Ir Med J. 2005 March; 98 (3): 73-74         


Abstract
The majority of injecting drug users in Ireland are infected with hepatitis C (HCV) and many attend general practice for methadone maintenance treatment. To describe awareness and experience of HCV infection, related investigations and treatment, a semi-qualitative interview study of current or former heroin users attending a general practice was carried out. Twenty-five patients (69% of total) were interviewed, of whom 23 were on methadone maintenance therapy at the time of the interview and 22 were HCV positive. While awareness of harm reduction measures and health implications of the infection was good, continued high-risk activity was common. Negative experiences at diagnosis, of subsequent investigations and treatments received were common. Only one person had been treated for HCV. We conclude there are a number of barriers to effective HCV management among heroin users and further research is needed to improve our understanding of this issue.

Introduction
Hepatitis C (HCV) infection is common among people who inject drugs or who have received contaminated blood products and those with chronic infection are at risk of cirrhosis and hepatocellular carcinoma^1,2. In a recent survey, 73% of patients attending general practice for methadone maintenance treatment in the Eastern Regional Health Authority (ERHA) area were HCV positive³.

Clinical guidelines for HCV management have recently been developed⁴. Effective implementation of such guidelines requires an understanding of existing health beliefs among the population at risk. Our aim was to document existing knowledge among current or former heroin users attending general practice regarding HCV infection, and to describe their experience of the infection, related diagnostic and therapeutic interventions.

Methods
The study took place in a general practice in an area of Dublin city with a longstanding history of heroin misuse.⁵ The practice had approximately 1300 patients eligible for free medical care under Ireland's General Medical Services (GMS) scheme, provided methadone maintenance treatment to 14 patients and had a further 22 patients who had used heroin registered with the practice.

While testing (and counselling) for HCV and other bloodborne virus infections was offered in the practice at the time of the study, other agencies in the area also provided this service and these included: specialist addiction treatment services, prison medical services, hepatology and other secondary care services.

All patients presenting to the practice over a six-week period in 2002 who had used heroin in the past were invited to participate in the study. The subject matter of the interview, its confidential nature and the anonymity of the data collected were explained by one of the GP principals in advance. Those willing to be interviewed were asked to present to a member of the research team, who had no input into clinical care.

An interviewer-administered semi-structured questionnaire collected data on: demography, previous heroin use, knowledge of issues relevant to those at risk of HCV infection, experience of HCV-related investigations and treatments (available from the authors on request). Bloodborne virus status was validated by cross-referencing with clinical records.

The transcripts were analysed manually, a category code applied to each section of meaningful text, appropriate indexing used to identify common themes, and the process repeated by two researchers independently. The quotations presented reflect the dominant themes identified ⁶. Quantitative data was analysed using Statistical Packages for the Social Sciences (Version 8.0).

The Irish College of General Practitioners Research Ethics Committee granted approval for this study.

Results

Quantitative data
Twenty-five patients were interviewed (69% of total number of current or former heroin users attending the practice). Although the sample was representative of all drug users attending the practice, it was older and contained relatively fewer males than a larger sample attending general practice for methadone maintenance treatment (see table 1)⁷.

Twenty-three were currently being prescribed methadone (14 at the practice and nine by local specialist addiction treatment services). Eight admitted using heroin in the six months prior to the interview. Fifteen had consumed alcohol in the previous week, with nine drinking more than the recommended weekly amount (14 units in women, 21 in men).

Those attending the practice for methadone maintenance treatment were less likely to report using heroin in the previous six months (29% compared to 44%) and more likely to report drinking alcohol excessively (43% compared to 11%), but neither to a statistically significant degree (p=0.40 and p=0.11 respectively).

All had heard of HCV, 22 had consulted a healthcare professional about HCV in the preceding year and 21 knew HCV infection was caused by injecting.

Twenty-two (88%) reported they were HCV positive. Of these, 21 were aware of the harmful effects of alcohol but 13 indicated their consumption had remained the same or had increased since diagnosis. Eight had further investigations for chronic HCV infection and one person had received antiviral therapy.

Eight of those who were HCV positive reported neither drinking alcohol excessively nor using heroin in the previous six months and four of these had been referred to secondary care for further investigations.

Qualitative data
Healthcare professionals and friends were the main sources of information about HCV. The sample attributed a wide range of health problems, (e.g. liver, immune, and renal) to HCV infection and identified 'not sharing needles', 'adopting safe sexual practices' and 'not using drugs' as ways to avoid infection.

Common reasons for drinking more alcohol since diagnosis included: to help psychological problems and to substitute for heroin.

"I'm not spending as much (money) on drugs, and I'm not thinking in the morning about how much money I have to score, so I drink more!"

Those who had reduced their consumption of alcohol since diagnosis did so because of concerns about health and as part of overall lifestyle change. Providing more information about harmful effects of alcohol and a need to consider alcohol in the context of a person's other addictions were suggested as ways to help people reduce alcohol intake.

"Seeing videos of what alcohol actually does to your liver when you have hepatitis, and giving more information about it (would be useful)."

When asked to recall the episode at which they were diagnosed with HCV infection, anxiety and resignation were the feelings reported:

"I wouldn't mind but I was in bits waiting for the results...the doctor was there going 'now... you have hepatitis C.' I was there going 'hurry up and tell me about the (HIV) virus.'"

While some people highlighted good practice on the part of the agency that diagnosed the infection, others felt the process was impersonal or that more information should have been given:

"No, the nurse was brilliant."

"The doctor just walked in and said I was HIV and Hep C positive - and walked back out. He said he would get a counsellor and send them up...but no-one came."

"I wanted to know what hepatitis is, what is needed for prevention, and what to do, now I have it."

Among those who had been referred for further investigations, reasons for not attending included anxiety and being too busy.

"I have to go to work! Sure the doctor is always telling me to go in and get my bloods done when I'm here, and what do I always do but run on out!"

Although considerable 'mythology' surrounding liver biopsies was apparent, those with direct knowledge of the intervention reported a positive attitude towards the test. However, negative perception of antiviral therapy is common.

"I heard stories from friends saying that they put a big hook in your side and take out part of your liver, but it wasn't like that at all."

"I was 13 stone, clean and didn't have to rely on drugs or anything, but after two months (of treatment with interferon) I had lost a stone, lost my appetite and become depressed. I remember I would get up in the morning, stick a needle in my stomach and then stick another one in my arm."

Discussion
These findings cannot be extrapolated to all heroin users or general practices in Ireland. The sample represents the majority of current or former heroin users attending one practice, some patients may have had a drug problem not known to the practice and self-reported information may have underestimated some activities.

Patients attending the practice for methadone maintenance had all been assessed by specialist addiction treatment services and stabilised on methadone prior to discharge to general practice and therefore have considerable exposure to health promotion messages. The relatively higher proportion who reported excessive alcohol consumption was an unexpected and worrying finding, but is possibly explained by the qualitative data which describes how individuals substitute dependence on one substance (heroin) with dependence on another (alcohol).

The findings that a minority had further investigations and only one person had been treated for HCV should be viewed in the context of only eight of the sample reporting they had not used heroin in the previous six months or were drinking alcohol excessively.

Problems caring for HCV among drug users in general practice include screening and under-referral^8,9 .As well as continued risk activity, this study suggests concerns regarding interventions and prior negative experiences of health services may be important factors in poor compliance, as with HIV infection^10,11 .

Recently developed clinical guidelines for the management of HCV among drug users attending general practice in Ireland recommend: providing lifestyle advice, screening for bloodborne viruses and facilitating subsequent diagnostic and therapeutic interventions.4 This paper has identified several barriers that need to be addressed to successfully implement these guidelines.

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