Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

Are we ready to treat hepatitis C virus in individuals with opioid use disorder: assessment of readiness in European countries on the basis of an expert-generated model

Individuals with a history of injecting drugs have a high prevalence of chronic hepatitis C (HCV) infection. Many have a history of opioid use disorder (OUD). Despite novel treatments with improved efficacy and tolerability, treatment is limited in the group. A faculty of experts shared insights from clinical practice to develop an HCV care-readiness model. Evidence and expert knowledge was collected. Ten experts developed a model of three factors (with measures): 'healthcare engagement', 'guidance' and 'place'. Overall, 40-90% of individuals with OUD engage with drug treatment services. Ten of 12 HCV guidelines provided specific advice for the OUD population. Ten of 12 OUD care guidelines provided useful HCV care advice. In 11 of 12 cases, location of HCV/drug treatment care was in different places. This readiness assessment shows that there are important limitations to successful HCV care in OUD. Specific actions should be taken: maintain/increase access to OUD treatment services/opioid agonist therapy, updating HCV guidance, locate care in the same place and allow wider prescribing of anti HCV medicines.

Direct-acting antiviral agents for HCV infection affecting people who inject drugs

Globally, 12 million people are estimated to have injected drugs in the past year, 50% of whom have chronic HCV infection, with people who have previously injected drugs presenting an additional large reservoir of infection. The availability of simple and tolerable interferon-free direct-acting antiviral agents (DAAs) for HCV infection, which have a cure rate of >95% represents one of the most exciting advances in clinical medicine in the past few decades. Adherence and response to DAA therapy among people who inject drugs (PWID) receiving opioid substitution therapy (OST) in clinical trials are comparable to populations without a history of injecting drugs. Further data are required among current PWID not receiving OST. Given the potential prevention benefits of treatment, DAAs have enhanced cost-effectiveness among PWID. As HCV therapy is expanded to populations of PWID with high-risk behaviours for re-exposure, acknowledgement that HCV reinfection will occur is crucial, and appropriate strategies must be in place to maximize prevention of reinfection and offer retreatment for reinfection. This Review will also discuss essential components for broadening access to HCV care for PWID as we strive for the global elimination of HCV infection.

Epidemiology of Hepatitis C Virus Among People Who Inject Drugs: Protocol for a Systematic Review and Meta-Analysis

Background

Hepatitis C virus (HCV) is a persistent epidemic among people who inject drugs (PWID), and PWID remain as the population experiencing the most significant impact of HCV-related morbidity and mortality worldwide.

Objective

The purpose of this systematic review and meta-analysis is to synthesize data on the epidemiology of HCV infection among PWID. Our main objectives are to characterize the global and regional distribution and determinants of HCV infection among PWID.

Methods

A search strategy is conducted that involves both the electronic and manual retrievals of literature. Reports are included in this review if they present data published between 2006 and 2015 on prevalent or incident HCV infection among current or former PWID. Standard meta-analytic techniques are performed to synthesize the pooled data and identify correlates of HCV infection.

Results

The search strategy has been performed, and data collection is in progress. Data analysis will follow, and the final results of this systematic review/meta-analysis are expected by December 2017.

Conclusions

This article describes the protocol for the systematic review and meta-analysis of epidemiology of HCV among PWID. We aim to provide synthesized data on HCV incidence and prevalence as well as to identify factors associated with HCV transmission. Our research contributes empirical evidence that informs scholarly, medical, and policy discussions concerning HCV.

Trial Registration

PROSPERO CRD42016035687; https://www.crd.york.ac.uk/prospero/display_record.asp? ID=CRD42016035687 (Archived by WebCite at http://www.webcitation.org/6ttYLn65N)

Large variation in measures used to assess outcomes of opioid dependence treatment: A systematic review of longitudinal observational studies

ISSUES

Treatment outcomes for drug users are critical for informing policy and therapeutic practice. The coherence of outcomes, changes and drug use measures from observational studies on opioid use treatment were reviewed.

APPROACH

Systematic review of the literature for longitudinal observational studies, from 1980 through November 2015, in all languages, with data on treated opioid users, using Pubmed, the Cochrane Library and additional strategies (e.g. Pubmed function 'related citations' and checking reference lists of eligible studies).

KEY FINDINGS

Twenty-seven studies were included (11 countries, 85 publications, recruitment 1962-2009). Baseline n was >65 686 and median follow-up 34.5 months (21 studies) or 51.4 person-months (10 studies). Eight outcome domains were identified: 'drug use' (21/27 studies), 'crime' (13), 'health' (13), 'treatment-related' outcomes (16), 'social functioning' (13), 'harms' (8), 'mortality' (13) and 'economic estimates' (2 studies). All studies using drug use outcomes included a binary (abstinence) category in at least one measure. Studies typically reported outcomes on less than half (on average 3.7 or 46%) of the eight outcome domains, while the average was 5.1 (64%) in seven studies initiated since 2000.

IMPLICATIONS AND CONCLUSION

Wide variation exists in outcome measures found in longitudinal observational studies of treatment of opioid users. This reduces replicability of studies and suggests a lack of common expectations on treatment success. Future studies should consider using all or most of eight outcome domains identified (excluding economic analyses if unfeasible), non-binary measures and amount/value of drugs used and consensus meetings with joint ownership of scientific, treatment and patient communities.

Spatial distribution of HIV, HCV, and co-infections among drug users in the southwestern border areas of China (2004-2014): a cohort study of a national methadone maintenance treatment program

Background

A methadone maintenance treatment (MMT) program to curb the dual epidemics of HIV/AIDS and drug use has been administered by China since 2004. Little is known regarding the geographic heterogeneity of HIV and hepatitis C virus (HCV) infections among MMT clients in the resource-constrained context of Chinese provinces, such as Guangxi. This study aimed to characterize the geographic distribution patterns and co-clustered epidemic factors of HIV, HCV and co-infections at the county level among drug users receiving MMT in Guangxi Zhuang Autonomous Region, located in the southwestern border area of China.

Methods

Baseline data on drug users’ demographic, behavioral and biological characteristics in the MMT clinics of Guangxi Zhuang Autonomous Region during the period of March 2004 to December 2014 were obtained from national HIV databases. Residential addresses were entered into a geographical information system (GIS) program and analyzed for spatial clustering of HIV, HCV and co-infections among MMT clients at the county level using geographic autocorrelation analysis and geographic scan statistics.

Results

A total of 31,015 MMT clients were analyzed, and the prevalence of HIV, HCV and co-infections were 13.05%, 72.51% and 11.96% respectively. Both the geographic autocorrelation analysis and geographic scan statistics showed that HIV, HCV and co-infections in Guangxi Zhuang Autonomous Region exhibited significant geographic clustering at the county level, and the Moran’s I values were 0.33, 0.41 and 0.30, respectively (P < 0.05). The most significant high-risk overlapping clusters for these infections were restricted to within a 10.95 km² radius of each of the 13 locations where P county was the cluster center. These infections also co-clustered with certain characteristics, such as being unmarried, having a primary level of education or below, having used drugs for more than 10 years, and receptive sharing of syringes with others. The high-risk clusters for these characteristics were more likely to reside in the areas surrounding P county.

Conclusions

HIV, HCV and co-infections among MMT clients in Guangxi Zhuang Autonomous Region all presented substantial geographic heterogeneity at the county level with a number of overlapping significant clusters. The areas surrounding P county were effective in enrolling high-risk clients in their MMT programs which, in turn, might enable people who inject drugs to inject less, share fewer syringes, and receive referrals for HIV or HCV treatment in a timely manner.

HCV avidity as a tool for detection of recent HCV infection: Sensitivity depends on HCV genotype

Accurate detection of incident hepatitis C virus (HCV) infection is required to target and evaluate public health interventions, but acute infection is largely asymptomatic and difficult to detect using traditional methods. Our aim was to evaluate a previously developed HCV avidity assay to distinguish acute from chronic HCV infection. Plasma samples collected from recent seroconversion subjects in two large Australian cohorts were tested using the avidity assay, and the avidity index (AI) was calculated. Demographic and clinical characteristics of patients with low/high AI were compared via logistic regression. Sensitivity and specificity of the assay for recent infection and the mean duration of recent infection (MDRI) were estimated stratified by HCV genotype. Avidity was assessed in 567 samples (from 215 participants), including 304 with viraemia (defined as ≥250 IU/mL). An inverse relationship between AI and infection duration was found in viraemic samples only. The adjusted odds of a low AI (<30%) decreased with infection duration (odds ratio [OR] per week of 0.93; 95% CI:0.89-0.97), and were lower for G1 compared with G3 samples (OR = 0.14; 95% CI:0.05-0.39). Defining recent infection as <26 weeks, sensitivity (at AI cut-off of 20%) was estimated at 48% (95% CI:39-56%), 36% (95% CI:20-52%), and 65% (95% CI:54-75%) and MDRI was 116, 83, and 152 days for all genotypes, G1, and G3, respectively. Specificity (≥52 weeks infection duration, all genotypes) was 96% (95% CI:90-98%). HCV avidity testing has utility for detecting recent HCV infection in patients, and for assessing progress in reaching incidence targets for eliminating transmission, but variation in assay performance across genotype should be recognized.

Healthcare contact and treatment uptake following hepatitis C virus screening and counseling among rural Appalachian people who use drugs

BACKGROUND

Hepatitis C virus (HCV) remains a major contributor to morbidity and mortality worldwide. Since 2009, Kentucky has led the United States in cases of acute HCV, driven largely by injection drug use in rural areas. Improved treatment regimens hold promise of mitigating the impact and transmission of HCV, but numerous barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved settings.

METHODS

503 rural people who use drugs were recruited using respondent-driven sampling and received HCV screening and post-test counseling. Presence of HCV antibodies was assessed using enzyme immunoassay of dried blood samples. Sociodemographic and behavioral data were collected using computer-based questionnaires. Predictors of contacting a healthcare provider for follow-up following HCV-positive serotest and counseling were determined using discrete-time survival analysis.

RESULTS

150 (59%) of 254 participants reported contacting a healthcare provider within 18 months of positive serotest and counseling; the highest probability occurred within six months of serotesting. 35 participants (14%) reported they were seeking treatment, and 21 (8%) reported receiving treatment. In multivariate time-dependent modeling, health insurance, internet access, prior substance use treatment, meeting DSM-IV criteria for generalized anxiety disorder, and recent marijuana use increased the odds of making contact for follow-up. Participants meeting criteria for major depressive disorder and reporting prior methadone use, whether legal or illegal, were less likely to contact a provider.

CONCLUSION

While only 8% received treatment after HCV-positive screening, contacting a healthcare provider was frequent in this sample of rural PWID, suggesting that the major barriers to care are likely further downstream. These findings offer insight into the determinants of engaging the cascade of medical treatment for HCV and ultimately, treatment-as-prevention. Further study and increased resources to support integrated interventions with effectiveness in other settings are recommended to mitigate the impact of HCV in this resource-deprived setting.

Prevalence and distribution of hepatitis C virus genotypes in Spain during the 2000-2015 period (the GEHEP 005 study)

We report the largest study on the prevalence and distribution of HCV genotypes in Spain (2000-2015), and we relate them with clinical, epidemiological and virological factors. Patients from 29 hospitals in 10 autonomous communities (Andalusia, Aragon, Castilla-Leon, Catalonia, Galicia, Canary Islands, Madrid Community, Valencian Community, Murcia Region and Basque Country) have been studied. Annual distribution of HCV genotypes and subtypes, as well as gender, age, transmission route, HIV and/or HBV coinfection, and treatment details were recorded. We included 48595 chronically HCV-infected patients with the following characteristics: median age 51 years (IQR, 44-58), 67.9% male, 19.1% HIV-coinfected, 23.5% HBV-coinfected. Parenteral transmission route was the most frequent (58.7%). Genotype distribution was 66.9% GT1 (24.9% subtype 1a and 37.9% subtype 1b), 2.8% GT2, 17.3% GT3, 11.4% GT4 and 0.1% GT5 and 0.02% GT6. LiPA was the most widely HCV genotyping test used (52.4%). HCV subtype 1a and genotypes 3 and 4 were closely associated with male gender, parenteral route of infection and HIV and HBV coinfection; in contrast, subtype 1b and genotype 2 were associated with female gender, nonparenteral route and mono-infection. Age was related to genotype distribution, and different patterns of distribution and biodiversity index were observed between different geographical areas. Finally, we describe how treatment and changes in transmission routes may have affected HCV genotype prevalence and distribution patterns. We present the most recent data on molecular epidemiology of hepatitis C virus in Spain. This study confirms that genotype distributions vary with age, sex, HIV and HBV coinfection and within geographical areas and epidemiological groups.

Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden

BACKGROUND

Severe mental illness is associated with increased morbidity and mortality. The elevated risk of blood-borne viruses (BBVs) in people with severe mental illness is of concern, but the full extent of this problem is unclear. We aimed to determine the prevalence of and risk factors for BBVs in people with severe mental illness.

METHODS

In this nationwide, population-based, cross-sectional study, we estimated the point prevalence of HIV, hepatitis B (HBV), and hepatitis C (HCV) in people with severe mental illness, including the total adult (≥18 years) Swedish population. We defined severe mental illness as a clinical diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or other psychotic illness according to the Swedish version of the International Statistical Classification of Diseases version 8, 9, or 10. We used multivariable logistic regression to determine the odds of BBVs in individuals with severe mental illness, relative to the general population, and to identify independent risk factors (age, sex, immigration status, socioeconomic status, education, and substance misuse) for BBV infection. We also did a sensitivity analysis excluding BBV diagnoses made before the introduction of the Register for Infection Disease Control (1997).

FINDINGS

Of 6 815 931 adults in Sweden, 97 797 (1·43%) individuals had a diagnosis of severe mental illness. Prevalence of BBVs was elevated in people with severe mental illness, of which 230 (0·24%) had HIV, 518 (0·53%) had HBV, and 4476 (4·58%) had HCV. After accounting for sociodemographic characteristics, the odds of HIV were 2·57 (95% CI 2·25-2·94, p<0·0001) times higher in people with severe mental illness than in the general population, whereas the odds of HBV were 2·29 (2·09-2·51, p<0·0001) times higher and the odds of HCV were 6·18 (5·98-6·39, p<0·0001) times higher. Substance misuse contributed most to the increased risk of BBV: after adjustment, odds ratios were 1·61 (1·40-1·85, p<0·0001) for HIV, 1·28 (1·16-1·41, p<0·0001) for HBV, and 1·72 (1·67-1·78, p<0·0001) for HCV.

INTERPRETATION

Our results highlight the need to address the issue of higher prevalence of BBVs in people with severe mental illness and identify interventions preventing infection. Targeting of comorbid substance misuse would have particular effect on reduction of BBV prevalence in this population.

FUNDING

Medical Research Council and Swedish Research Council.

Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection.

Elimination of HCV as a public health concern among people who inject drugs by 2030 - What will it take to get there?

INTRODUCTION

Globally, there is a considerable burden of HCV and HIV infections among people who inject drugs (PWID) and transmission of both infections continues. Needle and syringe programme (NSP) and opioid substitution therapy (OST) coverage remains low, despite evidence demonstrating their prevention benefit. Direct-acting antiviral therapies (DAA) with HCV cure >95% among PWID provide an opportunity to reverse rising trends in HCV-related morbidity and mortality and reduce incidence. However, HCV testing, linkage to care, and treatment remain low due to health system, provider, societal, and patient barriers. Between 2015 and 2030, WHO targets include reducing new HCV infections by 80% and HCV deaths by 65%, and increasing HCV diagnoses from <5% to 90% and number of eligible persons receiving HCV treatment from <1% to 80%. This commentary discusses why PWID should be considered as a priority population in these efforts, reasons why this goal could be attainable among PWID, challenges that need to be overcome, and key recommendations for action.

DISCUSSION

Challenges to HCV elimination as a global health concern among PWID include poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low HCV testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. Key recommendations for action include reforming drug policies (decriminalization of drug use and/or possession, or providing alternatives to imprisonment for PWID; decriminalization of the use and provision of sterile needles-syringes; and legalization of OST for people who are opioid dependent), scaling up and improving funding for harm reduction services, making health services accessible for PWID, supporting community empowerment and community-based programmes, improving access to affordable diagnostics and medicines, and eliminating stigma, discrimination, and violence against PWID.

CONCLUSIONS

The ambitious targets for HCV elimination set by WHO are achievable in many countries, but will require researchers, healthcare providers, policy makers, affected communities, advocates, the pharmaceutical and diagnostics industries, and governments around the world to work together to make this happen.

Exploring Patient Characteristics and Barriers to Hepatitis C Treatment in Patients on Opioid Substitution Treatment Attending a Community Based Fibro-scanning Clinic

BACKGROUND AND OBJECTIVES

Hepatitis C virus (HCV) infection is a major public health issue. There is substandard uptake in HCV assessment and treatment among people who inject drugs (PWID). Community fibroscanning is used to assess disease severity and target treatment.

METHODS

A survey was administered to a cohort of chronically HCV infected patients attending a community fibroscanning clinic. Questions targeted diagnosis of HCV, suitability, willingness and barriers to engagement in treatment. Descriptive and regression analysis, with thematic analysis of open-ended data was conducted.

RESULTS

There was high acceptance of community fibroscanning among this cohort with over 90% (68) attending. High levels of unemployment (90%) and homelessness (40%) were identified. Most patients were on methadone treatment and had been HCV infected for greater than 10 years with length of time since HCV diagnosis being significantly longer in patients with fibroscan scores > 8.5 kPa (P = 0.016). With each unit increase in methadone dose, the odds of the >8.5 fibroscan group increased by 5.2%. Patient identified barriers to engagement were alcohol and drug use, fear of HCV treatment and liver biopsy, imprisonment, distance to hospital and early morning appointments.

CONCLUSION

The study highlights the usefulness of community fibroscanning. Identifying barriers to treatment in this cohort affords an opportunity to increase the treatment uptake. The availability of afternoon clinics and enhanced prison linkage are warranted.

Hepatitis C in a Mobile Low-Threshold Methadone Program

INTRODUCTION

Data on the epidemiology of hepatitis C among individuals who use drugs in low-threshold settings are lacking, although crucial to assess the burden of disease and aid in the design of treatment strategies.

OBJECTIVE

The aim of this study was to characterize the epidemiology and disease related to hepatitis C in a population attending a low-threshold methadone program.

MATERIALS AND METHODS

A cross-sectional study in the population attending the Mobile Low-Threshold Methadone Program in Lisbon, Portugal, was carried out. The survey included assessment of risk factors for infection with hepatitis C virus (HCV) and liver disease, HCV serology and RNA detection, HCV genotyping, and liver disease staging.

RESULTS

A total of 825 participants were enrolled, 81.3% men, mean age 44.5 years. Injecting drug use (IDU) was reported by 58.4% - among these, 28.2% were people who inject drugs. Excessive drinking and HIV coinfection were reported by 33.4 and 15.9%, respectively. Among participants with active infection, 16.9% were followed up in hospital consultation. The overall seroprevalence for HCV was 67.6% (94.2% in IDU, 30.0% in non-IDU, 97.1% in people who inject drugs, and 75.6% in excessive drinkers). Among seropositives for HCV, active infection was present in 68.4%. Among individuals with active infection, the most common genotypes were 1a (45.3%) and 3a (28.7%), whereas 30% had severe liver fibrosis or cirrhosis. Age 45 years or older, HCV genotype 3, and coinfection with HIV were significant predictors of cirrhosis.

CONCLUSION

This population has a high burden of hepatitis C and several characteristics that favor dissemination of infection. Healthcare strategies are urgently needed to address hepatitis C in this setting.

Chronic hepatitis C and individuals with a history of injecting drugs in Spain: population assessment, challenges for successful treatment

In Spain, there is a need to improve chronic hepatitis C care among people who inject drugs (PWID). Injecting drug use is an important risk behaviour for hepatitis C virus (HCV) infection. Review of 28 sources of the relevant published literature mapped the size of the addiction-HCV population in Spain. Experts in opioid use disorder (OUD) treatment in Spain completed a consensus to define the population size, HCV prevalence and access or barriers to hepatitis C treatment for PWID populations. In Spain, over 300 000 individuals have a lifetime history of injecting drugs. Currently, 150 000 individuals in Spain have OUD; many have injected drugs. Each year, 80 000 individuals engage with treatment services for OUD. A proportion of this group continues to inject drugs. There is a high HCV prevalence in PWID - estimates of 60-80% in Spain. Uptake of hepatitis C therapy in PWID in Spain is limited; barriers include awareness of treatment pathways, advocacy for regular screening and effective joint care. There is an urgent need to address barriers to effective hepatitis C care for PWID in Spain. Practical and specific strategies including peer-led solutions, patient buddy systems and joint working models at the local level can make important short-term differences.

Monitoring quality and coverage of harm reduction services for people who use drugs: a consensus study

BACKGROUND AND AIMS

Despite advances in our knowledge of effective services for people who use drugs over the last decades globally, coverage remains poor in most countries, while quality is often unknown. This paper aims to discuss the historical development of successful epidemiological indicators and to present a framework for extending them with additional indicators of coverage and quality of harm reduction services, for monitoring and evaluation at international, national or subnational levels. The ultimate aim is to improve these services in order to reduce health and social problems among people who use drugs, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection, crime and legal problems, overdose (death) and other morbidity and mortality.

METHODS AND RESULTS

The framework was developed collaboratively using consensus methods involving nominal group meetings, review of existing quality standards, repeated email commenting rounds and qualitative analysis of opinions/experiences from a broad range of professionals/experts, including members of civil society and organisations representing people who use drugs. Twelve priority candidate indicators are proposed for opioid agonist therapy (OAT), needle and syringe programmes (NSP) and generic cross-cutting aspects of harm reduction (and potentially other drug) services. Under the specific OAT indicators, priority indicators included 'coverage', 'waiting list time', 'dosage' and 'availability in prisons'. For the specific NSP indicators, the priority indicators included 'coverage', 'number of needles/syringes distributed/collected', 'provision of other drug use paraphernalia' and 'availability in prisons'. Among the generic or cross-cutting indicators the priority indicators were 'infectious diseases counselling and care', 'take away naloxone', 'information on safe use/sex' and 'condoms'. We discuss conditions for the successful development of the suggested indicators and constraints (e.g. funding, ideology). We propose conducting a pilot study to test the feasibility and applicability of the proposed indicators before their scaling up and routine implementation, to evaluate their effectiveness in comparing service coverage and quality across countries.

CONCLUSIONS

The establishment of an improved set of validated and internationally agreed upon best practice indicators for monitoring harm reduction service will provide a structural basis for public health and epidemiological studies and support evidence and human rights-based health policies, services and interventions.

Prevalence of false-positive hepatitis C antibody results, National Health and Nutrition Examination Study (NHANES) 2007-2012

BACKGROUND

Screening large numbers of persons in a population with low prevalence of a disease leads to many false-positives. However, populations with low HCV prevalence may sometimes be recommended for HCV screening, for instance patients or healthcare workers after a possible healthcare-related exposure.

OBJECTIVES

We determined the percentage of true vs false-positive HCV antibody (anti-HCV) test results among 2007-2012 participants in the National Health and Nutrition Examination Study (NHANES), a nationally representative study with approximately 1% HCV infection prevalence, much lower than in groups typically recommended for HCV screening.

STUDY DESIGN

Anti-HCV test confirmation was performed using a recombinant immunoblot assay (RIBA) test and follow-up HCV RNA testing.

RESULTS

Overall, of 22,359 NHANES participants tested, 479 (2%) were anti-HCV screening reactive and 477 were tested for RIBA; of these 323 (68%) confirmed as true positive and 105 (22%) were false-positives. Many others (49, 10%) were RIBA indeterminate and likely false-positive. Because of these false positive tests, the overall prevalence of chronic infection among those testing anti-HCV screening reactive was much lower (218, 51%) than would be expected due to disease clearance alone (approximately 80%).

CONCLUSIONS

All screening anti-HCV positive tests should be followed by an HCV RNA test, in order to confirm whether the patient has current infection so that infected persons can be referred to care and treatment to avoid the significant morbidity and mortality associated with chronic HCV infection.

Characterization of chronic HCV infection in Northwest Spain: Impact of the treatment strategic plan of the Spanish National Health Service on HCV cure

The aim of the study was to characterize HCV infection in Northwest Spain and assess the impact of the Spanish Strategic Plan to cure HCV infection. Overall, 387 patients were included (60.9% HIV/HCV coinfected and 28.2% cirrhotic). Of these, 72.9% of patients that were recognized as priority for HCV treatment according to the Spanish Strategic Plan (≥F2, transplant or extrahepatic manifestations), initiated treatment during 2015. Globally, SVR12 was achieved in 96.5% of patients. The implementation of the Spanish Strategic Plan has been critical to advance in HCV cure, but 27.1% of priority patients still remain awaiting HCV treatment initiation.

Undiagnosed HIV and Hepatitis C infection in people who inject drugs: From new evidence to better practice

BACKGROUND

The objective of this study was to estimate the proportion of undiagnosed HIV or Hepatitis C virus (HCV) infection and to assess the risk factors associated with an undiagnosed infection.

METHODS

A questionnaire was distributed among people who inject drugs (PWID) in harm reduction centres in Catalonia, Spain 2008-2012 (n=2243). Self-report of HIV and HCV was compared to oral fluid tests to calculate the proportion of undiagnosed infection. Associations of undiagnosed HIV and HCV with age, origin, risk and protective factors of infection and services use were calculated using a Poisson regression model with robust variance.

RESULTS

The sensitivity of HIV self-report was 78.5% (75.2%-81.5%) and of HCV was 81.2% (79.1%-83.2%), being lower in younger and foreign-born PWID. Specificity for HCV was 55.9% (51.6%-60.1%). PWID who engaged in infection risk behaviors had lower risk of being undiagnosed. Being foreign-born and younger increased the risk of undiagnosed infection. PWID who had not accessed medical care in the last 6months had 1.46 (1.10-1.93) times more risk of undiagnosed HIV and 1.37 (1.11-1.70) times more risk of undiagnosed HCV.

CONCLUSION

Outreach programmes are essential to provide PWID, specially foreign-born and younger PIWD, access to HIV and HCV test.

Towards elimination of hepatitis B and C in European Union and European Economic Area countries: monitoring the World Health Organization's global health sector strategy core indicators and scaling up key interventions

The World Health Organization 'Global Health Sector Strategy on Viral Hepatitis 2016-2021' aimed at the elimination of viral hepatitis as a public health threat provides a significant opportunity to increase efforts for tackling the epidemics of hepatitis B and hepatitis C virus infections across Europe. To support the implementation and monitoring of this strategy, core epidemiological and programmatic indicators have been proposed necessitating specific surveys, the systematic collection of programmatic data and the establishment of monitoring across the care pathway. European Union and European Economic Area countries already made progress in recent years implementing primary and secondary prevention measures. Indeed, harm reduction measures among people who inject drugs reach many of those who need them and most countries have a universal hepatitis B vaccination programme with high coverage above 95%. However, while a further scaling up of prevention interventions will impact on incidence of new infections, treating those already infected is necessary to achieve reductions in mortality. The epidemiological, demographic and socio-political situation in Europe is complex, and considerable diversity in the programmatic responses to the hepatitis epidemic exists. Comprehension of such issues alongside collaboration between key organisations and countries will underpin any chance of successfully eliminating hepatitis.

Are the testing needs of key European populations affected by hepatitis B and hepatitis C being addressed? A scoping review of testing studies in Europe

Aim

To investigate whether or not key populations affected by hepatitis B and hepatitis C are being tested sufficiently for these diseases throughout the European region.

Methods

We searched MEDLINE and EMBASE for studies on HBV and HCV testing in the 53 Member States of the World Health Organization European Region following PRISMA criteria.

Results

136 English-language studies from 24 countries published between January 2007 and June 2013 were found. Most studies took place in 6 countries: France, Germany, Italy, the Netherlands, Turkey, and the United Kingdom. 37 studies (27%) addressed HBV, 46 (34%) HCV, and 53 (39%) both diseases. The largest categories of study populations were people who use drugs (18%) and health care patient populations (17%). Far fewer studies focused on migrants, prison inmates, or men who have sex with men.

Conclusions

The overall evidence base on HBV and HCV testing has considerable gaps in terms of the countries and populations represented and validity of testing uptake data. More research is needed throughout Europe to guide efforts to provide testing to certain key populations.

The need for treatment scale-up to impact HCV transmission in people who inject drugs in Montréal, Canada: a modelling study

Background

HCV transmission remains high in people who inject drugs (PWID) in Montréal. New direct-acting antivirals (DAAs), highly effective and more tolerable than previous regimens, make a “Treatment as Prevention” (TasP) strategy more feasible. This study assesses how improvements in the cascade of care could impact hepatitis C burden among PWID in Montréal.

Methods

We used a dynamic model to simulate HCV incidence and prevalence after 10 years, and cirrhosis complications after 10 and 40 years. Eight scenarios of improved cascade of care were examined.

Results

Using a baseline incidence and prevalence of 22.1/100 person-years (PY) and 53.1%, implementing the current cascade of care using DAAs would lead to HCV incidence and prevalence estimates at 10 years of 9.4/100PY and 55.8%, respectively. Increasing the treatment initiation rate from 5%/year initially to 20%/year resulted in large decreases in incidence (6.4/100PY), prevalence (36.6%), and cirrhosis complications (−18%/-37% after 10/40 years). When restricting treatment to fibrosis level ≥ F2 instead of F0 (reference scenario), such decreases in HCV occurrence were unreachable. Improving the whole cascade of care led to the greatest effect by halving both the incidence and prevalence at 10 years, and the number of cirrhosis complications after 40 years.

Conclusions

The current level of treatment access in Montréal is limiting a massive decrease in hepatitis C burden among PWID. A substantial treatment scale-up, regardless of fibrosis level, is necessary. While improving the rest of the cascade of care is necessary to optimize a TasP strategy and control the HCV epidemic, a treatment scale-up is first needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2256-5) contains supplementary material, which is available to authorized users.

Treatment optimization for HIV/HCV co-infected patients

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections affect millions of persons around the globe and cause profound morbidity and mortality. A major intersection exists between these two epidemics, with HCV infection being more common in persons with HIV than in the general population, largely due to shared routes of transmission. HCV co-infection increases risk for liver- and non-liver-related morbidity and mortality, making HCV treatment a priority in HIV co-infected persons, but the treatment of HCV in co-infected patients has been daunting for multiple reasons. Until recently, HCV treatment has frequently been deferred due to the low rates of cure, significant adverse effects, burdensome duration of therapy and drug-drug interactions with HIV antiretroviral medications. Untreated HCV has resulted in significant health consequences for the millions of those infected and has led to multiple downstream impacts on our healthcare systems around the world. The development of a remarkable number of new HCV direct-acting agents (DAAs) that are significantly more efficacious and tolerable than the previous interferon-based regimens has transformed this important field of medicine, with the potential to dramatically reduce the burden of infection and improve health outcomes in this population. This review will summarize the epidemiology and clinical impact of HIV/HCV co-infection and current approaches to the treatment of HCV in HIV/HCV co-infected patients.

Age- and time-dependent prevalence and incidence of hepatitis C virus infection in drug users in France, 2004-2011: model-based estimation from two national cross-sectional serosurveys

Hepatitis C virus (HCV) infection is a public health issue worldwide. Injecting drug use remains the major mode of transmission in developed countries. Monitoring the HCV transmission dynamic over time is crucial, especially to assess the effect of harm reduction measures in drug users (DU). Our objective was to estimate the prevalence and incidence of HCV infection in DU in France using data from a repeated cross-sectional survey conducted in 2004 and 2011. Age- and time-dependent HCV prevalence was estimated through logistic regression models adjusted for HIV serostatus or injecting practices. HCV incidence was estimated from a mathematical model linking prevalence and incidence. HCV prevalence decreased from 58·2% [95% confidence interval (CI) 49·7-66·8] in 2004 to 43·2% (95% CI 38·8-47·7) in 2011. HCV incidence decreased from 7·9/100 person-years (95% CI 6·4-9·4) in 2004 to 4·4/100 person-years (95% CI 3·3-5·9) in 2011. HCV prevalence and incidence were significantly associated with age, calendar time, HIV serostatus and injecting practices. In 2011, the highest estimated incidence was in active injecting DU (11·2/100 person-years). Given the forthcoming objective of generalizing access to new direct antiviral agents for HCV infection, our results contribute to decision-making and policy development regarding treatment scale-up and disease prevention in the DU population.

HCV prevalence and risk behaviours among injectors of new psychoactive substances in a risk environment in Hungary-An expanding public health burden

BACKGROUND

In Hungary a large increase in injecting new psychoactive substances (NPS) coincided with decreasing harm reduction efforts and rising HCV infection. We describe these, and assess changes in HCV prevalence and risk behaviours, 2011-2014, among NPS injectors, using 2011-2015 syringe exchange programme (SEP) data as a key contextual ('risk environment') variable.

METHODS

We conducted repeated national sero-behavioural surveys in people who inject drugs (PWID) injecting in the last month and attending SEPs or drug treatment centres (n=399, 2011; 384, 2014), using face-to-face interviews and dried blood-spot samples. Prevalence of injected drugs and SEP coverage (2011-2015) were assessed through our national SEP monitoring system and using population size estimates.

RESULTS

NPS injecting tripled among PWID attending SEPs in Hungary (2011: 26%; 2015: 80%). Among NPS injectors, HCV prevalence, sharing syringes and sharing any injecting equipment (last month), doubled (2011-2014: 37%-74%, 20%-48%, 42%-71%, respectively), significantly exceeding prevalence in other PWID groups. Among young NPS injectors (aged<25), HCV prevalence increased 7-fold (12%-76%), among new injectors (injecting<2years) 4-fold (13%-42%), coupled with high levels of equipment sharing (79% and 72% respectively). Not using a condom at last intercourse (79%), ever-imprisonment (65%) and last-year homelessness (57%) were highly prevalent among NPS injectors (2014). The number of syringes distributed per estimated PWID nationally fell from 114 to 81 (2011-2014) and dropped to 28 in 2015.

CONCLUSION

NPS injectors in Hungary are at severe risk of blood-borne infections due to high levels of injecting and sexual risk behaviours within a high-risk environment, including continuously low SEP provision, imprisonment and homelessness. An HIV outbreak cannot be excluded. Stronger investment in evidence-based prevention measures, with special focus on young and new injectors, and expansion of hepatitis C treatment are urgently needed.

Community nurse-led initiation of antiviral therapy for chronic hepatitis C in people who inject drugs does not increase uptake of or adherence to treatment

BACKGROUND

Chronic hepatitis C is common in people who inject drugs (PWID) and this population serves as a reservoir for infection. Treatment levels are low among this group, ranging from 1 to 19%. We explored whether a nurse-initiated community treatment model increased uptake of and adherence to interferon-based therapies.

METHODS

This was a cluster randomized trial of nurse-initiated versus physician-initiated antiviral therapy with pegylated interferon and ribavirin for hepatitis C virus in community clinics (trial registration: ISRCTN07774040).

RESULTS

The proportion of participants initiating treatment during follow-up was 10% with nurse-initiated (6/62) and 9% with physician-initiated (6/76) therapy. Adherence was similar in both groups, with only one patient in each arm not adhering to therapy. There were no serious adverse events, but interferon-related side effects were common. Drug and alcohol use did not change during therapy.

CONCLUSION

Despite easy access to antiviral therapy, uptake of treatment was poor, with no significant difference between the groups. Nurse-led initiation of interferon-based antiviral therapy in PWID did not lead to increased uptake of, response to or adherence with treatment. Further service improvement is unlikely to increase the proportion of PWID undergoing antiviral therapy for hepatitis C virus and early adoption of interferon-free regimens may increase the proportion initiating and completing treatment.

A multidimensional education program at substance dependence treatment centers improves patient knowledge and hepatitis C care

Background

HCV treatment among people who inject drugs (PWID) is low. Education programs may be suitable strategies to improve patients’ knowledge about their condition and to overcome barriers to access treatment.

Methods

The Health Educational Program (HEP) consisted of patient workshops and educational videos and leaflets, and healthcare professionals’ workshops. HEP was implemented at seven substance dependence treatment centers (STDC) in Portugal. The study comprised two cross-sectional evaluations conducted before and after HEP. At both evaluations, adult patients with confirmed HCV diagnosis and registered in the STDC were consecutively included. For patients that completed both evaluations, the overall knowledge score were calculated and compared with McNemar test. Linear regression modelling was used to evaluate factors associated with baseline knowledge. Rates of referral and attendance to referral specialist, treatment proposal, initiation and retention at both evaluations were also compared with McNemar test.

Results

Overall, 504 patients with chronic hepatitis C were included: 78 % male, mean age 42.3 ± 6.6 years, 14 % school education ≤ 4 years, disease duration 11.0 ± 6.0 years and 26 % HIV co-infected. A higher baseline knowledge was independently associated with educational level ≥ 10 years (regression coefficient [B] =15.13, p < 0.001), current use of intravenous drugs (B = 7.99, p = 0.038), previous referral for treatment (B = 4.26, p = 0.008) and previous HCV treatment (B = 5.40, p = 0.003). Following HEP, mean knowledge score increased from 69 % to 79 % (p < 0.001). The rate of patient referral to a liver specialist increased from 56.2 % to 67.5 % (p < 0.001).

Conclusions

An HEP conducted at STDCs improved significantly patient knowledge about hepatitis C, even among patients with a high baseline knowledge. The HEP has also increased the rate of referral to the liver specialist and showed a great potential to support healthcare professionals in managing HCV. Education programs may promote treatment access among PWID, a population that represents the majority of HCV infected patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1883-6) contains supplementary material, which is available to authorized users.

Hepatitis C virus (HCV) genotypes distribution: an epidemiological up-date in Europe

Hepatitis C virus (HCV) infection is a major public health burden in Europe, causing an increasing level of liver-related morbidity and mortality, characterized by several regional variations in the genotypes distribution.

A comprehensive review of the literature from 2000 to 2015 was used to gather country-specific data on prevalence and genotype distribution of HCV infection in 33 European countries (about 80 % of the European population), grouped in three geographical areas (Western, Eastern and Central Europe), as defined by the Global Burden of Diseases project (GBD).

The estimated prevalence of HCV in Europe is 1.7 % showing a decrease than previously reported (− 0.6 %) and accounting over 13 million of estimated cases. The lowest prevalence (0.9 %) is reported from Western Europe (except for some rural areas of Southern Italy and Greece) and the highest (3.1 %) from Central Europe, especially Romania and Russia. The average HCV viraemic rate is 72.4 %, with a population of almost 10 million of HCV RNA positive patients.

Genotype distribution does not show high variability among the three macro-areas studied, ranging between 70.0 % (Central Europe), 68.1 % (Eastern Europe) and 55.1 % (Western Europe) for genotype 1, 29.0 % (Western Europe), 26.6 % (Eastern Europe) and 21.0 % (Central Europe) for genotype 3. Genotype 2 seems, instead, to have a major prevalence in the Western Europe (8.9 %), if compared to Eastern (4.3 %) or Central (3.2 %), whereas genotype 4 is present especially in Central and Western area (4.9 % and 5.8 %, respectively).

Despite the eradication of transmission by blood products, HCV infection continues to be one of the leading blood-borne infections in Europe. The aim of this review is, therefore, to provide an update on the epidemiology of HCV infection across Europe, and to foster the discussion about eventual potential strategies to eradicate it.

Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands

BACKGROUND

People who inject drugs (PWID) are disproportionally affected by the hepatitis C virus (HCV) infection. The efficacy of HCV treatment has significantly improved in recent years with the introduction of direct-acting antivirals (DAAs). However, DAAs are more costly than pegylated-interferon and ribavirin (PegIFN/RBV). We aimed to assess the cost-effectiveness of four HCV treatment strategies among PWID and treatment scale-up.

METHODS

An individual-based model was used describing HIV and HCV transmission and disease progression among PWID. We considered two epidemiological situations. A declining epidemic, based on the situation in Amsterdam, the Netherlands, and a stable HCV epidemic, as observed in other settings. Data on HCV incidence, prevalence, treatment setting and uptake were derived from observed data among PWID in Amsterdam. We assessed the incremental cost-effectiveness ratio (ICER, costs in €/quality-adjusted life year (QALY)) of four treatment strategies: 1) PegIFN/RBV; 2) sofosbuvir/RBV for genotype 2-3 and dual DAA for genotype 1-4; 3) Dual DAA for all genotypes; 4) Dual DAA with 3x treatment uptake.

RESULTS

In both types of epidemic, dual DAA therapy was most cost-effective strategy. In the declining epidemic, dual DAA yielded an ICER of 344 €/QALY while in the stable epidemic dual DAA led to cost-savings. Scaling-up treatment was also highly cost-effective. Our results were robust over a range of sensitivity analyses.

CONCLUSION

HCV treatment with DAA-containing regimens is a highly cost-effective intervention among PWID. Based on the economic and population benefits of scaling-up treatment, stronger efforts are needed to achieve higher uptake rates among PWID.

HCV epidemiology in high-risk groups and the risk of reinfection

Injecting risk behaviours among people who inject drugs (PWID) and high-risk sexual practices among men who have sex with men (MSM) are important routes of hepatitis C virus (HCV) transmission. Current direct-acting antiviral treatment offers unique opportunities for reductions in HCV-related liver disease burden and epidemic control in high-risk groups, but these prospects could be counteracted by HCV reinfection due to on-going risk behaviours after successful treatment. Based on existing data from small and heterogeneous studies of interferon-based treatment, the incidence of reinfection after sustained virological response range from 2-6/100 person years among PWID to 10-15/100 person years among human immunodeficiency virus-infected MSM. These differences mainly reflect heterogeneity in study populations with regards to risk behaviours, but also reflect variations in study designs and applied virological methods. Increasing levels of reinfection are to be expected as we enter the interferon-free treatment era. Individual- and population-level efforts to address and prevent reinfection should therefore be undertaken when providing HCV care for people with on-going risk behaviour. Constructive strategies include acknowledgement, education and counselling, harm reduction optimization, scaled-up treatment including treatment of injecting networks, post-treatment screening, and rapid retreatment of reinfections.

Epidemiology of hepatitis C in Greece

Hepatitis C is a global health issue and constitutes a major cause of chronic liver disease worldwide. In this article, a comprehensive literature search was conducted for the prevalence of hepatitis C virus (HCV) infection in Greece, since data on the HCV prevalence, viremia and genotypes are important for developing strategies to manage or eliminate HCV infection. In addition, the pattern of HCV infection was analyzed according to the geographic region and the risk factors. These differences reflect not only distinct epidemiological characteristics among populations, but also differences on the strategy of data acquisition and quantification. Although there are not enough data, the estimation of the current prevalence of Hepatitis C in Greece ranges from 0.5% to 2%. The most important risk factors for HCV infection include blood product transfusion, intravenous drug use, chronic hemodialysis, organ transplantation, occupational exposure, sexual transmission, and vertical transmission. Because of lack of vaccine or effective post-exposure prophylaxis for HCV, the main focus of prevention is to recognize and control these risk factors. HCV infection in Greece is closely associated with the development of chronic liver disease, cirrhosis, and primary hepatocellular carcinoma. As far as the genotype distribution is concerned genotype 1 estimated to be 45%-47% and it constitutes the prevalent genotype in Greece, followed by genotype 3.

Tackling the burden of the hepatitis C virus in the UK: characterizing and assessing the clinical and economic consequences

OBJECTIVES

The hepatitis C virus (HCV) remains a significant public health issue. This study aimed to quantify the clinical and economic burden of chronic hepatitis C in the UK, stratified by disease severity, age and awareness of infection, with concurrent assessment of the impact of implementing a treatment prioritization approach.

STUDY DESIGN AND METHODS

A previously published back projection, natural history and cost-effectiveness HCV model was adapted to a UK setting to estimate the disease burden of chronic hepatitis C and end-stage liver disease (ESLD) between 1980 and 2035. A published meta-regression analysis informed disease progression, and UK-specific data informed other model inputs.

RESULTS

At 2015, prevalence of chronic hepatitis C is estimated to be 241,487 with 22.20%, 33.72%, 17.22%, 16.67% and 10.19% of patients in METAVIR stages F0, F1, F2, F3 and F4, respectively, but is estimated to fall to 193,999 by 2035. ESLD incidence is predicted to peak in 2031. Assuming all patients are diagnosed and treatment is prioritized in F3 and F4 using highly efficacious direct-acting antiviral (DAA) regimens, a 69.85% reduction in ESLD incidence is predicted between 2015 and 2035, and the cumulative discounted medical expenditure associated with the lifetime management of incident ESLD events is estimated to be £1,202,827,444.

CONCLUSIONS

The prevalence of chronic hepatitis C is expected to fall in coming decades; however, the ongoing financial burden is expected to be high due to an increase in ESLD incidence. This study highlights the significant costs of managing ESLD that are likely to be incurred without the employment of effective treatment approaches.

High variability of HIV and HCV seroprevalence and risk behaviours among people who inject drugs: results from a cross-sectional study using respondent-driven sampling in eight German cities (2011-14)

Background

People who inject drugs (PWID) are at increased risk of acquiring and transmitting HIV and Hepatitis C (HCV) due to sharing injection paraphernalia and unprotected sex. To generate seroprevalence data on HIV and HCV among PWID and related data on risk behaviour, a multicentre sero- and behavioural survey using respondent driven sampling (RDS) was conducted in eight German cities between 2011 and 2014. We also evaluated the feasibility and effectiveness of RDS for recruiting PWID in the study cities.

Methods

Eligible for participation were people who had injected drugs within the last 12 months, were 16 years or older, and who consumed in one of the study cities. Participants were recruited, using low-threshold drop-in facilities as study sites. Initial seeds were selected to represent various sub-groups of people who inject drugs (PWID). Participants completed a face-to-face interview with a structured questionnaire about socio-demographics, sexual and injecting risk behaviours, as well as the utilisation of health services. Capillary blood samples were collected as dried blood spots and were anonymously tested for serological and molecular markers of HIV and HCV. The results are shown as range of proportions (min. and max. values (%)) in the respective study cities. For evaluation of the sampling method we applied criteria from the STROBE guidelines.

Results

Overall, 2,077 PWID were recruited. The range of age medians was 29–41 years, 18.5–35.3 % of participants were female, and 9.2–30.6 % were foreign born. Median time span since first injection were 10–18 years. Injecting during the last 30 days was reported by 76.0–88.4 % of participants. Sharing needle/syringes (last 30 days) ranged between 4.7 and 22.3 %, while sharing unsterile paraphernalia (spoon, filter, water, last 30 days) was reported by 33.0–43.8 %. A majority of participants (72.8–85.8 %) reported incarceration at least once, and 17.8–39.8 % had injected while incarcerated. Between 30.8 and 66.2 % were currently in opioid substitution therapy. Unweighted HIV seroprevalence ranged from 0–9.1 %, HCV from 42.3–75.0 %, and HCV-RNA from 23.1–54.0 %. The implementation of RDS as a recruiting method in cooperation with low-threshold drop in facilities was well accepted by both staff and PWID. We reached our targeted sample size in seven of eight cities.

Conclusions

In the recruited sample of mostly current injectors with a long duration of injecting drug use, seroprevalence for HIV and HCV varied greatly between the city samples. HCV was endemic among participants in all city samples. Our results demonstrate the necessity of intensified prevention strategies for blood-borne infections among PWID in Germany.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3545-4) contains supplementary material, which is available to authorized users.

Access to therapy and therapy outcomes in the Swiss Hepatitis C Cohort Study: a person-centred approach

Socio-demographic and behavioural characteristics are associated with delayed diagnosis and disease progression in HCV-infected persons. However, many analyses focused on single variables rather than groups defined by several variables. We used latent class analysis to study all 4488 persons enrolled in the Swiss Hepatitis C Cohort Study. Groups were identified using predefined variables at enrolment. The number of groups was selected using the Bayesian information criterion. Mortality, loss to follow-up, cirrhosis, treatment status and response to antivirals were analysed using Laplace and logistic regressions. We identified five groups and named them according to their characteristics: persons who inject drugs, male drinkers, Swiss employees, foreign employees and retirees. Two groups did not conform to common assumptions about persons with chronic hepatitis C and were already in an advanced stage of the disease at enrolment: 'male drinkers' and 'retirees' had a high proportion of cirrhosis at enrolment (15% and 16% vs <10.3%), and the shortest time to death (adjusted median time 8.7 years and 8.8 years vs >9.0). 'Male drinkers' also had high substance use, but they were well educated and were likely to be employed. This analysis may help identifying high-risk groups which may benefit from targeted interventions.

Concordance between self-reported and measured HIV and hepatitis C virus infection status among people who inject drugs in Germany

Background

People who inject drugs (PWID) are disproportionately affected by both HIV and hepatitis C infection (HCV). Awareness of infection status is essential to ensure linkage to appropriate healthcare for those infected, who need treatment and regular follow-up, as well as for uninfected individuals, who need access to targeted testing and counselling services. In this paper we compare self-reported HIV and HCV status with serological markers of infection among PWID recruited through respondent driven sampling.

Methods

From 2011 through 2014, biological and behavioural data was collected from 2,077 PWID in Germany. Dried blood spots from capillary blood samples were collected and screened for HCV antibodies, HCV RNA and HIV-1/-2 antibodies. HIV reactive samples were confirmed by Western blot.

Results

Laboratory testing revealed that 5 % were infected with HIV and 81 % were aware of being infected. Chronic HCV infection was detected in 41 % of the participants, 2 % had an acute HCV infection, 22 % had a cleared infection, and 34 % were unexposed to HCV. The concordance between self-reported and measured HCV status was lower than for HIV, with 73 % of those with chronic HCV infection being aware of their infection.

Conclusions

We found a relatively high awareness of HIV and HCV infection status among PWID. Nevertheless, access to appropriate testing, counselling and care services targeted to the needs of PWID should be further improved, particularly concerning HCV.

Trial registration

Ethical approval was received from the ethics committee at the medical university of Charité, Berlin, Germany in May 2011 and with an amendment approved retrospectively on 19/11/2012 (No EA4/036/11). The German Federal Commissioner for Data Protection and Freedom of Information approved the study protocol retrospectively on 29/11/2012 (III-401/008#0035).

T Cell Distribution in Relation to HIV/HBV/HCV Coinfections and Intravenous Drug Use

Intravenous drug use (IDU) is one of the most important transmission routes for blood borne viruses, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). These infections alter the subset distributions of T cells; however, knowledge of such effects during HIV, HBV, and or HCV coinfection is limited. Therefore, we aimed to evaluate any associations between T cell distribution and the presence of HIV, HBV, and HCV coinfections among persons who inject drugs (PWID). Blood samples from 88 Caucasian PWID (mean age 30; 82% male) and 47 age-matched subjects negative for all three infections (mean age of 29; 83% male) were analyzed. The T cell markers CD3, CD4, CD8, CD45RA, CCR7, HLA-DR, and CCR5 were assessed using flow cytometry. Of the PWID, 40% were HIV+HBV+HCV+, 20% HBV+HCV+, 19% HCV+, and 13% negative for all three infections. The HIV+HBV+HCV+ PWID had lower percentages of CD4⁺ and higher percentages of CD8⁺ cells compared to triple negative PWID (p < 0.001 in all cases). The only difference between HBV+HCV+ with triple negative PWID was the lower CD4⁺ cell percentages among the former (52.1% and 58.6%, p = 0.021). Triple negative PWID had higher immune activation and number of CCR5⁺ cells compared to the controls. We suggest that the altered T cell subset distribution among PWID is mainly triggered by HIV infection and or IDU, while HBV and or HCV seropositivity has minimal additional effects on CD4⁺ cell distribution.