| |
The effect of social functioning and living arrangement on treatment intent, specialist assessment and treatment uptake for hepatitis C virus infection among people with a history of injecting drug use: The ETHOS study
|
| |
| |
Download the PDF here
from Jules: In the US I think many underestimate how many drug users are very much marginalized from being engaged in the healthcare system. This is not a boac & white issue, in the sense that drug users are either engaged in healthcare or they are not. There is a full spectrum, where a significant percent of those with a history of substance abuse/IDU are engaged in healthcare but there is a significant percent of HCV+ drug users who are not engaged in healthcare, and for this group it is difficult to engage in HCV care & treatment & to retain them through the entire process of screening, care, doing the series of labs and through the full treatment course. Many of the issues discussed in this article are relevant for the USA & inner city communities here. The point of this article is that social functioning as defined in this article is relevant to successful HCV care & treatment, to engaging patients into a successful care & treatment clinical situation.
International Journal of Drug Policy 26 (Nov 2015)
Emmanuel Fortier a,b,c, Maryam Alavi c, Michelle Micallef c, Adrian J. Dunlop d,e, Annie C. Balcomb f, Carolyn A. Day g,h, Carla Treloar i, Nicky Bath j, Paul S. Haber g,k, Gregory J. Dore c, Julie Bruneau a,b, Jason Grebely c,* on behalf of the ETHOS Study Group a Departement de medecine familiale et de medecine d'urgence, Universite de Montreal, Montreal, QC, Canada b Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada c The Kirby Institute, UNSW Australia, Sydney, NSW, Australia d University of Newcastle, Newcastle, NSW, Australia e Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia f Clinic 96, Kite St Community Health Centre, Orange, NSW, Australia g Drug Health Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia h Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia i Centre for Social Research in Health, UNSW Australia, Sydney, NSW, Australia jNSW Users & AIDS Association, Inc., Sydney, NSW, Australia k Sydney Medical School, University of Sydney, Sydney, NSW, Australia
Highlights
· Social functioning was assessed among people with a history of injecting and HCV.
· Social functioning was associated with employment, housing, injecting and stress.
· Low social functioning reduced early HCV treatment intent and specialist assessment.
· Living with someone was associated with increased HCV treatment uptake.
· Need for enhanced social functioning and social support to enhance treatment uptake.
Abstract
Background
The objective was to assess social functioning and its association with treatment intent, specialist assessment and treatment uptake for hepatitis C virus (HCV) infection among people with a history of injecting drug use.
Methods
ETHOS is a prospective observational cohort evaluating the provision of HCV assessment and treatment among people with chronic HCV and a history of injecting drug use, recruited from nine community health centres and opioid substitution treatment clinics (NSW, Australia). Social functioning was assessed using a short form of the Opioid Treatment Index social functioning scale. Those classified in the highest quartile (score >6) were considered having lower social functioning. Analyses were performed using logistic regression.
Results
Among 415 participants (mean age 41 years, 71% male), 24% were considered having lower social functioning, 70% had early HCV treatment intent (intention to be treated in the next 12 months), 53% were assessed by a specialist and 27% initiated treatment.
Lower social functioning was independently associated with unemployment, unstable housing, recent injecting drug use and moderate to extremely severe symptoms of depression, anxiety and stress.
Lower social functioning was independently associated with reduced early HCV treatment intent (aOR 0.51, 95% CI 0.30-0.84) and lower specialist assessment (aOR 0.48, 95% CI 0.29-0.79), but not HCV treatment uptake (aOR 0.76, 95% CI 0.40-1.43).
Living with someone was independently associated with HCV treatment uptake (with someone and children: aOR 2.28, 95% CI 1.01-5.14; with someone and no children: aOR 2.36, 95% CI 1.30-4.31), but not early HCV treatment intent or specialist assessment.
Conclusions
This study highlights the need for the development and implementation of strategies targeting people who inject drugs with lower social functioning to enhance HCV treatment intent and specialist assessment. Further, strategies to enhance social support may play a role in increasing HCV treatment uptake.
Introduction
The majority of new and existing cases of hepatitis C virus (HCV) infection in many high-and middle-income countries occur among people who inject drugs (PWID) (Hajarizadeh et al., 2013, Nelson et al., 2011). Although HCV treatment is safe and effective among PWID (Aspinall et al., 2013, Dimova et al., 2013), antiviral therapy uptake remains suboptimal in this population (Alavi et al., 2014, Grebely and Dore, 2014, Grebely et al., 2009, Iversen et al., 2014, Mehta et al., 2008). Strategies to enhance HCV care requires addressing several elements, including increased HCV testing, linkage to HCV care, improved liver fibrosis assessment, enhanced HCV treatment uptake, improved adherence and cure of HCV, collectively termed the "HCV cascade of care" (Yehia, Schranz, Umscheid, & Lo Re, 2014). Barriers to HCV care include those at the levels of the system, provider, and patient (Grebely et al., 2013, Morrill et al., 2005). Multiple patient-level barriers have been identified (Fraenkel et al., 2005, Grebely et al., 2008, Grebely et al., 2013, Grebely and Tyndall, 2011, Morrill et al., 2005, Osilla et al., 2009, Swan et al., 2010, Treloar et al., 2010), including many factors related to social functioning. Social functioning encompasses employment, income, housing, interpersonal relationship and conflicts, and living arrangements issues (Darke et al., 1991, Richardson et al., 2010). Understanding social functioning and its role in various steps of the HCV care cascade has important implications for the design and implementation of programs to enhance access to HCV care and treatment.
HCV treatment intent, specialist assessment and treatment uptake have been shown to be associated with one or several components related to social functioning (Darke et al., 1991, Richardson et al., 2010), including housing (Charlebois et al., 2012, Harris and Rhodes, 2013, Strathdee et al., 2005), living arrangement, employment and income (Kanwal et al., 2007, Moirand et al., 2007), social support (Gidding et al., 2011, Grebely et al., 2010, Moirand et al., 2007) and interpersonal conflicts (Harris & Rhodes, 2013). When scales specifically designed to measure social functioning have been used, higher social functioning has been associated with improved response to HCV therapy (Dore et al., 2010). However, the majority of studies are retrospective or cross-sectional, have limited sample sizes and have not considered the association between social functioning across multiple components of the HCV care cascade.
The specific aims of this study were: (1) to assess factors associated with lower social functioning; and (2) to evaluate the association of social functioning and living arrangement with specific components of the HCV care cascade (treatment intent, specialist assessment and treatment uptake for HCV infection) among participants with chronic HCV infection and a history of injecting drug use in the Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) study.
Discussion
This study assessed the role of social functioning and living arrangement on treatment intent, specialist assessment and treatment uptake for HCV infection among a cohort of people who inject drugs (PWID) with HCV infection, recruited from OST and community health clinics between 2009 and 2014 in New South Wales, Australia. Factors independently associated with lower social functioning included unemployment, unstable housing, recent injecting drug use and moderate to extremely severe symptoms of depression, anxiety and stress. Lower social functioning was independently associated with reduced early HCV treatment intent and lower specialist assessment, but not HCV treatment uptake. Living with someone was independently associated with HCV treatment uptake. This study highlights the need for development and implementation of strategies targeting PWID with lower social functioning to enhance HCV treatment intent and specialist assessment, and strategies to ensure appropriate social support when it comes to receiving treatment for HCV. These findings may have important implications in the design and implementation of public health and social programs to enhance access to HCV care and treatment.
Overall, the mean social functioning score in this study was 4.4, with one-quarter of participants having a score >6 (lower social functioning). These results are consistent with a previous validation study of this social functioning score within people receiving OST (mean social functioning score, 5.1) (Lawrinson et al., 2005).
Lower social functioning (score >6.0) was independently associated with unemployment, unstable housing, recent injecting drug use and moderate to extremely severe symptoms of depression, anxiety and stress. These results are not surprising, given that this social functioning scale addresses questions pertaining to money problems, conflict with partner/spouse, relatives or employer, and living with/time spent with people who use/do not use heroin or other illicit opioids (Darke et al., 1991, Richardson et al., 2010). Injecting drug use can have major consequences on social integration and social functioning among some PWID. Drug use may dictate the lifestyle of some PWID by promoting drug-seeking behaviours, impacting social networks (drug-using networks, and interpersonal conflicts with family and friends), housing, income and employment (Adlaf et al., 2005, Kemp et al., 2006, Richardson et al., 2010). Unemployment is a barrier to housing stability (Aubry et al., 2012, Richardson et al., 2010). In turn, housing instability has been shown to be associated with riskier drug-injecting behaviour and may impact social networks (Johnson and Chamberlain, 2008, Topp et al., 2013). Unstable housing, unemployment, low income and injecting drug use may contribute to an unstable lifestyle, affect mental health status and result in developing symptoms of depression, anxiety and/or stress (Alavi et al., 2012, Boscarino et al., 2015, Braitstein et al., 2005, Golden et al., 2005, Mackesy-Amiti et al., 2014, Whittaker et al., 2015, Yamini et al., 2011). Further, these factors all contribute to the disadvantage, marginalization and vulnerability among people with lower social functioning.
Lower social functioning was independently associated with reduced early HCV treatment intent and lower specialist assessment. It has been demonstrated that disadvantaged sub-groups of PWID are less likely to seek health care by fear of stigma, discrimination, judgemental attitudes, and misunderstanding of their needs and their lifestyle by healthcare providers (Neale et al., 2008, Ostertag et al., 2006). However, when adjusted for other factors, lower social functioning in the current study was not associated with HCV treatment uptake.
It is well documented that the quality of the relationship between patient and health professional has a direct impact on engagement in care, including HCV care (Osilla et al., 2009, Swan et al., 2010, Treloar et al., 2010, Treloar et al., 2013). As such, a trusted HCV peer-support worker, nurse, or specialist may facilitate addressing patient barriers to HCV care related to social functioning that might be present at the time of treatment contemplation or prior to engagement with an HCV specialist (Treloar, Rance, Dore, & Grebely, 2014). In addition, this interaction might improve knowledge of HCV, and enhance patient trust in the health care system and in their provider. Therefore, a patient with lower social functioning may become more confident in commencing HCV treatment following interaction with a HCV peer-support worker, nurse or specialist. This perhaps explains why lower social functioning was associated with treatment intent and specialist assessment, but not treatment uptake.
Living with someone (both with and without children) was independently associated with HCV treatment uptake. These data are consistent with previous qualitative literature demonstrating that social support is an important factor in facilitating entry into HCV care and treatment (Hopwood & Treloar, 2007). In order to deal with competing priorities, social support is essential throughout the treatment process, either for moral support or technical help. As such, living with someone likely provides important social support that facilitates entry into HCV treatment and assists in addressing issues that may arise during HCV treatment. However, it appears that various steps of the HCV treatment cascade have their own barriers/facilitators, which are important to understand. It should not be assumed that addressing barriers to HCV treatment intent and specialist assessment will necessarily sort out issues later in the cascade (or vice versa).
There are a number of limitations to this study. First, all participants were recruited among PWID attending drug and alcohol clinics and community health centres. Therefore, the study population may be more engaged in health services, resulting in an underestimation of lower social functioning in this population and an overestimation of the proportions with HCV treatment intent, specialist assessment and HCV treatment uptake. That being said, the mean social functioning score was similar to that observed among people currently receiving OST in the original validation study of the social functioning score. Second, several sociodemographic factors were included in the statistical models for this analysis and it is acknowledged that factors not statistically collinear may be clinically correlated. Finally, these findings may not be generalizable to other populations of people with HCV infection, particularly those less engaged in health services.
In summary, we have demonstrated that unemployment, unstable housing, recent injecting drug use and moderate to extremely severe symptoms of depression, anxiety and stress were independently associated with lower social functioning. Further, lower social functioning was associated with reduced early HCV treatment intent and lower specialist assessment, but not HCV treatment uptake. Living with someone (both with and without children) was independently associated with HCV treatment uptake.
This study suggests that variables related to social functioning (e.g. housing, income, social support) are important for influencing decisions around treatment intent and whether to see a specialist, but can be overcome following specialist assessment. However, treatment initiation may require enhanced social support (in this study, living with someone was associated with HCV treatment uptake). As such, practitioners should be educated about the sociodemographic challenges faced by PWID (such as lower social functioning, risky injecting behaviour, employment and housing instability, and stress), and about specific help they can and should provide, such as direct interventions or referrals to appropriate resources that can efficiently address these complex issues. The short form of the OTI social functioning scale seems to be an easy-to-use, efficient tool that could be utilized by practitioners to address social functioning issues and to screen patients receiving OST in need for specific interventions. Peer-support programs (provider-led or peer-led) have also been successful in providing the social support necessary to enhance engagement in HCV care (Crawford and Bath, 2013, Keats et al., 2015, Treloar et al., 2015). They have also been shown to reduce patients' mistrust in the health care system, address barriers to HCV treatment through discussions with workers and peers, and improve knowledge about HCV and treatment (Crawford and Bath, 2013, Keats et al., 2015, Treloar et al., 2015). As such, peer-support models should be further evaluated as a strategy to enhance engagement in HCV care.
An evaluation of various strategies to enhance social functioning and social support prior to and during treatment for HCV infection may be warranted, given their importance in the HCV care cascade.
|
|
| |
| |
|
|
|
