Publications by authors named "Carla Treloar"

165 Publications

Australian health and medical workers' concerns around providing care to people living with hepatitis B.

Health Soc Care Community 2021 Apr 6. Epub 2021 Apr 6.

Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia.

There is established literature on health workers' attitudes towards working with people living with stigmatised health conditions and behaviours, such as HIV, hepatitis C and injecting drug use. Less is known about health workers' attitudes and concerns around providing care to people living with hepatitis B virus (HBV), which is concerning as research indicates that negative attitudes may impact on the quality of care provided to these populations, with adverse health outcomes for clients. The aim of this paper is to examine health and medical workers' concerns about providing care to people living with HBV, and the factors that may influence these concerns. Australian health and medical workers (n = 551) completed an online survey measuring their concerns about providing care to people living with HBV, stigmatising attitudes towards this group, perceived comfort of themselves and colleagues in providing care towards clients with HBV, and witnessing their colleagues behaviour in a discriminatory way towards clients with HBV. Multiple regression was used to ascertain factors predictive of health workers' concerns about working with clients with HBV. Results showed that older participants and those who had spent less time working in the health and medical field had greater concerns about caring for people living with HBV. Workers who did not know someone living with HBV, who were less comfortable around clients with HBV, who perceived their colleagues to be less comfortable working with clients with HBV, and who had more negative attitudes towards this group also had greater concerns around providing care to people living with HBV. Efforts should be made to improve health and medical workers' attitudes towards working with people with HBV. This may also improve workers' level of comfort with people with HBV and reduce the reported reticence they have towards working with this client group.
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http://dx.doi.org/10.1111/hsc.13368DOI Listing
April 2021

Stigma as understood by key informants: A social ecological approach to gay and bisexual men's use of crystal methamphetamine for sex.

Int J Drug Policy 2021 Mar 25;94:103229. Epub 2021 Mar 25.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia.

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities.
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http://dx.doi.org/10.1016/j.drugpo.2021.103229DOI Listing
March 2021

Expert stakeholder perspectives on the acceptability of treatment-as-prevention in prison: a qualitative substudy of the 'Surveillance and Treatment of Prisoners with Hepatitis C' project (SToP-C).

Addiction 2021 Mar 10. Epub 2021 Mar 10.

Centre for Social Research in Health, UNSW Sydney, Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia.

Background And Aims: Mathematical modelling has demonstrated the theoretical feasibility of HCV treatment-as-prevention strategies in custodial settings, yet limited empirical data exists. The Australian 'Surveillance and Treatment of Prisoners with Hepatitis C' study is the world's first trial of hepatitis C virus (HCV) treatment-as-prevention in prison. This study aimed to analyse how expert stakeholders involved in the Australian HCV response assessed the acceptability of HCV treatment-as-prevention in prison using interview data from the SToP-C qualitative substudy.

Design And Setting: Qualitative analysis using semi-structured interviews in Australia.

Participants: Nineteen key HCV experts.

Measurements: Drawing upon Sekhon's theoretical framework of acceptability, data were organized thematically under four component constructs of acceptability: affective attitude; ethicality; opportunity costs; and perceived effectiveness.

Findings: Most differences in participant assessments of acceptability were a matter of relative emphasis and prioritization rather than absolute polarity. Nonetheless, a small minority of participants was overtly critical of the approach. Arguing against the focus on treatment, they instead advocated for prevention-as-prevention, including the improvement and expansion of existing harm reduction measures.

Conclusions: Qualitative analysis of expert stakeholder assessments of the acceptability of hepatitis C virus treatment-as-prevention in Australian prisons found no opposition to the universal rollout of direct-acting anti-virals, but most voiced concern regarding the lack of effective primary prevention in Australian prisons.
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http://dx.doi.org/10.1111/add.15477DOI Listing
March 2021

Comparing Australian health worker and student attitudes and concerns about providing care to people living with hepatitis B.

Health Promot J Austr 2021 Mar 9. Epub 2021 Mar 9.

Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia.

Issue Addressed: Hepatitis B (HBV) is a major public health issue with over 250 million people chronically infected worldwide. In Australia, prevalence is higher among migrant communities and these groups may be reticent to attend health care services due to concerns about experiencing stigma and discrimination. The way health workers perceive their clients, particularly those of migrant backgrounds, may influence the way they treat these clients and the quality of care provided. This study investigated and compared the attitudes and concerns health workers and health students have towards working with clients living with HBV.

Methods: Health workers (n = 551) and students (n = 199) completed an online survey which investigated attitudes towards people living with HBV, comfort with providing care for these clients and concerns they have about working with them.

Results: Health students expressed less comfort (U = 47 611, z = -2.73, P = .006) and reported more concerns about working with people with HBV than qualified health workers (U = 61611.50, z = 2.64, P = .008). Students' concerns were centred around their own ability to provide care rather than issues related to clients. There were no differences in overall attitudes towards people living with HBV between health workers and students.

Conclusion: To address concerns that health workers and students may have in working with people living with HBV, particularly those from migrant communities, and to ensure that health workers feel comfortable and confident, HBV workforce development should be included in undergraduate and postgraduate training programmes as well as in continuing professional education. SO WHAT?: This will assist the health workforce to develop competency in the treatment of people living with HBV, with the ultimate aim of providing best quality, non-judgemental care to all people living with HBV.
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http://dx.doi.org/10.1002/hpja.475DOI Listing
March 2021

Priorities and practices of risk reduction among gay and bisexual men in Australia who use crystal methamphetamine for sex.

Int J Drug Policy 2021 Feb 15;93:103163. Epub 2021 Feb 15.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2054, Australia.

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex.
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http://dx.doi.org/10.1016/j.drugpo.2021.103163DOI Listing
February 2021

Violence and hepatitis C transmission in prison-A modified social ecological model.

PLoS One 2020 1;15(12):e0243106. Epub 2020 Dec 1.

The Kirby Institute, UNSW Sydney, Sydney, Australia.

Background: Transmission of hepatitis C virus (HCV) among the prisoner population is most frequently associated with sharing of non-sterile injecting equipment. Other blood-to-blood contacts such as tattooing and physical violence are also common in the prison environment, and have been associated with HCV transmission. The context of such non-injecting risk behaviours, particularly violence, is poorly studied. The modified social-ecological model (MSEM) was used to examine HCV transmission risk and violence in the prison setting considering individual, network, community and policy factors.

Methods: The Australian Hepatitis C Incidence and Transmission Study in prisons (HITS-p) cohort enrolled HCV uninfected prisoners with injecting and non-injecting risk behaviours, who were followed up for HCV infection from 2004-2014. Qualitative interviews were conducted within 23 participants; of whom 13 had become HCV infected. Deductive analysis was undertaken to identify violence as risk within prisons among individual, network, community, and public policy levels.

Results: The risk context for violence and HCV exposure varied across the MSEM. At the individual level, participants were concerned about blood contact during fights, given limited scope to use gloves to prevent blood contamination. At the network level, drug debt and informing on others to correctional authorities, were risk factors for violence and potential HCV transmission. At the community level, racial influence, social groupings, and socially maligned crimes like sexual assault of children were identified as possible triggers for violence. At the policy level, rules and regulations by prison authority influenced the concerns and occurrence of violence and potential HCV transmission.

Conclusion: Contextual concerns regarding violence and HCV transmission were evident at each level of the MSEM. Further evidence-based interventions targeted across the MSEM may reduce prison violence, provide opportunities for HCV prevention when violence occurs and subsequent HCV exposure.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243106PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7707477PMC
January 2021

Knowledge and beliefs about hepatitis B virus infection and associated factors among Chinese migrants in Australia: The result of a quantitative study.

Health Soc Care Community 2020 Nov 25. Epub 2020 Nov 25.

Faculty of Arts & Social Sciences, Centre for Social Research in Health, University of New South Wales, Sydney, Australia.

Chinese immigrants to Australia have an increased prevalence of hepatitis B virus (HBV) infection compared to the general population. Despite this, engagement with HBV screening and healthcare for chronic hepatitis B (CHB) among immigrants of Chinese background is relatively low. This study investigated knowledge about HBV among this high-risk community and explored sociodemographic factors that might influence this knowledge. During February to September 2019, first generation Chinese immigrants from mainland China and their immediate descents residing in Sydney and Melbourne were recruited via convenience and snowball sampling and completed a survey in either English or Chinese. Survey items included HBV knowledge, attitudes towards people living with CHB and demographic information. Three hundred and ninety-six participants completed the survey. The median HBV knowledge score was 53% correct, indicating that knowledge about HBV was low to middle range among participants. While participants had the most knowledge in the domain of perceptions and understandings of HBV, this was still low. Participants also had limited knowledge about HBV prevention, transmission and treatment. Those with higher English proficiency, post-secondary education, lower levels of HBV-related stigma and those who had contact with people living with CHB appeared to have greater HBV knowledge. This study showed that HBV knowledge among Chinese people originally from mainland China living in Australia is limited and even deficient in some key areas. Additionally, the relationships between HBV knowledge and particular sociodemographic variables, knowing someone living with HBV and stigma associated with HBV provides key information to assist in the development of targeted health promotion to increase HBV knowledge and change stigmatising attitudes towards HBV among the Chinese community in Australia.
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http://dx.doi.org/10.1111/hsc.13239DOI Listing
November 2020

Making legitimacy: Drug user representation in United Nations drug policy settings.

Int J Drug Policy 2021 Jan 28;87:103014. Epub 2020 Oct 28.

Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia.

Background: The importance of engaging people who use drugs in drug policy development is increasingly acknowledged including in recent UN documents. Little scholarly attention has been paid to 'drug user representation' in the global drug policy setting of the UN such as the Commission on Narcotic Drugs (CND). This paper examines 'drug user representation' in key UN drug policy processes over three decades.

Method: A mapping process was undertaken using a corpus of publicly available documents from the UNGASS on Drugs and associated CND processes to identify relevant policy processes from 1987 to 2019 (n = 15) which were then assess for presence/absence of 'drug user representation'. Those processes with positive evidence of 'drug user representation' (n = 9) were critically interrogated across three co-constitutive domains of the subjects, objects and forms of 'drug user representation'.

Results: Our analysis shows that despite calls for greater involvement, dominant UN drug policy discourses and other practices delimit both the political subjectivities available to people who use/have used drugs and their capacity to bring their voices to bear in this context. The analysis also highlights that human rights-based discourses, employed by 'drug user representatives', have emerged as an important practice of resistance against the problematic and delimiting power effects of existing UN discourses, governing practices and modes of engagement.

Conclusions: In addition to the practices of resistance being undertaken by 'drug user representatives', we suggest there is a need to improve how 'drug user representation' is being made possible and done in the sites of UN drug policy deliberation and, that these sites should be opened for questioning. This we argue will not only have a positive impact on political legitimacy for 'drug user representation', but on the health and human rights of people who use/have used drugs.
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http://dx.doi.org/10.1016/j.drugpo.2020.103014DOI Listing
January 2021

Identifying risk and protective factors, including culture and identity, for methamphetamine use in Aboriginal and Torres Strait Islander communities: Relevance of the 'communities that care' model.

Soc Sci Med 2020 12 17;266:113451. Epub 2020 Oct 17.

Poche Centre for Indigenous Health, School of Public Health, The University of Queensland, St Lucia, Qld 4067, Australia. Electronic address:

Background And Aims: There is a need for more evidence to guide efforts to address harmful methamphetamine use amongst young Aboriginal and Torres Strait Islander Australians. 'Communities that Care' (CTC) is an evidence-based process developed to prevent alcohol and other drug-related harm but its suitability for use in Aboriginal contexts has not been established. This study sought to explore whether risk and protective factors for methamphetamine use, as described by Aboriginal stakeholders, align with the CTC risk and protective factor framework.

Method: Focus groups and individual interviews were conducted in Aboriginal communities nationally. Data were analysed thematically using the CTC framework as a deductive coding framework. Additional themes were captured and summarised.

Results: Participants were 147 (80% Aboriginal; 44% female) key stakeholders aged between 16 and 69 (median=40), recruited via organisational and community networks in each site. Relevant factors were identified in all four CTC domains: community, family, school, peer/individual. However, these four domains did not capture issues of central importance to Aboriginal people. These were summarised as an additional domain, 'Culture and Identity.'

Conclusions: Given that the Communities that Care risk and protective framework did not sufficiently capture issues of central importance to Aboriginal people, there is a need for different, community-informed models that reflect the unique determinants of use in this context.
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http://dx.doi.org/10.1016/j.socscimed.2020.113451DOI Listing
December 2020

Rethinking the relationship between sex work, mental health and stigma: a qualitative study of sex workers in Australia.

Soc Sci Med 2021 Jan 22;268:113468. Epub 2020 Oct 22.

Scarlet Alliance, Australia.

Aims: Sex workers may experience stigma both related to their occupation as well as to mental health issues that they face. There is limited research on the lived experience of sex workers managing mental health and stigma. This study examined the experiences of sex workers in Australia in relation to stigma surrounding sex work, and sex workers' mental health, including self-management and experiences of accessing mental health services.

Method: Six focus groups and two interviews were conducted with 31 sex workers. Data collection was co-moderated by a sex worker and a university-based researcher. Analysis was informed by an approach which positioned sex workers as agential and capable, and which drew attention to structural aspects of stigma.

Results: Sex workers identified that the stigma surrounding their profession had a significant impact on their mental health. The need to manage risks through selective disclosure of sex work was a pervasive experience. Management of mental health and the stigma associated with sex work was described as a responsibility primarily of the individual through self-care activities and occasional access to mental health services. Participants reported poor treatment from mental health practitioners who saw sex workers as victims lacking agency, imposed beliefs that sex work was the pathological root cause of mental health issues, or approached the issue with fascination or voyeurism. Other presenting issues (especially mental health) were lost or obscured in therapeutic encounters resulting in suboptimal care.

Conclusion: The threat of stigma is pervasive and has mental health implications for sex workers. Our findings point to the need for increased training and capacity development for mental health practitioners, funding for peer support services to ameliorate internalised stigma, and action from governments to introduce enabling legal environments, stigma reduction programs and structural protections from sex work stigma.
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http://dx.doi.org/10.1016/j.socscimed.2020.113468DOI Listing
January 2021

Applying a diffusion of innovations framework to the scale-up of direct-acting antiviral therapies for hepatitis C virus infection: Identified challenges for widespread implementation.

Int J Drug Policy 2020 Oct 12;86:102964. Epub 2020 Oct 12.

The Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Background And Aims: Interferon-free, direct-acting antivirals (DAAs) for hepatitis C virus (HCV) offer much promise to achieve World Health Organization targets by 2030. However, impediments at the practitioner and health-system level will continue to obstruct the scale-up of DAAs worldwide unless identified and acted upon. Applying a diffusion of innovations framework, the aim of this study was to identify structural factors impacting practitioner experiences of managing HCV treatment.

Methods: In-depth, semi-structured, telephone interviews took place between September 2018 and April 2019 to investigate barriers and facilitators for engaging in HCV management and DAA therapy amongst general practitioners (GPs) who prescribe opioid agonist therapy and drug and alcohol specialists in Australia. Interviews were transcribed verbatim, de-identified, and coded, and data were analysed with iterative categorisation and thematic analysis using Everett Rogers's diffusion of innovation framework.

Results: amongst 30 participants (12 GPs, 18 drug and alcohol specialists), several structural factors were reported to impede practitioner efforts to deliver optimal HCV care. Two primary themes were explored: contextual factors for the diffusion of DAA therapies, including attempts by participants to shift clinic culture and respond to siloed health structures, and adopter factors. Some participants chose to 'rock the boat' by circumventing clinic protocol and HCV guidelines to treat more clients, effectively shifting adopter categories to become greater advocates in HCV care. Also, while a role for GPs as the 'new adopters' in HCV management was discussed, many participants expressed uncertainty as to how much GPs should become involved in the diffusion of DAA therapies more widely.

Conclusions: Reducing the global burden of HCV infection will not be possible without the widespread delivery of HCV treatment amongst practitioners. Practitioners and health workers require leadership and resources from health authorities so that the individual and population-level benefits of DAA therapy are realised.
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http://dx.doi.org/10.1016/j.drugpo.2020.102964DOI Listing
October 2020

The role of social capital in facilitating hepatitis C treatment scale-up within a treatment-as-prevention trial in the male prison setting.

Addiction 2021 May 18;116(5):1162-1171. Epub 2020 Oct 18.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia.

Background And Aims: Hepatitis C (HCV) is a global public health concern, particularly in the prison setting where prevalence is substantially higher than in the general population. Direct-acting antivirals have changed the treatment landscape, allowing for treatment scale-up efforts potentially sufficient to achieve prevention of onward transmission (treatment-as-prevention). The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study was the first trial to examine the efficacy of HCV treatment-as-prevention in the prison setting. Social capital is a social resource which has been found to influence health outcomes. This qualitative study sought to understand the role of social capital within an HCV treatment-as-prevention trial in the prison setting.

Design: Semi-structured in-depth interviews were undertaken with participants recruited from the SToP-C study following HCV treatment completion (with cure).

Setting: Three male correctional centres in New South Wales, Australia (including two maximum-security and one minimum-security).

Participants: Twenty-three men in prison participated in semi-structured interviews.

Measurements: Thematic analysis of transcripts was completed using a social capital framework, which enabled exploration of the ways in which bonding, bridging and linking social capital promoted or inhibited HCV treatment uptake within a treatment-as-prevention trial.

Findings: Social capital fostered HCV treatment uptake within an HCV treatment-as-prevention trial in the prison setting. Bonding social capital encouraged treatment uptake and alleviated concerns of side effects, bridging social capital supported prison-wide treatment uptake, and linking social capital fostered trust in study personnel (including nurses and correctional officers), thereby enhancing treatment engagement.

Conclusions: Social capital, including bonding, bridging and linking, can play an important role in hepatitis C treatment-as-prevention efforts within the male prison setting.
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http://dx.doi.org/10.1111/add.15277DOI Listing
May 2021

HIV stigma by association among Australian gay and bisexual men.

AIDS 2020 09;34 Suppl 1:S53-S61

Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia.

Objective: The negative effects of HIV stigma may extend beyond those who are HIV-positive, to people who are perceived to be at risk of HIV. This article examines HIV stigma by association among Australian gay and bisexual men (GBM).

Design: Cross-sectional, online survey of 1280 Australian gay and bisexual men. This article focuses on HIV stigma from within a larger study that investigated stigma related to sexual identity.

Methods: Bivariate and multivariable comparisons were made between men who experienced HIV stigma by association and those who did not. A serial mediation model was tested to investigate relationships between GBM community attachment, sexual identity stigma, HIV testing frequency, HIV stigma by association, psychological distress, and rejection of sex partners.

Results: Results found that 5% of participants were HIV-positive, yet over 70% reported that they had been stigmatized by others for their perceived risk of acquiring HIV. Multivariable analysis indicated that HIV stigma by association was associated with more frequent HIV testing, greater GBM community attachment, experiencing stigma related to sexual identity and psychological distress. Our results suggest flow-on effects of HIV stigma by association, such as being more likely to reject other GBM on the basis of their HIV status or not testing for HIV.

Conclusion: Our results underscore the notion that HIV stigma can have broader, negative effects on HIV-affected populations. There is a need to address HIV stigma within GBM communities and society more broadly in order to encourage HIV testing and prevention among GBM.
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http://dx.doi.org/10.1097/QAD.0000000000002565DOI Listing
September 2020

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in Mutual Support Groups Coordinated by SMART Recovery Australia: Protocol for a Pilot Study.

JMIR Res Protoc 2020 Jul 9;9(7):e15113. Epub 2020 Jul 9.

SMART Recovery Australia, Sydney, Australia.

Background: Despite the importance and popularity of mutual support groups, there have been no systematic attempts to implement and evaluate routine outcome monitoring (ROM) in these settings. Unlike other mutual support groups for addiction, trained facilitators lead all Self-Management and Recovery Training (SMART Recovery) groups, thereby providing an opportunity to implement ROM as a routine component of SMART Recovery groups.

Objective: This study protocol aims to describe a stage 1 pilot study designed to explore the feasibility and acceptability of a novel, purpose-built mobile health (mHealth) ROM and feedback app (Smart Track) in SMART Recovery groups coordinated by SMART Recovery Australia (SRAU) The secondary objectives are to describe Smart Track usage patterns, explore psychometric properties of the ROM items (ie, internal reliability and convergent and divergent validity), and provide preliminary evidence for participant reported outcomes (such as alcohol and other drug use, self-reported recovery, and mental health).

Methods: Participants (n=100) from the SMART Recovery groups across New South Wales, Australia, will be recruited to a nonrandomized, prospective, single-arm trial of the Smart Track app. There are 4 modes of data collection: (1) ROM data collected from group participants via the Smart Track app, (2) data analytics summarizing user interactions with Smart Track, (3) quantitative interview and survey data of group participants (baseline, 2-week follow-up, and 2-month follow-up), and (4) qualitative interviews with group participants (n=20) and facilitators (n=10). Feasibility and acceptability (primary objectives) will be analyzed using descriptive statistics, a cost analysis, and a qualitative evaluation.

Results: At the time of submission, 13 sites (25 groups per week) had agreed to be involved. Funding was awarded on August 14, 2017, and ethics approval was granted on April 26, 2018 (HREC/18/WGONG/34; 2018/099). Enrollment is due to commence in July 2019. Data collection is due to be finalized in October 2019.

Conclusions: To the best of our knowledge, this study is the first to use ROM and tailored feedback within a mutual support group setting for addictive behaviors. Our study design will provide an opportunity to identify the acceptability of a novel mHealth ROM and feedback app within this setting and provide detailed information on what factors promote or hinder ROM usage within this context. This project aims to offer a new tool, should Smart Track prove feasible and acceptable, that service providers, policy makers, and researchers could use in the future to understand the impact of SMART Recovery groups.

Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336.

International Registered Report Identifier (irrid): PRR1-10.2196/15113.
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http://dx.doi.org/10.2196/15113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380906PMC
July 2020

Survey methods and characteristics of a sample of Aboriginal and Torres Strait Islander and non-Indigenous people who have recently used methamphetamine: the NIMAC survey.

Drug Alcohol Rev 2020 09 22;39(6):646-655. Epub 2020 Jun 22.

Infectious Diseases Aboriginal Health Research, Aboriginal Health Equity Unit, South Australian Health and Medical Research Institute, Adelaide, Australia.

Introduction And Aims: There is a need for detailed information on methamphetamine use in Aboriginal and Torres Strait Islander communities. We describe a national survey on methamphetamine use among Aboriginal and Torres Strait Islander people and non-Indigenous people.

Design And Methods: Participants aged 16 years or older who reported using methamphetamine in the past year were recruited for a cross-sectional survey through 10 Aboriginal Community Controlled Organisations. Surveys were completed anonymously on electronic tablets. Measures included the Australian Treatment Outcomes Profile, the Severity of Dependence Scale, subscales from Opiate Treatment Index and the Kessler 10. A Chronic Stress Scale was used to assess culturally situated chronic stress factors.

Results: Of the 734 participants, 416 (59%) were Aboriginal or Torres Strait Islander and 331 (45%) were female. In the previous year, most participants reported smoking (48.7%) or injecting (34%) methamphetamine and 17.4% reported daily use. Aboriginal and Torres Strait Islander people did not differ significantly from non-Indigenous participants on methamphetamine use patterns (age at first use, frequency of use, main mode of use, injecting risk, poly drug use). Aboriginal and Torres Strait Islander participants felt less able to access health care (32% vs. 48%, P < 0.001), including mental health services (19% vs. 29%, P < 0.002), were less likely to report a mental health diagnosis (50% vs. 60%, P < 0.002) and were more likely to turn to family for support (52% vs. 34%, P < 0.001).

Discussion And Conclusions: We recruited and surveyed a large sample of Aboriginal and Torres Strait Islander people from which we can derive detailed comparative data on methamphetamine use and related health service needs for Aboriginal and Torres Strait Islander and non-Indigenous Australians.
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http://dx.doi.org/10.1111/dar.13085DOI Listing
September 2020

Progress towards elimination of hepatitis C infection among people who inject drugs in Australia: The ETHOS Engage Study.

Clin Infect Dis 2020 May 18. Epub 2020 May 18.

The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.

Background & Aims: Evaluating progress towards HCV elimination is critical. This study estimated prevalence of current HCV infection and HCV treatment uptake among people who inject drugs (PWID) in Australia.

Methods: ETHOS Engage is an observational study of PWID attending drug treatment clinics and needle and syringe programs (NSP). Participants completed a questionnaire including self-reported treatment history and underwent point-of-care HCV RNA testing (Xpert® HCV Viral Load Fingerstick).

Results: Between May 2018-September 2019, 1,443 participants were enrolled (64% injected drugs in the last month, 74% receiving opioid agonist therapy [OAT]). HCV infection status was uninfected (28%), spontaneous clearance (16%), treatment-induced clearance (32%), and current infection (24%). Current HCV was more likely among people who were homeless (adjusted odds ratio: 1.47; 95%CI: 1.00, 2.16), incarcerated in previous year (2.04; 1.38, 3.02), and those injecting drugs ≥daily (2.26; 1.43, 2.42). Among those with previous chronic or current HCV, 66% (n=520/788) reported HCV treatment. In adjusted analysis, HCV treatment was lower among females (0.68; 0.48, 0.95), participants who were homeless (0.59; 0.38, 0.96), and those injecting ≥daily (0.51; 0.31, 0.89). People aged ≥45 (1.46; 1.06, 2.01) and people receiving OAT (2.62; 1.52, 4.51) were more likely to report HCV treatment.

Conclusions: Unrestricted DAA access in Australia has yielded high treatment uptake among PWID attending drug treatment and NSPs, with a marked decline in HCV prevalence. To achieve elimination, PWID with greater marginalisation may require additional support and tailored strategies to enhance treatment.
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http://dx.doi.org/10.1093/cid/ciaa571DOI Listing
May 2020

Stigmatising attitudes towards people who inject drugs, and people living with blood borne viruses or sexually transmissible infections in a representative sample of the Australian population.

PLoS One 2020 27;15(4):e0232218. Epub 2020 Apr 27.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Stigma has significant detrimental health outcomes for those affected. This study examined socio-demographic characteristics that were associated with stigmatising attitudes among the general population towards people who inject drugs, and people living with blood borne viruses or sexually transmissible infections. Questions were included in the Australian Survey of Social Attitudes (total sample = 1,001). Attitudes towards each of the target populations were measured by 5-item stigma scales. Bivariate analyses and multiple regression analyses were conducted to identify socio-demographic characteristics associated with stigmatising attitudes. Knowing a person affected by a stigmatised attribute was associated with reduced stigmatising attitudes, while voting for a conservative political party was associated with increased stigmatising attitudes. Age, gender, education, income, and marital status were each related to some stigmatising attitudes. Results also highlight differences between attitudes towards a stigmatised behaviour (i.e., injecting drug use) and stigmatised conditions (i.e., blood borne viruses and sexually transmissible infections). Identifying socio-demographic characteristics that are associated with stigmatising attitudes may have global implications for informing stigma reduction interventions, in order to promote positive health outcomes for affected communities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232218PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185717PMC
July 2020

Destabilising the 'problem' of chemsex: Diversity in settings, relations and practices revealed in Australian gay and bisexual men's crystal methamphetamine use.

Int J Drug Policy 2020 04 14;78:102697. Epub 2020 Feb 14.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2054, Australia.

In Australia, the crystalline form of methamphetamine ("crystal") is a commonly used illicit substance associated with sexual activity among gay and bisexual men. Attention to psychoactive substance use among this population is the subject of increasing global concern regarding the intentional and simultaneous combination of sex and drugs, often referred to as "chemsex". While not all gay and bisexual men who use psychoactive substances report problematic use, those who do often become representative of chemsex practices more generally, and the harms they experience become attributable to all men who use drugs for sex. The way in which these practices have been framed over the past few decades contributes to the rise of a narrow set of understandings of chemsex defined by the circumstances and behaviours presumed of drug-enhanced sexual activity. In effect, these understandings now align recognisable combinations of sexual and drug-using practices with assumed correlates of risk. The Crystal, Pleasures and Sex between Men study conducted 88 interviews with gay and bisexual men in four Australian cities between 2017 and 2018. Findings from the project revealed that men used crystal in a variety of settings and relations, which mediated their sexual practices and patterns of use. In looking at the wider context in which practices were associated with the combination of sex and drugs, we identified experiences that the contemporary discourse of chemsex-in its rhetorical proposition of at-risk behaviours and circumstances-may leave out of consideration. Our findings indicate that researchers should remain open to the variability and contingency of settings, relations and practices in gay and bisexual men's different networks when recommending public health responses to their engagement in drug-enhanced sexual activity. Accordingly, we seek to destabilise the definition of chemsex that precludes consideration of the influence of experiences beyond pre-determined risk parameters.
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http://dx.doi.org/10.1016/j.drugpo.2020.102697DOI Listing
April 2020

Perceptions and concerns of hepatitis C reinfection following prison-wide treatment scale-up: Counterpublic health amid hepatitis C treatment as prevention efforts in the prison setting.

Int J Drug Policy 2020 03 8;77:102693. Epub 2020 Feb 8.

Centre for Social Research in Health, UNSW Sydney, Level 2, Goodsell Building, Sydney NSW 2052, Australia.

Background: Hepatitis C (HCV) infection is highly prevalent within the prison setting. Direct-acting antiviral (DAA) therapies have changed the HCV treatment landscape, offering simple treatment (with minimal side-effects) and high efficacy. These advances have enabled the first real-world study of HCV treatment as prevention (TasP), the Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study. This paper draws on data from qualitative interviews completed with SToP-C participants following prison-wide DAA treatment scale-up.

Methods: Semi-structured interviews were undertaken with 23 men in prison following HCV treatment completion to identify ongoing risk practices, perceptions of strategies for HCV prevention within the prison setting, experiences of HCV treatment (as prevention), and perceptions of reinfection following cure. Analysis was undertaken using a counterpublic health lens to identify risks and perceptions of reinfection among people treated for HCV within the prison setting.

Results: Participants identified a number of challenges of meaningful HCV 'cure' in the absence of increased access to prevention strategies (e.g., opioid agonist therapy and prison needle syringe programs) along with concerns that 'cure' was only temporary whilst incarcerated. 'Cure' status included self-perceptions of being "clean", while also imposing responsibility on the individual to maintain their 'cure' status.

Conclusion: HCV DAA treatment is provided somewhat under the guise of 'cure is easy', but fails to address the ongoing risk factors experienced by people who inject drugs in prisons, as well as other people in prison who may be at risk of blood-to-blood exposure. Health messaging regarding HCV treatment and treatment for reinfection should be tailored to ensure patient-centred care. Health interventions in prison must address the whole person and the circumstances in which they live, not just the illness.
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http://dx.doi.org/10.1016/j.drugpo.2020.102693DOI Listing
March 2020

Treading lightly: Finding the best way to use public health surveillance of hepatitis C diagnoses to increase access to cure.

Int J Drug Policy 2020 01 16;75:102596. Epub 2019 Nov 16.

Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia; Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, VIC 3004, Australia; Peter Doherty Institute for Infection and Immunity, Parkville, VIC 3052, Australia; School of Population and Global Health, University of Melbourne, Parkville, VIC 3052, Australia.

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http://dx.doi.org/10.1016/j.drugpo.2019.11.004DOI Listing
January 2020

A qualitative exploration of SMART Recovery meetings in Australia and the role of a digital platform to support routine outcome monitoring.

Addict Behav 2020 02 8;101:106144. Epub 2019 Oct 8.

SMART Recovery Australia, Sydney, Australia.

Previous research has reported on the benefits of mutual support groups. However, such groups do not routinely collect data on participant outcomes. Moreover, the effect of collecting outcomes measures on these groups is unknown. The objective of this mixed methods study was to elicit participant views on using a novel, purpose built digital platform for routine outcome monitoring (ROM) as a standard component of a mutual support group. SMART Recovery, or the Self-Management and Recovery Training program, is group-based and uses professional clinicians to facilitate discussion and foster mutual support for a range of addictive behaviours, alongside Cognitive Behavioural Therapy and Motivational Interviewing techniques. This paper reports on the qualitative component of this study and how participants perceive ROMs, and the potential shift to technological resources. Twenty semi-structured telephone interviews were conducted with participants from SMART Recovery groups across New South Wales, Australia. Participants discussed their use of mutual support within group meetings to manage their recovery, including: naming their goals in front of peers; learning from clinicians and group discussion; and developing reciprocal and caring relationships. They also described any previous experience with routine outcomes measures and how digital technologies might enhance or hinder group function. Participants valued mutual support groups and reported that digital technologies could be complementary to physical, weekly group meetings. They were also concerned that the introduction of technological resources might pose a threat to physical meetings, thereby risking their access to mutual support. Findings have implications for the implementation of ROM when delivered via digital mechanisms, and indicate threats and opportunities that warrant consideration for future initiatives.
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http://dx.doi.org/10.1016/j.addbeh.2019.106144DOI Listing
February 2020

The role of social support in moderating the relationship between HIV centrality, internalised stigma and psychological distress for people living with HIV.

AIDS Care 2020 07 4;32(7):850-857. Epub 2019 Sep 4.

Centre for Social Research in Health, The University of New South Wales, Sydney, Australia.

Research has documented the negative impact of stigma on health outcomes for people living with HIV (PLHIV). How central HIV is to the identity of the individual may increase the negative effects of stigma, including greater psychological distress, while having strong social supports may play a buffering role. This study aimed to establish whether internalised stigma mediates the relationship between the centrality of HIV identity and psychological distress, while also assessing the role of social support as a moderator. PLHIV ( = 181) responded to a survey assessing experiences of living with HIV focussed on centrality of HIV identity, internalised stigma, and wellbeing. After controlling for age and education, findings from the mediation analysis show that the more central HIV is to an individual's identity, the more stigma is internalised and the greater the negative impact on psychological wellbeing. However, this is only the case for people with low levels of social support. Regardless of how central HIV is to identity, social support appears to act as a buffer and promote positive wellbeing. For those working with PLHIV, promoting the importance of good social support systems may be one way to address some of the negative impacts of stigma.
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http://dx.doi.org/10.1080/09540121.2019.1659914DOI Listing
July 2020

Involving peers in research: the UNSW community reference panel.

Harm Reduct J 2019 08 30;16(1):52. Epub 2019 Aug 30.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

There is limited literature about how to best "do" community involvement in research and no one model of community involvement in research that has been shown to be more effective than others. This paper presents one way to receive the input of people with experiences relevant to research with marginalised groups, including people who use and inject drugs. The UNSW Community Reference Panel is a virtual network of people from across Australia who are engaged to provide input and consultation on research design, processes, materials, and outputs. Although this panel goes some way towards community involvement and consultation in the research process, it does not take the place of other aspects of community governance and ownership, especially as informed by principles of research with Indigenous peoples. This model is an example of a means to bring the voices and perspectives of people who are generally excluded from the research and decision-making structures that affect their lives, including people who inject drugs, to influence the questions that are asked in research, how research gets done, and to what purpose research findings are put.
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http://dx.doi.org/10.1186/s12954-019-0325-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716864PMC
August 2019

Elimination of hepatitis C virus infection among people who use drugs: Ensuring equitable access to prevention, treatment, and care for all.

Int J Drug Policy 2019 10 23;72:1-10. Epub 2019 Jul 23.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

There have been major strides towards the World Health Organization goal to eliminate hepatitis C virus (HCV) infection as a global public health threat. The availability of simple, well-tolerated direct-acting antiviral therapies for HCV infection that can achieve a cure in >95% of people has provided an important tool to help achieve the global elimination targets. Encouragingly, therapy is highly effective among people receiving opioid agonist therapy and people who have recently injected drugs. Moving forward, major challenges include ensuring that new infections are prevented from occurring and that people who are living with HCV are tested, linked to care, treated, receive appropriate follow-up, and have equitable access to care. This editorial highlights key themes and articles in a special issue focusing on the elimination of HCV among people who inject drugs. An overarching consideration flowing from this work is how to ensure equitable access to HCV treatment and care for all. This special issue maps the field in relation to: HCV prevention; the cascade of HCV care; strategies to enhance testing, linkage to care, and treatment uptake; and HCV treatment and reinfection. In addition, papers draw attention to the 'risk environments' and socio-ecological determinants of HCV acquisition, barriers to HCV care, the importance of messaging around the side-effects of new direct-acting antiviral therapies, the positive transformative potential of treatment and cure, and the key role of community-based drug user organizations in the HCV response. While this special issue highlights some successful efforts towards HCV elimination among people who inject drugs, it also highlights the relative lack of attention to settings in which resources enabling elimination are scarce, and where elimination hopes and potentials are less clear, such as in many low and middle income countries. Strengthening capacity in areas of the world where resources are more limited will be a critical step towards ensuring equity for all so that global HCV elimination among PWID can be achieved.
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http://dx.doi.org/10.1016/j.drugpo.2019.07.016DOI Listing
October 2019

Stigma, Anxiety, and Depression Among Gay and Bisexual Men in Mixed-Orientation Marriages.

Qual Health Res 2020 03 17;30(4):622-633. Epub 2019 Jul 17.

UNSW Sydney, Sydney, New South Wales, Australia.

The mental health of gay and bisexual men in mixed-orientation marriages is poorly understood. In this article, the authors explore the development of anxiety and depression among gay and bisexual men in heterosexual marriages. Sixteen men, living in the Australian states of New South Wales, Queensland, Victoria, and Tasmania were interviewed throughout 2016 and 2017. An analysis of interviews identified four main themes, namely, compulsory heterosexuality, existential distress, compartmentalization, and integration and resolution. Participants reported experiencing anxiety and depression, which were exacerbated by the stigmatization of same-sex attraction and by an overwhelming distress from feelings of shame and guilt regarding their marital infidelity. Findings indicate that gay and bisexual men in mixed-orientation marriages develop anxiety and depression in response to the exigencies of compulsory heterosexuality and the compartmentalizing of same-sex attraction and identity during heterosexual marriage. Coming-out as same-sex attracted resolved men's distress by facilitating an integrative self-structure.
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http://dx.doi.org/10.1177/1049732319862536DOI Listing
March 2020

Making sense of 'side effects': Counterpublic health in the era of direct-acting antivirals.

Int J Drug Policy 2019 10 17;72:77-83. Epub 2019 Jun 17.

Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia. Electronic address:

Direct-Acting Antiviral (DAA) treatments for hepatitis C have been widely promoted by health promotion professionals and medical clinicians as being 'side-effect free'. In this paper, we draw on data that troubles this approach. We used a mixed method design to collect data from people who inject drugs, and who were DAA treatment naïve, in New South Wales, Australia. We describe knowledge about and perceptions of DAA treatment. We found that concerns about side effects were commonplace - for example, one-third (37%) of participants who had not taken up treatment worried "a lot" about 'side effects' - and that these concerns were underpinned by a general distrust and suspicion of medical institutions and their technologies, including widespread negative associations linked to interferon treatment. In trying to make sense of this, we draw on the concept of counterpublic health and its recognition that the everyday health needs, knowledges and aspirations of subordinated citizens frequently contradict the normative frameworks governing public health interventions. We suggest that failing to engage with concerns about 'side effects' could hinder elimination efforts. Our analysis suggests that addressing the issue of 'side effects' within the 'public' discourse of DAAs will not dampen or damage elimination efforts, as some might fear, but rather it will legitimate the concerns of people who inject, decrease their suspicion of medical interventions, and better support the uptake of DAA treatments.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.002DOI Listing
October 2019

Enhancing engagement in hepatitis C care among people who inject drugs.

Addiction 2019 12 26;114(12):2104-2106. Epub 2019 Jun 26.

Centre for Social Research in Health, University of New South Wales, Sydney, Australia.

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http://dx.doi.org/10.1111/add.14698DOI Listing
December 2019

Hepatitis C virus testing, liver disease assessment and direct-acting antiviral treatment uptake and outcomes in a service for people who are homeless in Sydney, Australia: The LiveRLife homelessness study.

J Viral Hepat 2019 08 2;26(8):969-979. Epub 2019 May 2.

The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.

People who are homeless have increased hepatitis C virus (HCV) infection risk, and are less likely to access primary healthcare. We aimed to evaluate HCV RNA prevalence, liver disease burden, linkage to care and treatment uptake and outcomes among people attending a homelessness service in Sydney. Participants were enrolled in an observational cohort study with recruitment at a homelessness service over eight liver health campaign days. Finger-stick whole-blood samples for Xpert® HCV Viral Load and venepuncture blood samples were collected. Participants completed a self-administered survey and received transient elastography and clinical assessment by a general practitioner or nurse. Clinical follow-up was recommended 2-12 weeks after enrolment. For participants initiating direct-acting antiviral (DAA) therapy, medical records were audited retrospectively and treatment outcome data were collected. Among 202 participants (mean age, 48 years), 82% were male (n = 165), 39% (n = 78) reported ever injecting drugs, of whom 63% (n = 49) injected in the previous month. Overall, 23% (n = 47) had detectable HCV RNA and 6% (n=12) had cirrhosis. HCV RNA prevalence among participants with either injecting or incarceration history was 35% (37/105), compared to 4% (3/73) among participants without these risk factors. Among those with detectable HCV RNA, 23 (49%) commenced therapy, of whom 65% (n = 15) achieved sustained virological response, while the remainder had no available treatment outcome. No participant had documented virological failure. HCV DAA treatment uptake among people attending a homelessness service was encouraging, but innovative models of HCV care are required to improve linkage to care and treatment uptake among this highly marginalized population.
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http://dx.doi.org/10.1111/jvh.13112DOI Listing
August 2019

Priorities and recommended actions for how researchers, practitioners, policy makers, and the affected community can work together to improve access to hepatitis C care for people who use drugs.

Int J Drug Policy 2019 04 8;66:87-93. Epub 2019 Feb 8.

The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia. Electronic address:

It is estimated that 6.1 million people with recent injecting drug use (PWID) are living with hepatitis C virus (HCV). Although HCV-related morbidity and mortality among PWID continues to increase, the advent of direct acting antiviral (DAA) HCV regimens with cure rates >95% provides an opportunity to reverse the rising burden of disease. Additionally, given evidence that opioid substitution therapy and high-coverage needle and syringe programs can reduce HCV incidence by up to 80%, there is an opportunity to reduce HCV transmission with increased coverage of harm reduction services. However, there are significant patient, provider, health system, structural, and societal barriers that impede access to HCV prevention and care for PWID. The International Network on Hepatitis in Substance Users (INHSU), in collaboration with the Australasian Society for HIV, Viral Hepatitis, Sexual Health Medicine (ASHM), Harm Reduction International, the Canadian Network on Hepatitis C, Canadian Research Initiative in Substance Misuse, the National Viral Hepatitis Roundtable, Médecins du Monde and CATIE, held a roundtable discussion prior to the Harm Reduction Conference in Montreal, Canada on 13th May 2017 to discuss how to improve HCV prevention and care for PWID. Over 100 international researchers, practitioners, policy makers, advocates, and affected community members came together to discuss shared priorities for action, develop actionable next steps and to create partnerships to enable application of priorities. This paper highlights the key priority areas identified by participants including: enhancing global coverage of harm reduction services; addressing punitive drug policies; ensuring access to affordable HCV diagnostics and treatment; improving the evidence-base for HCV prevention, testing, linkage to care and treatment; implementing integrated HCV programs; advancing peer-based models of HCV care; and tackling social determinants of health inequalities for PWID. This paper also highlights the recommended actions for each priority identified by the participants from this roundtable.
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http://dx.doi.org/10.1016/j.drugpo.2019.01.012DOI Listing
April 2019

Beyond interferon side effects: What residual barriers exist to DAA hepatitis C treatment for people who inject drugs?

PLoS One 2018 30;13(11):e0207226. Epub 2018 Nov 30.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Recent advances in the efficacy and tolerability of hepatitis C treatments and the introduction of a universal access scheme for the new Direct Acting Antiviral (DAA) therapies in March 2016, has resulted in a rapid increase in the uptake of hepatitis C treatment in Australia. Despite these positive developments, recent data suggest a plateauing of treatment numbers, indicating that more work may need to be done to identify and address ongoing barriers to hepatitis C treatment access and uptake. This paper aims to contribute to our understanding of the ongoing barriers to DAA therapies, with a focus on people who inject drugs. The paper draws on participant interview data from a qualitative research study based on a participatory research design that included a peer researcher with direct experience of both hepatitis C DAA treatment and injecting drug use at all stages of the research process. The study's findings show that residual barriers to DAA treatment exist at personal, provider and system levels and include poor venous access, DAA treatments not considered 'core-business' by opioid substitution treatment (OST) providers, and patients having to manage multiple health and social priorities that interfere with keeping medical appointments such as childcare and poor access to transport services. Further, efforts to increase access to and uptake of DAA hepatitis C treatment over time will require a focus on reducing stigma and discrimination towards people who inject drugs as this remains as a major barrier to care for many people.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207226PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6267952PMC
April 2019