Research paperLiver disease knowledge and acceptability of non-invasive liver fibrosis assessment among people who inject drugs in the drug and alcohol setting: The LiveRLife Study
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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2021, International Journal of Drug PolicyCitation Excerpt :However, less is known about lowering the barriers to pre-treatment evaluation, a major hurdle to treatment initiation. Many studies trying to streamline pre-treatment evaluation rely on elastography (Foucher et al., 2009; Marshall et al., 2015; Thurnheer, Schulz, Nguyen, MacLachlan, & Sasadeusz, 2016), which can be expensive and difficult to access in some settings (Borgia, 2015). While pangenotypic direct acting antiviral (DAA) regimens have simplified treatment safety, there are important clinical indications for pre-treatment evaluation such as screening for cirrhosis or hepatic decompensation using non-invasive fibrosis surrogates Fibrosis-4 (FIB-4) or Aspartate aminotransferase to Platelet Ratio Index (Burrage et al., 2020; Chou R, 2013; Fraser et al., 2019; Snyder & Gajula, 2006).
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2020, AlcoholCitation Excerpt :Making successive measurements of LS during withdrawal induces a motivational role of the FibroScan® examination, which aims to change patient behavior (Lahmek et al., 2014). It has been shown in PWID that FibroScan® plays a key role in the detection of viral hepatitis, including hepatitis C, as well as other potential liver comorbidities (Marshall et al., 2015; Pateria et al., 2013). It is very well accepted and provides the patient with his/her real-time "liver status”.