Hepatitis B, Hepatitis C, tuberculosis and sexually-transmitted infections among HIV positive patients in Kazakhstan

In contrast with global trends, HIV prevalence in Kazakhstan and other Central Asian countries has been rising in recent years. In this study, we analyzed hepatitis B (HBV), hepatitis C (HCV), tuberculosis (TB) and sexually-transmitted (STI) co-infections among 500 HIV positive study participants recruited from all regions of Kazakhstan. Among our study participants, 27%, 8%, 2%, and 5% were coinfected with, respectively, HCV, TB, HBV, and STI. A considerable proportion of the study participants was also found with triple or quadruple infections of HCV/TB (12%), TB/STI (0.8%), HCV/STI (2%), HCV/HBV (1%), HBV/TB (0.4%), HBV/STI (0.2%), HBV/HCV/TB (0.4%), HBV/HCV/STI (0.2%), or HCV/TB/STI (0.2%). Strong associations were found of certain age groups, duration of HIV infection, and practices of injection drug use and sexual contact with PLWH, with co-infections of HIV/HCV and HIV/TB. The odds of having death was 4.07 times higher with TB/HIV as compared to other co-infections. Co-occurrence of HIV with HCV, HBV, and TB infections among participants of this study highlights the necessity of regular screening for HCV infection among HIV infected patients, together with implementation of vigilant vaccination protocols against HBV and TB. Additionally, persons who inject drugs especially need to be focused for harm reduction efforts that include opiate substitution therapy, needle or syringe exchange programs, regular screening, and increased availability of ART and direct acting antivirals.

“I want to stop using drugs. What should I do next?”

The care of individuals living with HIV who inject drugs involves a unique subset of patients. People who inject drugs have become a key driver of new cases in the United States as the opiate epidemic has impacted such a large group of the population. The proliferation of oral narcotics prompted increased use of injectable opiates as the sale of oral medications became both more expensive and difficult. This epidemic has been confluent with the development of addiction, which can be very hard to treat, as well as the impact of adherence of active addiction on antiretroviral therapy medications. The challenge to the clinician caring for people who inject drugs is to become fluent in the treatment of HIV, hepatitis C virus, and hepatitis B virus, the psychosocial skills of dealing with addiction, and opiate substitution therapy. The chapter outlines approaches to care for this population that can assist with these clinical challenges as the actual selection of medications will not be unique for this population. Therefore, different approaches are being learned, not different sets of medications (except for opiate substitution treatment).

Political and Governance Challenges to Achieving Global HIV Goals with Injecting Drug Users: The Case of Pakistan

Background: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently set the ambitious "90-90-90 target" of having 90% of people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve viral suppression by 2020. This ambitious new goal is occurring in a context of global "scale-down" following nearly a decade of heightened investment in HIV prevention and treatment efforts. Arguably international goals spur action, however, setting unrealistic goals that do not take weak health systems and variations in the nature of the epidemic across countries into consideration may set them up for failure in unproductive ways that lead to a decline in confidence in global governance institutions. This study explores how policy actors tasked with implementing HIV programs navigate the competing demands placed upon them by development targets and national politics, particularly in the current context of waning international investments towards HIV. Methods: To examine these questions, we interviewed 29 key informants comprising health experts in donor organizations and government employees in HIV programs in Pakistan, a country where HIV programs must compete with other issues for attention. Themes were identified inductively through an iterative process and findings were triangulated with various data sources and existing literature. Results: We found both political and governance challenges to achieving the target, particularly in the context of the global HIV scale-down. Political challenges included, low and heterogeneous political commitment for HIV and a conservative legal environment that contributed towards a ban on opiate substitution therapy, creating low treatment coverage. Governance challenges includedstrained state and non-governmental organization (NGO) relations creating a hostile service delivery environment, weak bureaucratic and civil society capacity contributing to poor regulation of the health infrastructure, and resource mismanagement on both the part of the government and NGOs. Conclusion: Our findings suggest that in a context of waning international attention to HIV, policy actors on the ground face a number of practical hurdles to achieving the ambitious targets set out by international agencies. Greater attention to the political and governance challenges of implementing HIV programs in low- and middle-income countries (LMICs) could help technical assistance agencies to develop more realistic implementation plans.

Integrated Hepatitis C Care for People Who Inject Drugs (Heplink): Protocol for a Feasibility Study in Primary Care (Preprint)

BACKGROUND Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and death. Drug use remains the significant cause of new infections in the European Union, with estimates of HCV antibody prevalence among people who inject drugs ranging from 5% to 90% in 29 European countries. In Ireland and the European Union, primary care is a key area to focus efforts to enhance HCV diagnosis and treatment among people who inject drugs. OBJECTIVE The Heplink study aims to improve HCV care outcomes among opiate substitution therapy (OST) patients in general practice by developing an integrated model of HCV care and evaluating its feasibility, acceptability, and likely efficacy. METHODS The integrated model of care comprises education of community practitioners, outreach of an HCV-trained nurse into general practitioner (GP) practices, and enhanced access of patients to community-based evaluation of their HCV disease (including a novel approach to diagnosis, that is, Echosens FibroScan Mini 430). A total of 24 OST-prescribing GP practices were recruited from the professional networks and databases of members of the research consortium. Patients were eligible if they are aged ≥18 years, on OST, and attend the practice for any reason during the recruitment period. Baseline data on HCV care processes and outcomes were extracted from the clinical records of participating patients. RESULTS This study is ongoing and has the potential to make an important impact on patient care and provide high-quality evidence to help GPs make important decisions on HCV testing and onward referral. CONCLUSIONS A substantial proportion of HCV-positive patients on OST in general practice are not engaged with specialist hospital services but qualify for direct-acting antiviral drugs treatment. The Heplink model has the potential to reduce HCV-related morbidity and mortality. REGISTERED REPORT IDENTIFIER RR1-10.2196/9043