Study participants

Instruments and measures

Demographics for both patients and MMT staff and drug use history for patients were collected via a self-developed questionnaire.

Statistical analyses

Statistical Product and Service Solutions 20.0 (SPSS 20.0) was used to conduct the statistical analyses. Continuous data are presented as the mean and SD. Between-group differences for continuous variables were evaluated using Student’s t test. Between-group comparisons for categorical variables were performed using the chi-square test or Fisher’s exact test when necessary.

Characteristics of the participants and hepatitis prevalence

A total of 70% of patients tested were positive for HCV. Among those tested positive, 38.1% reported their HCV status as negative or unknown. For HCV-negative patients, 16.7% reported that their test results were positive. Additionally, 8.3% of the participants were HBV positive. Participants who were HCV negative were significantly more likely to be infected with HBV compared to those who were HCV positive (χ ² = 4.156, p = 0.041). No participants were infected with HIV.

HCV knowledge and risk factors

In this study, 15% of patients reported drinking alcohol during the last year, and 8.3% met the criteria of harmful drinking. HCV-positive patients displayed more harmful drinking behavior than HCV-negative patients, but the difference was not significant.

Overall, three quarters of the patients had a self-reported poor health situation, and 45.4% had been depressed in the past 6 months. In total, 44.9% of the participants experienced mild depression or more severe depression symptoms in the last week according to the BDI and 16.3% expressed suicide notions. HCV-positive participants were more likely to have suicide notions compared to HCV-negative participants.

Patients’ perceptions of HCV-related services

MMT staff characteristics and HCV-related services provided in their clinics

Main findings of this study

To the best of our knowledge, this study was the first to investigate HCV knowledge, related services provided, and barriers against HCV-related services for both patients and staff in MMT clinics in China. In the current study, 70% of the participants were HCV positive; thus, the infection rate was significantly higher than in two other studies conducted in MMT clinics 3 years ago (57.0 and 51.3%, respectively) [7, 16]. Consistent with previous studies, many HCV-positive patients were not aware of their serostatus due to limited knowledge and the long duration of clinical progression of HCV infection. There were no epidemiological or longitudinal data; thus, we could not determine the reasons for the increasing HCV infection rate, but the sharp increase of infection rate shows us that long-term follow-up is necessary to monitor changes in patients’ HCV status.

Regarding HCV knowledge, similar to other studies conducted in China and the western countries, both patients and staff had limited HCV knowledge. The patient HCV knowledge score was the same as a previous study in China [16], whereas it was lower than that reported in a US study, which had a mean score of 11.1 (4.1) [21]. The extremely poor HCV knowledge of the MMT staff (mean score of 10.9 (3.1)) is alarming because given individual’s perceptions about drug-related risks are determined in part by their knowledge. The limited knowledge would be a greater barrier for patients accessing HCV-related services and can also decrease staff’s self-confidence to provide related services. Similar to a previous study, needle sharing rates were fairly low compared to other regions in China [7, 8].

Unprotected sexual behavior was confirmed in this study; almost 10% of patients reported having had multiple sexual partners, and more than 10% reported not using condoms with casual or commercial partners. The primary route of HCV transmission was through infected blood; it remains controversial whether hepatitis C can be transmitted through sexual activity. However, condom use was also recommended to prevent HCV transmission, particularly in those with multiple partners who might have a higher risk of erosion to the genitalia. Because drug users are a high-risk population for HCV transmission, protective sexual behavior education should be provided in the prevention program.

Other risk factors that will potentially accelerate the progress to severe liver disease in HCV-positive patients, including alcohol consumption and co-infection of HCV and HBV, have been identified in this study. These findings suggest that individual interventions should be provided to HCV-positive patients in MMT clinics.

Barriers preventing patients from using HCV-related services

As shown in Table 3, patients expressed the needs to receive HCV-related education, testing, and medical support when they receive treatment, although there were no differences between HCV-positive and HCV-negative patients. However, the patients also described their attitude regarding the barriers that may prevent them from using current services. More than three fourths of the patients reported that the cost of medical treatment prevented them from receiving medical treatment. Other barriers existed, such as difficulty in finding HCV treatment institutes and lacking time to receive treatment. In China, most drug users were not employed and thus did not have social health insurance. Therefore, even if they had the motivation to access medical treatment, economic barriers remained. These barriers prevented patients from accessing therapy, particularly the combination of multiple barriers in the system, which indicates that clinical interventions may not be enough to change the situation; therefore, the government should make more effective measures to improve access.

HCV-related services in MMT treatment

Overall, the results were not optimistic regarding the HCV knowledge of MMT staff and related services provided in their treatment site. A few more issues were present in this study. It is difficult for staff with limited education who are relatively older to learn new intervention skills. The average time spent working in MMT clinics was 45.3 (20.5) months; however, only 16.9% of staff reported received HCV-related training. Given the limited resources of these clinics, it is difficult for them to provide HCV education and counseling to patients during their routine work. More than half of the staff reported providing pre- and post-test counseling to patients, but most HCV-positive patients were not aware of their HCV status, which indicated that standard HCV testing counseling was not delivered to the patients. From our qualitative research, we found that there was no uniform procedure to inform patients of their HCV test results even though the HCV antibody test was a routine screening test in the MMT clinics. For example, a patient stated that “withdraw blood when I get the treatment, but nobody told me why”, “staff did not tell me the test result, they posted it on the blackboard, I do not understand the meaning of positive and negative”. Limited HCV service for drug users has been addressed in other studies as well. The barriers come from both individuals and the entire system and include the limited resources in MMT clinics, the overload of patient cases, and limited welfare for patients. HCV intervention should be a “combination intervention,” that is, it should involve all possible resources; when all these services are combined in MMT clinics, the combination intervention will benefit the patients [22].

We acknowledge a number of limitations in this study. First, the patients in our study were recruited from Shanghai MMT clinics and thus may not be representative of patients in other areas. Second, we could not exclude the possibility of self-reported bias in the drug users. Finally, there may be other barriers or facilities that prevent or enhance the HCV service that we did not examine in the current study. Future work will be conducted to clarify these issues.