Visits to primary care physicians and the impact on Hepatitis C Virus (HCV) transmission among HCV- seronegative persons who inject drugs

Introduction: Persons who inject drugs (PWID) are confronted with a considerably high risk of infection with the Hepatitis C Virus (HCV). To effectively avert HCV transmission rates in this population, international guidelines recommend combining multiple prevention strategies. While the role of primary care physicians (PCP) in HCV prevention is increasingly emphasized, PWID have generally suboptimal contacts with primary healthcare services, and little is known about the factors that may enhance or deter contacts. Further, no study has yet examined the effect of visiting a PCP on HCV transmission among PWID. Aims: This investigation had three specific objectives: (I) to examine the prevalence of visiting a PCP, (II) to explore the associated factors, and (III) to assess the effect of visiting a PCP as part of a comprehensive prevention approach, on HCV transmission, among PWID at risk of HCV infection. Methods: A prospective cohort study, HEPCO, was carried out among HCV-seronegative PWID in Montréal, Canada (2004 – 2011). At each semi-annual visit, an interviewer-administered questionnaire elicited information on socio-demographic factors, drug use patterns and related behaviors, as well as healthcare and community-based services use. Blood samples were drawn and tested for HCV antibodies. Using the Gelberg-Andersen Health Model, logistic regression analyses were carried out on baseline data to examine predisposing, need and enabling factors associated with PCP visits. To investigate the association between visiting a PCP and HCV incidence, a Cox-regression model was conducted among participants reporting needle exchange program (NEP) attendance at baseline. Results: Of 349 participants having completed the baseline questionnaire (80.8% male, mean age: 34), 32.1% reported having visited a PCP in the previous six months. In logistic regression analyses, among predisposing factors, male gender (Adjusted Odds Ratio (AOR)= 0.45, [0.25 - 0.82]), chronic homelessness (AOR= 0.09, [0.01 – 0.69]) and cocaine injection (AOR= 0.46, [0.28-0.75]) were negatively associated with PCP visits. Need factors did not correlate significantly with the outcome. Among enabling factors, reporting a greater proportion of the income through stable sources (AOR= 2.07, [1.18 – 3.62]), contact with food banks (AOR= 2.02, [1.20 – 3.38]) and contact with street nurses (AOR= 3.85 [1.49 – 9.96]) were positively associated with PCP visits. Among 160 HCV-seronegative PWID having attended NEP at baseline and followed-up at least once, HCV incidence was 23.1 per 100 person-years [18.0 – 29.3]. In a multivariate Cox regression model adjusting for age, gender and HCV-risk factors, visiting a PCP was found to significantly reduce the risk of HCV-seroconversion (Adjusted Hazard Ratio= 0.52, [0.27 – 0.98]). Interpretation: Only a minority of PWID reported having visited a PCP. While specific predisposing factors seem to render PWID less likely to visit PCP, contacts with community-based outreach services may play an important role in engaging these individuals into primary care. Further, findings suggest that visiting a PCP, as part of a comprehensive HCV prevention approach, has a protective effect on HCV transmission.

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