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      Practical steps to improve chronic hepatitis C treatment in people with opioid use disorder

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          Abstract

          Objectives

          People with a history of injecting drugs have high prevalence of hepatitis C virus (HCV) infection, and many have opioid use disorder (OUD). Modern HCV therapies with improved efficacy and tolerability are available, but access is often limited for this group, who may be underserved for health care and face social inequity. This work develops practical steps to improve HCV care in this population.

          Methods

          Practical steps to improve HCV care in OUD populations were developed based on clinical experience from Spain, structured assessment of published evidence.

          Results

          Options for improving care at engagement/screening stages include patient education programs, strong provider–patient relationship, peer support, and adoption of rapid effective screening tools. To facilitate work up/treatment, start options include simplified work up process, integration of HCV and OUD care, and continuous psychosocial support prior, during, and after HCV treatment.

          Conclusion

          It is important to plan on local basis to set up a joint integrated approach between specific drug treatment services and local points of HCV care. The elements for a specific integrated program should be chosen from options identified, including education services, peer input, organization to make HCV screening and treatment easier by co-location of services, and wider access to prescribing direct-acting antiviral (DAA) therapy.

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          Most cited references66

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          Hepatitis C treatment access and uptake for people who inject drugs: a review mapping the role of social factors

          Background Evidence documents successful hepatitis C virus (HCV) treatment outcomes for people who inject drugs (PWID) and interest in HCV treatment among this population. Maximising HCV treatment for PWID can be an effective HCV preventative measure. Yet HCV treatment among PWID remains suboptimal. This review seeks to map social factors mediating HCV treatment access. Method We undertook a review of the social science and public health literature pertaining to HCV treatment for PWID, with a focus on barriers to treatment access, uptake and completion. Medline and Scopus databases were searched, supplemented by manual and grey literature searches. A two step search was taken, with the first step pertaining to literature on HCV treatment for PWID and the second focusing on social structural factors. In total, 596 references were screened, with 165 articles and reports selected to inform the review. Results Clinical and individual level barriers to HCV treatment among PWID are well evidenced. These include patient and provider concerns regarding co-morbidities, adherence, and side effect management. Social factors affecting treatment access are less well evidenced. In attempting to map these, key barriers fall into the following domains: social stigma, housing, criminalisation, health care systems, and gender. Key facilitating factors to treatment access include: combination intervention approaches encompassing social as well as biomedical interventions, low threshold access to opiate substitution therapy, and integrated delivery of multidisciplinary care. Conclusion Combination intervention approaches need to encompass social interventions in relation to housing, stigma reduction and systemic changes in policy and health care delivery. Future research needs to better delineate social factors affecting treatment access.
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            Understanding barriers to hepatitis C virus care and stigmatization from a social perspective.

            A large body of literature emphasizes the relationship between stigma and adverse health outcomes and health access measures. For people living with hepatitis C virus (HCV), stigma is a defining feature given the association of HCV with the socially demonized practice of injection drug use. However, there is little literature that specifically examines stigma as a barrier to HCV care and treatment. This review argues that the relationship between the person living with HCV and their health worker can work to ameliorate the effects of stigma. We draw on an emerging literature that examines the positive association between a patient's "trust" in their health worker and outcomes such as increased healthcare utilization and reduced risk behaviors. We investigate a growing body of health services research that acknowledges the importance of stigma and demonstrates ways to build positive, enabling relationships between patient, health worker, and health setting.
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              Models of care for the management of hepatitis C virus among people who inject drugs: one size does not fit all.

              One of the major obstacles to hepatitis C virus (HCV) care in people who inject drugs (PWID) is the lack of treatment settings that are suitably adapted for the needs of this vulnerable population. Nevertheless, HCV treatment has been delivered successfully to PWID through various multidisciplinary models such as community-based clinics, substance abuse treatment clinics, and specialized hospital-based clinics. Models may be integrated in primary care--all under one roof in either addiction care units or general practitioner-based models--or can occur in secondary or tertiary care settings. Additional innovative models include directly observed therapy and peer-based models. A high level of acceptance of the individual life circumstances of PWID rather than rigid exclusion criteria will determine the level of success of any model of HCV management. The impact of highly potent and well-tolerated interferon-free HCV treatment regimens will remain negligible as long as access to therapy cannot be expanded to the most affected risk groups.
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                Author and article information

                Journal
                Hepat Med
                Hepat Med
                Hepatic Medicine: Evidence and Research
                Hepatic Medicine : Evidence and Research
                Dove Medical Press
                1179-1535
                2019
                24 December 2018
                : 11
                : 1-11
                Affiliations
                [1 ]Psychiatric Service, University of Salamanca Health Care Complex, Institute of Biomedicine of Salamanca, University of Salamanca, Salamanca, Spain, croncero@ 123456saludcastillayleon.es
                [2 ]Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
                [3 ]School of Medicine, Complutense University of Madrid, Madrid, Spain
                [4 ]Gregorio Marañón Health Research Institute, Madrid, Spain
                [5 ]applied strategic, London, UK
                [6 ]Department of Infectious Diseases and Microbiology, Valme University Hospital, Seville, Spain
                [7 ]Provincial Center of Drug Addiction, Malaga, Spain
                [8 ]Addiction Treatment Center of Villamartín, Cádiz, Spain
                [9 ]Addiction and Dual Diagnosis Unit, Vall Hebron University Hospital, Barcelona, Spain
                [10 ]Psychiatry Service, Biomedical Research Networking Center for Mental Health Network, Vall Hebron University Hospital, Barcelona, Spain
                [11 ]Autonomous University of Barcelona, Barcelona, Spain
                [12 ]Spanish Society of Dual Diagnosis, Bilbao, Spain
                [13 ]Institute of Addictions, Madrid, Spain
                Author notes
                Correspondence: Carlos Roncero, Psychiatric Service, University of Salamanca Health Care Complex (Complejo Asistencial Universitario de Salamanca), Institute of Biomedicine of Salamanca, University of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain, Tel +34 923 29 1200 ext 55448, Email croncero@ 123456saludcastillayleon.es
                Article
                hmer-11-001
                10.2147/HMER.S187133
                6307489
                30613166
                0718b113-5f14-4fd5-a04d-b68c8b91b4e1
                © 2019 Roncero et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                hcv,opioid use disorder,treatment,elimination,practical recommendations

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