered. In turn, this needs to be considered alongside the context and culture necessary for successful hepatitis C treatment delivery.[Treloar CJ, Fraser SM. Hepatitis C treatment in pharmacotherapy services: Increasing treatment uptake needs a critical view. Drug Alcohol Rev 2009;28:436–440] [ABSTRACT FROM AUTHOR]

Social marginalization is associated with poor health outcomes for affected people. However, in a psychosocial study of treatment for hepatitis C infection conducted in Sydney, Australia, participants living in socially disadvantaged circumstances applied adaptive approaches learned from past experiences of drug dependence, living with symptoms of chronic illness, coping with depression and childhood sexual abuse to enable them to cope with severe treatment-related side-effects. This finding has implications for the clinical management of hepatitis C treatment; the factors and processes that facilitate adaptive coping to adversity associated with social marginalization can be assessed for their clinical contribution to coping with an arduous regimen. [ABSTRACT FROM AUTHOR]

Abstract: Exploration of patients’ illicit drug use during treatment for hepatitis C virus (HCV) infection is largely absent from the clinical literature. This paper explores injecting and other illicit drug use among people receiving interferon-based treatment for HCV infection, from the perspective of one group of health professionals. Data are presented from a qualitative study of six health professionals responsible for managing HCV treatment regimens at three major metropolitan hospitals across Sydney, Australia. During semi-structured in-depth interviews, participants discussed patients’ use of injected and non-injected illicit drugs while coping with a demanding therapeutic regimen. Health professionals highlighted the socially conservative environment of healthcare and its negative perceptions of illicit drug users. Also discussed are the management of people who inject during treatment and the efficacy of cannabis to reduce side effects. The findings of this study indicate that while the health professionals adopted a harm reduction approach to patients’ illicit drug use during HCV treatment, information regarding the risks and benefits of illicit drug use is silenced in this context. While ever prohibition remains Australia''s illicit drug policy this situation appears unlikely to change. Research which investigates the extent of illicit drug use during HCV treatment, the risks and benefits associated with their use in this context, and the harms of perpetuating a duplicitous healthcare system is required. [Copyright &y& Elsevier]

Clinical trials of interferon-based treatments for hepatitis C infection show decrements in patients' health-related quality of life due to side effects of therapy. The impact of side effects on patients' overall quality of life still remains unclear. To explore this issue, the authors interviewed people living in New South Wales, Australia, who had undergone treatment for hepatitis C. Their aim in this article is to report participants' experiences of treatment side effects. In Australia, this information is important, because a new interferon-based regimen has been adopted as the mainstay of hepatitis C treatment, and it is predicted that many more people will seek treatment. The authors argue for further qualitative research to enhance knowledge of the impact of this therapy. [ABSTRACT FROM AUTHOR]

Background and aims: Mathematical modelling has demonstrated the theoretical feasibility of HCV treatment‐as‐prevention strategies in custodial settings, yet limited empirical data exists. The Australian 'Surveillance and Treatment of Prisoners with Hepatitis C' study is the world's first trial of hepatitis C virus (HCV) treatment‐as‐prevention in prison. This study aimed to analyse how expert stakeholders involved in the Australian HCV response assessed the acceptability of HCV treatment‐as‐prevention in prison using interview data from the SToP‐C qualitative substudy. Design and setting: Qualitative analysis using semi‐structured interviews in Australia. Participants: Nineteen key HCV experts. Measurements Drawing upon Sekhon's theoretical framework of acceptability, data were organized thematically under four component constructs of acceptability: affective attitude; ethicality; opportunity costs; and perceived effectiveness. Findings Most differences in participant assessments of acceptability were a matter of relative emphasis and prioritization rather than absolute polarity. Nonetheless, a small minority of participants was overtly critical of the approach. Arguing against the focus on treatment, they instead advocated for prevention‐as‐prevention, including the improvement and expansion of existing harm reduction measures. Conclusions: Qualitative analysis of expert stakeholder assessments of the acceptability of hepatitis C virus treatment‐as‐prevention in Australian prisons found no opposition to the universal rollout of direct‐acting anti‐virals, but most voiced concern regarding the lack of effective primary prevention in Australian prisons. [ABSTRACT FROM AUTHOR]

The recent advent of new, highly effective, direct-acting antivirals (DAAs) is dramatically reshaping the hepatitis C virus (HCV) treatment landscape and prisons are set to play an important role. While there is a substantial literature addressing the centrality of stigma to experiences of living with HCV in the community, including as a barrier to treatment, scant attention has been paid to documenting how HCV-stigma figures within the distinct sociality of prison life. This article focuses on initial, pretreatment interviews with prisoner participants (n = 32) from the first, real-world trial of HCV 'treatment-as-prevention' in prison: Australia's Surveillance and Treatment of Prisoners with Hepatitis C (SToP-C) study. Drawing on recent developments in stigma theory alongside Goffman's original insights, we posit HCV-stigma as a relational, contingent and political process, materialised across the network of power relations in prison. Participant accounts describe a complex picture, with reports ranging from those suggesting the 'normalisation' of HCV to those detailing the potential effects of HCV-stigma, including additional disciplinary attention from officers and/or the rejection from peer networks by fellow prisoners. While acknowledging the limiting effects HCV-stigma may yet have on treatment-as-prevention efforts, we speculate that with committed political leadership, operational investment, sufficient prisoner engagement, interventions such as SToP-C may also afford opportunities for such effects to be challenged, disrupted, and even left behind. [ABSTRACT FROM AUTHOR]

Background and Aims: Hepatitis C virus (HCV) is highly prevalent within the prison setting. Although HCV testing and treatment are available within prisons, system barriers can impede progress along the HCV care cascade for those who are incarcerated. The PIVOT intervention used a 'one‐stop‐shop' model (i.e. point‐of‐care HCV RNA testing, Fibroscan‐based liver disease assessment and treatment) at a reception prison in New South Wales, Australia. This analysis sought to understand the role of point‐of‐care HCV RNA testing at intake in reducing barriers to the HCV care cascade within the male prison setting. Design and Setting: Qualitative analysis using semi‐structured interviews in a reception prison in Australia. Participants: Twenty‐four men enrolled in the PIVOT study; all participants had undergone HCV point‐of‐care testing in the intervention arm. Measurements: Høj's Integrated Framework informed this analysis. Findings: Participants widely expressed the view that point‐of‐care HCV RNA testing on entry was beneficial for care engagement. Point‐of‐care testing was perceived as timely (compared with standard pathology) and reduced opportunities for adjudication by correctional officers due to fewer clinic visits for testing and results. Adoption of routine opt‐out testing at prison intake was regarded as an important strategy for normalising HCV testing (and likely to increase pathways to treatment uptake) and fostered patient candidacy (i.e. self‐perceived eligibility to access care). Conclusion: Twenty‐four men in prison in New South Wales, Australia, who underwent opt‐out point‐of‐care HCV RNA testing on entry into prison, widely supported the programme as a means of overcoming barriers to HCV testing and treatment in the prison setting, as well as providing public health benefits through early detection of HCV infection among people entering into custody. [ABSTRACT FROM AUTHOR]

Reducing barriers to hepatitis C-related care requires us to strategically target opportunities at each health level in order to facilitate engagement among people who inject drugs (PWID). To this end, it is also critical that we understand more clearly what is meant and expected by health-care engagement among PWID.

Until the recent introduction of direct-acting antiviral (DAA) medications, the only available hepatitis C treatments were lengthy and onerous interferon-based therapies, with relatively weak success rates. While experiences of interferon-based treatment have been well documented, there is a need to better understand how the experiences of the 'old' treatments shape contemporary treatment experiences. This article uses the concept of 'post-crisis' developed in critical scholarship on HIV/AIDS, and recent theorisations of 'curative time', to explore the relationship between contemporary treatment experiences and the legacies of interferon-based therapies. In mobilising these concepts, we trouble linear temporal logics that take for granted distinctions between the past and present, old and new, and cure and post-cure, and draw attention to the fluidity of time and the overlapping co-constitutive terrains of meaning that shape treatment experiences. Drawing on 50 interviews with people affected by hepatitis C, we argue that the curative imaginary of DAA treatments – that is, the temporal framing applied to hepatitis C in which cure is expected and assumed – is shaped by the logic of crisis. Here, knowledge of and the possibilities for the new treatments and living with hepatitis C remain tethered to crisis accounts of interferon. Unlike HIV/AIDS, in which the disease itself was figured as crisis, many participants described interferon-based treatments as the crisis: as worse than living with hepatitis C. While the new treatments were widely described as simple and easy, we argue that treatment is not so straightforward and that the crisis/post-crisis relation is central to this complexity. We conclude by considering the significance of these post-crisis enactments for understanding the recent plateauing of DAA treatment uptake, and reflect on how post-crisis futures of hepatitis C 'cure' need to address the ongoing constitutive effects of interferon-based treatments. [ABSTRACT FROM AUTHOR]

This study explores the perception of and readiness for hepatitis C treatment within a sample of 77 clients already participating in drug treatment, with a view to identifying likely barriers and incentives to hepatitis C treatment within a drug treatment population. Participants with hepatitis C did not demonstrate a consistent, in-depth knowledge of the infection, lacked confidence in symptom recognition, and had little awareness of treatment options. Those without obvious symptoms or liver deterioration did not have a pressing interest in treatment, and many had heard concerning stories about the side effects of hepatitis C treatment. For those coping with anxiety or depression, the increased risk of a depressive episode under interferon treatment was a major barrier to treatment. [ABSTRACT FROM AUTHOR]

• Women who inject drugs face gendered barriers to care that impact on engagement with HCV services. • Compared to men, women who inject drugs had similar HCV testing, but lower treatment uptake. • Among women, those aged <45 had lower HCV testing and treatment, and higher HCV prevalence. • Women aged <45 need enhanced, gender-informed support to increase HCV testing and treatment. Evaluating gender-specific trends in hepatitis C virus (HCV) treatment uptake among men and women who inject drugs is crucial for ensuring equitable progress towards HCV elimination. This study aimed to quantify differences in testing, treatment, and current HCV infection between men and women who inject drugs. ETHOS Engage is an observational cohort study of people who inject drugs attending drug treatment clinics and needle and syringe programs in Australia recruited from May 2018-September 2019 (wave 1) and November 2019-April 2021 (wave 2). Participants completed a questionnaire including self-reported HCV testing and treatment history and underwent point-of-care HCV RNA testing (Xpert® HCV Viral Load Fingerstick). Logistic regression was used to compare the factors associated with self-reported HCV testing and treatment and current HCV infection for men and women who inject drugs. Among 2,395 participants enrolled in ETHOS Engage, 66% (n = 1,591) were men, 33% (n = 786) women, and <1% (n = 18) did not identify as a man or woman. HCV testing history and current infection were similar among men and women. Among men or women ever eligible for HCV treatment (ever chronic HCV) (n = 1,242), women were less likely to report a history of HCV treatment compared to men (227/352, 64% vs. 631/890, 71%; p = 0.03). Among women, those aged <45 were less likely to report HCV testing (aOR: 0.57, 95%CI: 0.36, 0.90), treatment (aOR: 0.47, 95%CI: 0.29, 0.77), and more likely to have HCV infection (aOR: 1.48, 95%CI: 1.00, 2.20) Among women, those of childbearing age (<45) were less likely to report testing and treatment and were more likely to have current HCV infection. Women <45 years old should be a priority population for HCV care. Services that interface with these women should be optimised to enhance HCV testing and treatment. [ABSTRACT FROM AUTHOR]

Since the advent of direct‐acting antiviral hepatitis C treatments, widespread enthusiasm about disease elimination has emerged. This article examines experiences of hepatitis C treatment and cure in this period. Mobilising Fraser and Seear's (Making disease, making citizens: The politics of hepatitis C, Ashgate, 2011) approach to hepatitis C as a 'gathering', we analyse cure not as a biomedical phenomenon but as a social and material event. To do so, we take a Science and Technology Studies‐inspired approach to analyse three complementary cases drawn from an Australian project on experiences of hepatitis C, treatment and cure. First, we analyse the ways a friendship between two women combines with adjustments to treatment access to produce a gathering that makes cure possible. Second, we analyse the forces that gather and distribute responsibility when a cure does not occur in a context shaped by oversimplified treatment logics. Third, we analyse a gathering of relations in which hepatitis C lingers, thereby limiting the cure's possible transformative effects. We argue that, even in an era defined by highly effective medicines, the hepatitis C cure is not necessarily straightforward, but an unpredictable gathering constituted by a fragile coalescing of social and material forces. [ABSTRACT FROM AUTHOR]

Background and Aims: Hepatitis C (HCV) is a global public health concern, particularly in the prison setting where prevalence is substantially higher than in the general population. Direct‐acting antivirals have changed the treatment landscape, allowing for treatment scale‐up efforts potentially sufficient to achieve prevention of onward transmission (treatment‐as‐prevention). The Surveillance and Treatment of Prisoners with hepatitis C (SToP‐C) study was the first trial to examine the efficacy of HCV treatment‐as‐prevention in the prison setting. Social capital is a social resource which has been found to influence health outcomes. This qualitative study sought to understand the role of social capital within an HCV treatment‐as‐prevention trial in the prison setting. Design Semi‐structured in‐depth interviews were undertaken with participants recruited from the SToP‐C study following HCV treatment completion (with cure). Setting: Three male correctional centres in New South Wales, Australia (including two maximum‐security and one minimum‐security). Participants: Twenty‐three men in prison participated in semi‐structured interviews. Measurements Thematic analysis of transcripts was completed using a social capital framework, which enabled exploration of the ways in which bonding, bridging and linking social capital promoted or inhibited HCV treatment uptake within a treatment‐as‐prevention trial. Findings Social capital fostered HCV treatment uptake within an HCV treatment‐as‐prevention trial in the prison setting. Bonding social capital encouraged treatment uptake and alleviated concerns of side effects, bridging social capital supported prison‐wide treatment uptake, and linking social capital fostered trust in study personnel (including nurses and correctional officers), thereby enhancing treatment engagement. Conclusions: Social capital, including bonding, bridging and linking, can play an important role in hepatitis C treatment‐as‐prevention efforts within the male prison setting. [ABSTRACT FROM AUTHOR]

There have been major strides towards the World Health Organization goal to eliminate hepatitis C virus (HCV) infection as a global public health threat. The availability of simple, well-tolerated direct-acting antiviral therapies for HCV infection that can achieve a cure in >95% of people has provided an important tool to help achieve the global elimination targets. Encouragingly, therapy is highly effective among people receiving opioid agonist therapy and people who have recently injected drugs. Moving forward, major challenges include ensuring that new infections are prevented from occurring and that people who are living with HCV are tested, linked to care, treated, receive appropriate follow-up, and have equitable access to care. This editorial highlights key themes and articles in a special issue focusing on the elimination of HCV among people who inject drugs. An overarching consideration flowing from this work is how to ensure equitable access to HCV treatment and care for all. This special issue maps the field in relation to: HCV prevention; the cascade of HCV care; strategies to enhance testing, linkage to care, and treatment uptake; and HCV treatment and reinfection. In addition, papers draw attention to the 'risk environments' and socio-ecological determinants of HCV acquisition, barriers to HCV care, the importance of messaging around the side-effects of new direct-acting antiviral therapies, the positive transformative potential of treatment and cure, and the key role of community-based drug user organizations in the HCV response. While this special issue highlights some successful efforts towards HCV elimination among people who inject drugs, it also highlights the relative lack of attention to settings in which resources enabling elimination are scarce, and where elimination hopes and potentials are less clear, such as in many low and middle income countries. Strengthening capacity in areas of the world where resources are more limited will be a critical step towards ensuring equity for all so that global HCV elimination among PWID can be achieved. [ABSTRACT FROM AUTHOR]

Direct-Acting Antiviral (DAA) treatments for hepatitis C have been widely promoted by health promotion professionals and medical clinicians as being 'side-effect free'. In this paper, we draw on data that troubles this approach. We used a mixed method design to collect data from people who inject drugs, and who were DAA treatment naïve, in New South Wales, Australia. We describe knowledge about and perceptions of DAA treatment. We found that concerns about side effects were commonplace - for example, one-third (37%) of participants who had not taken up treatment worried "a lot" about 'side effects' - and that these concerns were underpinned by a general distrust and suspicion of medical institutions and their technologies, including widespread negative associations linked to interferon treatment. In trying to make sense of this, we draw on the concept of counterpublic health and its recognition that the everyday health needs, knowledges and aspirations of subordinated citizens frequently contradict the normative frameworks governing public health interventions. We suggest that failing to engage with concerns about 'side effects' could hinder elimination efforts. Our analysis suggests that addressing the issue of 'side effects' within the 'public' discourse of DAAs will not dampen or damage elimination efforts, as some might fear, but rather it will legitimate the concerns of people who inject, decrease their suspicion of medical interventions, and better support the uptake of DAA treatments. [ABSTRACT FROM AUTHOR]

Summary: Hepatitis C virus (HCV) infection is a major public health concern. Globally, 15% of those incarcerated are HCV‐antibody positive (anti‐HCV). Even where HCV treatment is available within prisons, treatment uptake has remained low. This qualitative study was conducted to understand the barriers and facilitators for the delivery of HCV treatment in prisons from the perspectives of prisoners. This is important to inform health messaging for HCV treatment within correctional institutions. Thirty‐two prisoners (including eight women) with a history of injecting drug use participated in this qualitative study. Participants were equally recruited across four correctional centres (n = 8 per site). Overall, 16 participants (50%) had chronic HCV at their most recent test, and two participants were awaiting test results at time of interview. Structural (eg proximity of health clinic) and patient‐level (routine and motivation) factors were viewed as facilitators of HCV treatment within the prison setting. Structural (eg risk of reinfection) and social (eg lack of confidentiality and lack of social support) factors were perceived as barriers to prison‐based HCV care and treatment. In conclusion, to increase HCV treatment uptake, prison‐based programmes should implement (or advocate for) patient‐centred treatment approaches that protect privacy, provide social support, and promote access to clean needles and substitution therapy to protect prisoners from reinfection. [ABSTRACT FROM AUTHOR]

Recent advances in the efficacy and tolerability of hepatitis C treatments and the introduction of a universal access scheme for the new Direct Acting Antiviral (DAA) therapies in March 2016, has resulted in a rapid increase in the uptake of hepatitis C treatment in Australia. Despite these positive developments, recent data suggest a plateauing of treatment numbers, indicating that more work may need to be done to identify and address ongoing barriers to hepatitis C treatment access and uptake. This paper aims to contribute to our understanding of the ongoing barriers to DAA therapies, with a focus on people who inject drugs. The paper draws on participant interview data from a qualitative research study based on a participatory research design that included a peer researcher with direct experience of both hepatitis C DAA treatment and injecting drug use at all stages of the research process. The study’s findings show that residual barriers to DAA treatment exist at personal, provider and system levels and include poor venous access, DAA treatments not considered ‘core-business’ by opioid substitution treatment (OST) providers, and patients having to manage multiple health and social priorities that interfere with keeping medical appointments such as childcare and poor access to transport services. Further, efforts to increase access to and uptake of DAA hepatitis C treatment over time will require a focus on reducing stigma and discrimination towards people who inject drugs as this remains as a major barrier to care for many people. [ABSTRACT FROM AUTHOR]

Historic models of hepatitis C treatment have not been suitably adapted for people who inject drugs (PWIDs). With the availability of highly effective direct acting antivirals (DAAs) and the possibility to eliminate hepatitis C as a public health threat, there is an urgency to improve treatment provision and uptake among PWID. This commentary explores the role of needle and syringe programs (NSPs) in providing hepatitis C treatment to PWID through an exploration of Positively Hep, a peer-referral, incentive-based project in Sydney, Australia. Positively Hep uses peer-networks to engage clients and introduce them to hepatitis C education, screening, and treatment. Within the first 26 months of operation, Positively Hep has provided education about hepatitis C and DAA treatments to 326 individuals, and has tested 145 people, 44% (n = 64) of whom have tested positive. Of these individuals, 21 (33%) have begun treatment, and 18 (28%) have successfully completed treatment. Positively Hep highlights the benefits of having trustworthy, timely, convenient, and client-friendly services to engage PWID and support them throughout hepatitis C treatment. This commentary is intended to prompt discussion about incorporating hepatitis C treatment into NSP service delivery, which could increase treatment uptake among PWID and support progress toward elimination targets. [ABSTRACT FROM AUTHOR]

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection. [ABSTRACT FROM AUTHOR]

Background: In Canada, interferon-free, direct-acting antiviral hepatitis C virus (HCV) regimens are costly. This presents challenges for universal drug coverage of the estimated 220 000 people with chronic HCV infection nationwide. The study objective was to appraise criteria for reimbursement of 4 HCV direct-acting antivirals in Canada. Methods: We reviewed the reimbursement criteria for simeprevir, sofosbuvir, ledipasvir--sofosbuvir and paritaprevir--ritonavir--ombitasvir plus dasabuvir in the 10 provinces and 3 territories. Data were extracted from April 2015 to June 2016. The primary outcomes extracted from health ministerial websites were: 1) minimum fibrosis stage required, 2) drug and alcohol use restrictions, 3) HIV coinfection restrictions and 4) prescriber type restrictions. Results: Overall, 85%-92% of provinces/territories limited access to patients with moderate fibrosis (Meta-Analysis of Histologic Data in Viral Hepatitis stage F2 or greater, or equivalent). There were no drug and alcohol use restrictions; however, several criteria (e.g., active injection drug use) were left to the discretion of the physician. Quebec did not reimburse simeprevir and sofosbuvir for people coinfected with HIV; no restrictions were found in the remaining jurisdictions. Prescriber type was restricted to specialists in up to 42% of provinces/territories. Interpretation: This review of criteria of reimbursement of HCV direct-acting antivirals in Canada showed substantial interjurisdictional heterogeneity. The findings could inform health policy and support the development and adoption of a national HCV strategy. [ABSTRACT FROM AUTHOR]

With the advent of highly effective antiviral treatment for hepatitis C, many people have undergone treatment and been cured. Others, however, have not undergone treatment, even where it is free and readily available. Australia's aim of eliminating the disease by 2030 means this group is of concern to researchers, health professionals and policymakers. This article draws on 50 interviews conducted for a research project on treatment experiences to examine treatment non-uptake in Australia. Informed by Berlant's (2007) work on 'slow death', it analyses experiences of non-uptake to explain the dynamics at work in such outcomes. The analysis is divided into three parts. First, participant Cal describes a lifetime in which hepatitis C, homelessness and prison have shaped his outlook and opportunities. Second, Evan describes intergenerational drug consumption, family contact with the prison system and an equally long history with hepatitis C. Finally, Rose also describes a long history of hepatitis C, complex struggles to improve life and contact with the prison system. All three accounts illuminate the dynamics shaping treatment decisions, calling to mind Berlant's slow death as a process of being 'worn out by the activity of reproducing life' under conditions that both demand self-management, and work against it. In concluding, the article points to Berlant's distinction between 'epidemics' and 'endemics', arguing that its politics apply directly to hepatitis C. In doing so, it highlights the need to address the criminalising, pathologising, capitalist context of 'attrition' (Berlant) that wears out lives even as it fetishises autonomy, responsibility and choice. [ABSTRACT FROM AUTHOR]

Injecting drug use remains the major risk factor for hepatitis C ( HCV) transmission. A minority of long-term injecting drug users remain seronegative and aviraemic, despite prolonged exposure to HCV - termed highly exposed seronegative subjects. Natural killer (NK) cells have been implicated in this apparent protection. A longitudinal nested, three group case-control series of subjects was selected from a prospective cohort of seronegative injecting drug users who became incident cases ( n = 11), remained seronegative ( n = 11) or reported transient high-risk behaviour and remained uninfected ( n = 11). The groups were matched by age, sex and initial risk behaviour characteristics. Stored peripheral blood mononuclear cells were assayed in multicolour flow cytometry to enumerate natural killer cell subpopulations and to assess functional activity using Toll-like receptor ligands before measurement of activation, cytokine production and natural cytotoxicity receptor expression. Principal components were derived to describe the detailed phenotypic characteristics of the major NK subpopulations (based on CD56 and CD16 co-expression), before logistic regression analysis to identify associations with exposed, seronegative individuals. The CD56dim CD16+ ( P = 0.05, OR 6.92) and CD56dim CD16− ( P = 0.05, OR 6.07) principal components differed between exposed, seronegative individuals and pre-infection samples of the other two groups. These included CD56dim CD16+ and CD56dim CD16− subsets with CD56dim CD16+ IFN- γ and TNF- α on unstimulated cells, and CD56dim CD16− CD69+, CD107a+, IFN- γ and TNF- α following TLR stimulation. The cytotoxic CD56dim NK subset thus distinguished highly exposed, seronegative subjects, suggesting NK cytotoxicity may contribute to protection from HCV acquisition. Further investigation of the determinants of this association and prospective assessment of protection against HCV infection are warranted. [ABSTRACT FROM AUTHOR]

Aims To estimate adherence and response to therapy for chronic hepatitis C virus (HCV) infection among people with a history of injecting drug use. A secondary aim was to identify predictors of HCV treatment response. Design Prospective cohort recruited between 2009 and 2012. Participants were treated with peg-interferon alfa-2a/ribavirin for 24 (genotypes 2/3, G2/3) or 48 weeks (genotype 1, G1). Setting Six opioid substitution treatment (OST) clinics, two community health centres and one Aboriginal community-controlled health organization providing drug treatment services in New South Wales, Australia. Participants Among 415 people with a history of injecting drug use and chronic HCV assessed by a nurse, 101 were assessed for treatment outcomes (21% female). Measurements Study outcomes were treatment adherence and sustained virological response (SVR, undetectable HCV RNA >24 weeks post-treatment). Findings Among 101 treated, 37% ( n = 37) had recently injected drugs (past 6 months) and 62% ( n = 63) were receiving OST. Adherence ≥ 80% was 86% ( n = 87). SVR was 74% (75 of 101), with no difference observed by sex (males: 76%, females: 67%, P = 0.662). In adjusted analysis, age < 35 (versus ≥ 45 years) [adjusted odds ratio (aOR) = 5.06, 95% confidence interval (CI) = 1.47, 17.40] and on-treatment adherence ≥ 80% independently predicted SVR (aOR = 19.41, 95% CI = 3.61, 104.26]. Recent injecting drug use at baseline was not associated with SVR. Conclusions People with a history of injecting drug use and chronic hepatitis C virus attending opioid substitution treatment and community health clinics can achieve adherence and responses to interferon-based therapy similar to other populations, despite injecting drugs at baseline. Younger age and adherence are predictive of improved response to hepatitis C virus therapy. [ABSTRACT FROM AUTHOR]

Introduction: Current diagnostic pathways require multiple healthcare provider visits and lead to a drop-off in the hepatitis C virus (HCV) testing and treatment care cascade. In prison settings, frequent transitioning between prisons and the community further reduces uptake of testing and treatment. The PIVOT study evaluated a 'one-stop-shop' intervention integrating point-of-care HCV RNA testing, Fibroscan®-based liver disease assessment, and treatment prescription at a reception prison in Australia. This qualitative sub-study was undertaken to assess patient acceptability of point-of-care HCV RNA testing in the reception prison setting.Methods: Twenty-four men in prison enrolled in the PIVOT study participated in semi-structured interviews; all of whom had undergone point-of-care HCV RNA testing in the PIVOT study. Patients were purposefully selected to ensure comparable representation of people with and without a history of injecting drug use and people with and without prior HCV testing experience (standard venepuncture). Sekhon's Theoretical Framework of Acceptability, consisting of seven components (affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness, and self-efficacy), informed this qualitative analysis.Results: Acceptability of fingerstick point-of-care HCV RNA testing was evident across four components: affective attitude, burden, self-efficacy, and perceived effectiveness. Patients described point-of-care testing as "quick and easy" (affective attitude), while swift results were viewed as alleviating anxiety associated with long wait times for standard pathology (burden). Patients averse to venepuncture (e.g., fear of needles or poor vein health) found the fingerstick method accessible, thereby enabling participation in HCV screening (self-efficacy). Participants attributed confidence in test results predominantly due to trust in the healthcare system or trust in the personnel administering the test (perceived effectiveness).Conclusion: People entering custody perceive fingerstick HCV RNA point-of-care testing to be an acceptable method and preferred this method to standard HCV testing via venepuncture. In light of these findings, prison health authorities should consider the role of opt-out point-of-care HCV RNA testing upon prison entry. [ABSTRACT FROM AUTHOR]

Abstract: The hepatitis C virus (HCV) epidemic is a significant public health challenge in Australia. Current initiatives to expand access to HCV treatment focus on opiate substitution therapy (OST) settings where the prevalence of hepatitis C among clients is high. In Australia, the provision of OST for many clients is via large clinics, with an estimated median of 150 clients per service. Conceptually informed by the work of Michel Foucault, our analysis of the proposed integrated treatment model focuses on the critical but overlooked question of organisational culture and power operating within OST. We argue that the specific context of OST not merely reflects but actively participates in the political economy of social exclusion via which the socio-spatial segregation and stigmatisation of the service user as ‘drug user’ is enacted. This paper analyses data collected from two samples during 2008/9: OST clients living in New South Wales, Australia and a range of OST health professionals working in Australian settings. In total, 27 interviews were conducted with current OST clients; 19 by phone and 8 face-to-face. One focus group and 16 telephone interviews were conducted with OST health professionals. Our analysis of key themes emerging from the interview data suggests that the successful introduction of HCV treatment within the OST clinic is not a given. We are concerned that particular areas of tension, if not explicit contradiction, have been overlooked in current research and debates informing the proposed combination treatment model. We question the appropriateness of co-locating a notoriously arduous, exacting treatment (HCV) within the highly surveillant and regulatory environment of OST. While applauding the intention to improve access to HCV care and treatment for people who inject drugs we caution against a treatment model that risks further entrenching (socio-spatial) stigmatisation amongst those already experiencing significant marginalisation. [Copyright &y& Elsevier]

Background: Hepatitis C (HCV) infection is highly prevalent within the prison setting. Direct-acting antiviral (DAA) therapies have changed the HCV treatment landscape, offering simple treatment (with minimal side-effects) and high efficacy. These advances have enabled the first real-world study of HCV treatment as prevention (TasP), the Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study. This paper draws on data from qualitative interviews completed with SToP-C participants following prison-wide DAA treatment scale-up.Methods: Semi-structured interviews were undertaken with 23 men in prison following HCV treatment completion to identify ongoing risk practices, perceptions of strategies for HCV prevention within the prison setting, experiences of HCV treatment (as prevention), and perceptions of reinfection following cure. Analysis was undertaken using a counterpublic health lens to identify risks and perceptions of reinfection among people treated for HCV within the prison setting.Results: Participants identified a number of challenges of meaningful HCV 'cure' in the absence of increased access to prevention strategies (e.g., opioid agonist therapy and prison needle syringe programs) along with concerns that 'cure' was only temporary whilst incarcerated. 'Cure' status included self-perceptions of being "clean", while also imposing responsibility on the individual to maintain their 'cure' status.Conclusion: HCV DAA treatment is provided somewhat under the guise of 'cure is easy', but fails to address the ongoing risk factors experienced by people who inject drugs in prisons, as well as other people in prison who may be at risk of blood-to-blood exposure. Health messaging regarding HCV treatment and treatment for reinfection should be tailored to ensure patient-centred care. Health interventions in prison must address the whole person and the circumstances in which they live, not just the illness. [ABSTRACT FROM AUTHOR]

Background: Recent advances in the treatment of hepatitis C virus (HCV) infection provide the possibility of eliminating HCV as a public health threat. This focus on HCV elimination through treatment, however, is also driving a concomitant focus on ‘achieving cure’ as the primary outcome of treatment. The aim of this paper is to explore what people who inject drugs consider to be important in relation to outcomes of HCV treatment, and whether there are outcomes ‘beyond cure’ that might be important to understand as part of improving engagement in treatment. Methods: A peer researcher with experience of both HCV treatment and injecting drug use conducted interviews with 24 people in the following groups in Melbourne, Australia: (1) people who had refused or deferred HCV treatment; (2) people who were actively thinking about, planning and/or about to commence HCV treatment; (3) people currently undertaking HCV treatment and (4) people who had recently completed HCV treatment. Results: The findings show that people who inject drugs are seeking outcomes ‘beyond cure’ including improved physical and mental health, positive changes in identity and social relationships and managing future health and risk. Participants indicated that these other outcomes had not been addressed within their experience of HCV treatment. Conclusion: While cure is an obvious outcome of HCV treatment, patients are seeking change in other areas of their lives. This study also provides valuable insights for the development of patient-reported measures in this context, which would be an important step towards more patient-centred approaches to HCV treatment. [ABSTRACT FROM AUTHOR]

Background: Hepatitis C (HCV) is a global public health concern. There is a global prevalence of 15% among the world's prisoner population, suggesting the need for priority HCV treatment among this population group. New highly efficacious therapies with low side effects, known as directing-acting antivirals, became available under Australia's universal healthcare scheme on 1 March 2016. This creates an opportune time to trial treatment as prevention as an elimination strategy for HCV in prison settings. This paper examines whether policies in Australian jurisdictions support treatment scale-up to achieve elimination among this priority population. Methods: A comprehensive search was conducted using Google and other web-based search functions to locate all publicly available policies in each Australian state and territory related to HCV health and HCV-related prison health. Ministers (corrections and health) were contacted from each jurisdiction to identify any additional policies. Inductive and deductive analyses were conducted for each jurisdiction, with documents being assessed against a set of four a priori criteria. Documents included in the analysis were current at 1 September 2017, or 18 months following treatment availability. Results: A total of 18 documents were located, including both health ( n = 12) and corrections/prison health ( n = 6) documents relevant to HCV. Jurisdictions ranged in their commitments for delivering HCV harm reduction strategies and treatment availability within the prison setting. Conclusion: Few jurisdictions have updated or published HCV-related health or prisoner health policies following availability of directing-acting antivirals. Current policies do not provide effective support for implementing treatment scale-up that could be possible under universal access to HCV treatment among this priority population. [ABSTRACT FROM AUTHOR]