Research paper
Liver disease knowledge and acceptability of non-invasive liver fibrosis assessment among people who inject drugs in the drug and alcohol setting: The LiveRLife Study

https://doi.org/10.1016/j.drugpo.2015.07.002Get rights and content

Highlights

  • PWID had moderate levels of HCV and liver disease knowledge.

  • PWID stated high willingness to receive HCV treatment.

  • Frequency of injection drug use was independently associated with knowledge.

  • Transient elastography (TE) was the most preferred liver disease assessment method pre- and post-TE.

  • Nearly one-fifth of participants had either severe fibrosis or cirrhosis.

Abstract

Background

The aim of this study was to assess factors associated with baseline knowledge of HCV and liver disease, acceptability of transient elastography (TE) assessment (FibroScan®), and willingness and intent to receive HCV treatment among persons with a history of injection drug use participating in a liver health promotion campaign.

Methods

The LiveRLife campaign involved three phases: (1) campaign resource development; (2) campaign resource testing; and (3) campaign implementation. Participants were enrolled in an observational cohort study with recruitment at four clinics – one primary health care facility, two OST clinics, and one medically supervised injecting centre – in Australia between May and October 2014. Participants received educational material, nurse clinical assessment, TE assessment, dried blood spot testing, and completed a knowledge survey.

Results

Of 253 participants (mean age 43 years), 68% were male, 71% had injected in the past month, and 75% self-reported as HCV positive. Median knowledge score was 16/23. In adjusted analysis, less than daily injection (AOR 5.01; 95% CI, 2.64–9.51) and no daily injection in the past month (AOR 3.54; 95% CI, 1.80–6.94) were associated with high knowledge (≥16). TE was the most preferred method both pre- (66%) and post-TE (89%) compared to liver biopsy and blood sample. Eighty-eight percent were ‘definitely willing’ or ‘somewhat willing’ to receive HCV treatment, and 56% intended to start treatment in the next 12 months. Approximately 68% had no/mild fibrosis (F0/F1, ≥2.5 to ≤7.4 kPa), 13% moderate fibrosis (F2, ≥7.5 to ≤9.4 kPa), 10% severe fibrosis (F3, ≥9.5 to ≤12.4 kPa), and 9% had cirrhosis (F4, ≥12.5 kPa).

Conclusion

Liver disease and HCV knowledge was moderate. High acceptability of TE by PWID provides strong evidence for the inclusion of TE in HCV-related care, and could help to prioritise HCV treatment for those at greatest risk of liver disease progression.

Introduction

Injecting drug use is the leading risk factor for hepatitis C virus (HCV) infection in most high-income countries (Hajarizadeh, Grebely, & Dore, 2013). Rates of advanced liver disease complications, associated healthcare costs, and liver disease-related mortality among people who inject drugs (PWID) are rising (Grebely & Dore, 2011). However, HCV assessment and treatment uptake among PWID remains exceptionally low (about 1–2% treated per year) (Alavi et al., 2014, Alavi et al., 2015, Grebely et al., 2009, Iversen et al., 2014, Mehta et al., 2008).

HCV knowledge is limited among PWID (Doab et al., 2005, Norton et al., 2014, Treloar et al., 2011). Higher HCV knowledge has been shown to be associated with a greater likelihood of receiving HCV assessment and treatment (Grebely et al., 2011, Treloar et al., 2011) and PWID identify a lack of HCV knowledge as a primary barrier to seeking treatment (Alavi et al., 2013, Grebely et al., 2008).

PWID currently receiving opioid substitution therapy (OST) typically have poor HCV knowledge and have low rates of assessment and treatment (Alavi et al., 2013, Grebely et al., 2011, Treloar et al., 2011). It is troubling that this low level of knowledge is observed among PWID receiving OST despite the fact that they regularly frequent a healthcare setting and have repeated contact with healthcare providers (Treloar, Hull, Dore, & Grebely, 2012). However, PWID receiving OST still state a high willingness to receive treatment (Treloar et al., 2012), and evidence shows that recurring contact with a healthcare provider is associated with HCV treatment uptake (Mehta et al., 2008).

It appears that in its current form, an OST-only model is unlikely to provide the level of patient-provider engagement necessary to facilitate widespread HCV assessment and treatment (Treloar, Rance, Dore, & Grebely, 2014). Additional research is required to evaluate targeted educational interventions that will not only improve HCV and liver disease knowledge among PWID but also strengthen patient-provider engagement to further increase assessment and treatment uptake.

There are attitudinal as well as knowledge barriers; for example, PWID have identified receiving a liver biopsy as a barrier to HCV assessment and treatment (Doab et al., 2005, Swan et al., 2010). Liver disease assessments via transient elastography (TE) – an ultrasound technique that evaluates the extent of liver damage – provide a non-invasive alternative to accurately measure HCV-related fibrosis (Castéra et al., 2005, Shaheen et al., 2007). Among street-based PWID in France, TE (FibroScan®) had complete acceptance (100%) and led to treatment uptake for 10% of HCV-positive participants who were previously undiagnosed (Foucher et al., 2009). Hence, TE assessment may facilitate entry into care, particularly among PWID with HCV who state a lack of HCV-related symptoms as a reason to not seek assessment (Treloar et al., 2014).

The LiveRLife study is a liver health promotion campaign designed to enhance liver disease assessments using TE assessment in the drug and alcohol setting among persons with a history of injection drug use. The aims of this study are to assess factors associated with baseline HCV and liver disease knowledge, willingness to receive TE assessment, and willingness and intent to receive HCV treatment.

Section snippets

Study design

The LiveRLife campaign was comprised of three phases: (1) campaign resource development; (2) campaign resource testing; and (3) campaign implementation. Ethics approval was received from the Human Research Ethics Committee at St Vincent's Hospital Sydney (Australia).

Phase I: campaign resource development

Phase I of the LiveRLife campaign involved message development for LiveRLife resources. The primary aims were to: (1) investigate knowledge and attitudes among PWID regarding liver disease assessment and treatment uptake; and (2)

Study participants

The baseline characteristics among the total sample of 253 participants are shown in Table 1. Overall, the mean age was 43 years (standard deviation, 10), 68% (n = 171) were male, 75% (n = 190) had injected in the past six months. Among participants who injected in the past month (n = 179), 42% (n = 75) stated heroin as the last drug injected. Additionally, 71% (n = 180) were currently receiving OST, of which 75% (n = 135) were receiving methadone. About 75% (n = 189) of the total sample (n = 253)

Discussion

In this cohort of PWID recruited from drug and alcohol settings in New South Wales, Australia, the overall median proportion with correct baseline HCV and liver disease knowledge was 70%. There were noticeable gaps in knowledge of HCV antibody testing, factors impacting on HCV disease progression, and response rates to HCV treatment. TE was highly acceptable as a method for liver disease assessment, and nearly one-fifth of participants demonstrated advanced liver disease (F3/F4) following TE

Conflict of interest

JG is a consultant/advisor and has received research grants from Abbvie, Bristol Myers Squibb, Gilead Sciences and Merck. GD is a consultant/advisor and has received research grants from Abbvie, Bristol Myers Squibb, Gilead, Merck, Janssen and Roche. The remaining authors do not have a conflict of interest.

Financial support

The study was funded from Merck Sharp & Dohme, Australia. The Kirby Institute is funded by the Australian Government Department of Health and Ageing. The views expressed in this publication do not necessarily represent the position of the Australian Government. GD is supported by a National Health and Medical Research Council Practitioner Research Fellowship. JG is supported by a National Health and Medical Research Council Career Development Fellowship. SJ is supported by an Australian

Acknowledgements

The authors would like to thank the study participants for their contribution to the research, as well as researchers and staff who have participated in the project. We would specifically like to thank: Ingrid van Beek, Rosemary Gilliver (Kirketon Road Centre, NSW Australia); William Wood (Sydney Medically Supervised Injecting Centre, NSW Australia); Julian Keats and Susan Hazelwood (Newcastle Pharmacotherapy Service, NSW Australia) and; Nives Houlihan and Jana Van der Jagt (Coffs Harbour Drug

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