Research paperHepatitis C testing in general practice settings: A cross-sectional study of people who inject drugs in Australia
Introduction
Chronic Hepatitis C remains a major source of morbidity and mortality. Globally chronic Hepatitis C affects about 70 million people (Blach et al., 2017). Within developed countries many of those affected are people who inject drugs (PWID) and comprise the largest affected group (Degenhardt et al., 2016).
Treatment uptake has been poor and more than 700,000 people die globally of HCV-related conditions each year (Lanini, Easterbrook, Zumla, & Ippolito, 2016). Many barriers exist that impact treatment uptake including patient-level, provider-level, and system-level barriers. Direct acting antivirals (DAA) are a significant clinical advance that promises to alleviate some of these barriers. Treatment is more efficacious (>90% cure), side effects are substantially reduced, and treatment time has been shortened (Dore, Ward, & Thursz, 2014; Kohli, Shaffer, Sherman, & Kottilil, 2014; Lam, Jeffers, Younoszai, Fazel, & Younossi, 2015).
Although DAAs will address some barriers, others remain. Poor uptake of testing and assessment, low pharmacy coverage stocking medications, low levels of GP training and confidence, long treatment service waiting times, and the effects of discrimination and stigma remain barriers, especially for PWID (Bruggmann, 2012; Doab, Treloar, & Dore, 2005; Harris & Rhodes, 2013; Hopwood & Treloar, 2013).
Appropriate testing has numerous benefits both for the individual tested and for public health. Antibody testing (anti-HCV) detects exposure to the virus. Confirmatory testing, also called HCV RNA testing, uses a PCR (polymerase chain reaction) test to detect chronic infection. Limited provision of appropriate confirmatory testing among people with hepatitis C antibodies is a major gap in the HCV cascade of care (Snow, Scott, Clothier, MacLachlan, & Cowie, 2016). Accurate detection of HCV followed by appropriate post-test discussion can effectively reduce transmission risk by educating people living with HCV on how to modify risk behaviours and improve health outcomes through early referral for management and/or treatment (Bruneau et al., 2014). Post-test discussion is guided by the type of test performed (antibody or RNA), and the setting of the testing/consultation (Australasian Society for HIV Medicine, 2012; Ghany, Strader, Thomas, & Seeff, 2009). Themes that should be discussed include providing information on further testing that may be required, next steps in staging the disease for those who are RNA positive, potential treatment options, and precautions that can be taken to reduce the risk of transmission and improve health outcomes (i.e. diet and alcohol intake) (Australasian Society for HIV Medicine, 2012).
The World Health Organisation has developed treatment targets for the Global Health Sector Strategies for HIV, viral hepatitis, STIs, 2016–2021. These goals include reducing new cases by 90% (2030), and reducing mortality by 65% (2030). Key to achieving these goals will be targeting specific populations, in particular, PWID. Among developed countries, PWID are most at risk for contracting and transmitting the disease (Hajarizadeh, Grebely, & Dore, 2013). Providing treatment to this population will have significant impact upon reducing new cases (Martin, Vickerman et al., 2013).
Access to appropriate testing remains an important aspect of reaching PWID. Current efforts to increase testing within the opioid substitution therapy (OST) setting will reach some PWID, but not all. Australia has high coverage of OST (Mathers et al., 2010) but even so, in a sentinel sample of PWID up to one-third may not be eligible for OST and hence not come into contact with those services (Butler et al., 2015, Larney et al., 2016).
While much research has focused on investigating HCV care in OST in Australia and abroad, very little exists regarding HCV care in general practice (i.e. primary health care provider) settings. General practitioners (GPs) are typically easy to access, locally available, and where universal health care is available, are often free or low cost. Therefore, GP settings may be ideal for increasing access to appropriate HCV testing. We aimed to determine: 1. The proportion of PWID who accessed HCV antibody testing in the general practice setting; 2. The proportion of anti-HCV positive PWID who received confirmatory RNA testing in the GP setting compared to those tested at other sites (e.g. specialist, hospital, corrective services); and 3. What types of information PWID recall being given at time of diagnosis, and if this is different across sites.
Section snippets
Method
The Illicit Drug Reporting System (IDRS) is an annual illicit drug sentinel surveillance system conducted in every capital city in Australia. Methods are described in full elsewhere (Stafford & Breen, 2016). Briefly, a cross-sectional non-probability sample of PWID reporting at least monthly illicit drug injection in the preceding six months were recruited. They were reached through needle and syringe programs, peer referral, user representative groups, and street press advertising.
Results
Eight-hundred and eighty-eight participants were recruited. The sample had a mean age of 42 years (SD: 8.94; range 17–71), and 67% were male (Table 1).
Antibody testing was high, with 93% (n = 735) of the sample reporting having had at least one antibody test. Participants who reported antibody testing were significantly less likely (68% vs 88%, p = 0.002) to have completed year 10 of high school (the minimum level of schooling required in Australia), they were more likely to have a history of
Discussion
In this Australian sample of people who regularly inject drugs, HCV antibody testing was common, but RNA testing to confirm chronic infection was less so. This represents a missed opportunity for linking patients to treatment options, or at the bare minimum empowering patients with accurate information about their HCV status. Progression through the treatment cascade to linkage to care and treatment relies on appropriate testing. Improvement in testing will result in a flow on effect for
Limitations
Our study was based on a convenience sample of PWID. The population parameters of PWID are unknown, and it is therefore unclear whether the sample is representative of the broader PWID population. We relied on self-report, and data may therefore be limited by recall and social desirability bias. However, drug users’ self-report is considered sufficiently reliable and valid to provide descriptions of drug use-related problems (Darke, 1998). Although there are mixed data on the sensitivity of
Conclusions
Settings for HCV testing need to be broad and varied as no single model of care will suit everyone (Bruggmann & Litwin, 2013). GPs are typically easy to access, locally available and are already doing a large proportion of the testing for HCV among PWID in Australia. In terms of scaling up testing and treatment, increasing GP participation in HCV care will substantially grow the HCV workforce. Our findings suggest that the general practice setting is a common and accessible setting for PWID to
Funding
The Illicit Drug Reporting System Project was supported by funding from the Australian Government. The current paper design, conduct and interpretation of findings are the work of the investigators; theses funders had no role in this paper.
SL has received untied educational funding from Indivior.
Acknowledgements
The Illicit Drug Reporting System Project is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grants Fund. The current paper design, conduct and interpretation of findings are the work of the investigators; the funders had no role in this paper. The authors would like to acknowledge the contribution of collaborators from the following institutions; National Drug and Alcohol Research Centre — UNSW Australia, Queensland Alcohol and
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