Hepatitis C virus acquisition among injecting drug users: a cohort analysis of a national repeated cross-sectional survey of needle and syringe program attendees in Australia, 1995-2004

A Global Meta-analysis of the Prevalence of HIV, Hepatitis C Virus, and Hepatitis B Virus Among People Who Inject Drugs-Do Gender-Based Differences Vary by Country-Level Indicators?

BACKGROUND

Women-specific factors exist that increases vulnerability to drug-related harms from injection drug use, including blood-borne viruses (BBVs), but gender-based differences in BBV prevalence have not been systematically examined.

METHODS

We conducted meta-analyses to estimate country, regional, and global prevalence of serologically confirmed human immunodeficiency virus (HIV), hepatitis C virus (HCV; based on detection of anti-HCV antibody), and hepatitis B virus (HBV; based on detection of HBV surface antigen) in people who inject drugs (PWID), by gender. Gender-based differences in the BBV prevalence (calculated as the risk among women relative to the risk among men) were regressed on country-level prevalence and inequality measures (Gender inequality index, Human development index, Gini coefficient, and high, low or middle income of the country).

RESULTS

Gender-based differences varied by countries and regions. HIV prevalence was higher among women than men in sub-Saharan Africa (relative risk [RR], 2.8; 95% confidence interval [CI], 1.8-4.4) and South Asia (RR, 1.7; 95% CI, 1.1-2.7); anti-HCV was lower among women in the Middle East and North Africa (RR, 0.6; 95% CI, .5-.7) and East and Southeast Asia (RR, 0.8; 95% CI, .7-.9). Gender-based differences varied with country-levels of the BBV prevalence in the general population, human development, and income distribution.

CONCLUSION

HIV was more prevalent in women who inject drugs as compared to their male counterparts in some countries, but there is variation between and within regions. In countries where women are at higher risks, there is a need to develop gender-sensitive harm-reduction services for the particularly marginalized population of women who inject drugs.

Randomized feasibility trial of directly observed versus unobserved hepatitis C treatment with ledipasvir-sofosbuvir among people who inject drugs

AIMS

The advent of direct-acting antivirals for hepatitis C virus (HCV) and limited effectiveness of prevention have generated interest in "Treatment as Prevention" (TasP), in which those most likely to transmit HCV (i.e. people who inject drugs [PWID]) are treated to reduced secondary transmission. However, there are scant data regarding the feasibility of treating PWID at high risk for secondary transmission or the optimal approach to treatment delivery.

METHODS

We conducted a 2:1 randomized trial of modified directly-observed (mDOT) versus unobserved HCV treatment with ledipasvir-sofosbuvir daily for 8 weeks among PWID with 36 weeks of follow-up in San Francisco from 2015-2017. We evaluated recruitment-enrollment, treatment completion, end-of-treatment and 12-week response, and reinfection rate.

RESULTS

Of 83 individuals eligible for screening, 72 (87.6%) attended the screening visit, 33 were eligible, and 31 enrolled; mean age was 42 years, 81% were male, 74% white. All but one participant (in the mDOT arm) completed treatment and 89.4% of mDOT and 96.6% of unobserved arm visits were attended. HCV was undetectable for 96.8% (30/31) at end of treatment and 89.7% (26/29) 12 weeks later (1 relapse, 1 reinfection), with no differences by arm. Two additional reinfections were subsequently identified, for a reinfection rate of 16.3 (95% CI 5.3-50.5) per 100 person-years of observation.

CONCLUSIONS

It was feasible to recruit active PWID for HCV treatment and achieve high retention, viral response, and satisfaction with either mDOT or unobserved protocols, supporting treatment of PWID at risk of transmitting HCV to others. The reinfection rate suggests we successfully reached a high-risk population and that successful HCV TasP initiatives may aim to be sufficient in scope to significantly lower prevalence in the community.

TRIAL REGISTRATION

clinicaltrials.gov NCT02609893.

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs

BACKGROUND

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugsNeedle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak.

OBJECTIVES

To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs.

SEARCH METHODS

We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic-related systematic reviews for eligible papers.

SELECTION CRITERIA

We included prospective and retrospective cohort studies, cross-sectional surveys, case-control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion.

MAIN RESULTS

We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person-years of follow-up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person-years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples.Overall, we found very low-quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low-quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89).

AUTHORS' CONCLUSIONS

OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.

Reduction in Needle Sharing Among Seattle-Area Injection Drug Users Across 4 Surveys, 1994-2013

OBJECTIVES

We evaluated time trends in sharing needles and other injection equipment from 1994 to 2013 among injection drug users in the Seattle, Washington area.

METHODS

We combined data from 4 sources: the Risk Activity Variables, Epidemiology, and Network (RAVEN) study, recruited from institutional settings; the Kiwi study, recruited from jails; National HIV Behavioral Surveillance system (NHBS) surveys, which used respondent-driven sampling; and surveys at needle-exchange sites.

RESULTS

Levels of needle sharing were higher in the earlier studies: RAVEN, 1994 to 1997 (43%) and Kiwi, 1998 to 2002 (61%). In the NHBS surveys, the initial level of 44% in 2005 declined to 31% in the period 2009 to 2012. Across needle-exchange surveys (2009-2013) the level was 21%. There was a parallel reduction in sharing other injection equipment. These trends persisted after control for sociodemographic and risk-associated variables. There was a contemporaneous increase in the number of needles distributed by local needle exchanges and a decline in the number of reported HIV cases among injection drug users.

CONCLUSIONS

The apparent long-term reduction in sharing injection equipment suggests substantial success in public health efforts to reduce the sharing of injection equipment.

Imprisonment of opioid-dependent people in New South Wales, Australia, 2000–2012: a retrospective linkage study

There are few data about the incarceration of opioid-dependent people involving large representative cohorts. We aimed to determine the prevalence and duration of incarceration in a large cohort of opioid-dependent people in Australia using data linkage methods, and estimate the costs associated with their incarceration.Method: Retrospective linkage study of all entrants to opioid substitution therapy (OST) for the treatment of opioid dependence in NSW, 1985–2010, with data on incarceration, 2000-2012. The number and duration of incarcerations were calculated. The average daily cost of incarceration was applied to days of incarceration in the cohort.Results: Among 47,196 opioid-dependent people, 37% (43% of men and 24% of women) had at least one episode of incarceration lasting one or more days. Men had a median of three(ranging between 1-47) incarcerations, and women, two (1-35). Indigenous men spent 23% of follow-up time incarcerated, compared with 8% for non-Indigenous men; similarly, Indigenous women spent a substantially greater proportion of time incarcerated than non-Indigenous women (8% vs. 2%). Costs of incarceration of this cohort between 2000 and 2012 totalled nearly AUD $3 billion.Conclusions: This is the first study to examine incarceration of opioid-dependent people across an entire population of such users. Our findings suggest that a substantial minority of opioid-dependent people experience incarceration, usually on multiple occasions and at significant cost. Treatment for opioid dependence, inside and outside prisons, may help reduce incarceration of this cohort.

The role of social networks and geography on risky injection behaviors of young persons who inject drugs

BACKGROUND

Little is known about young persons who inject drugs (PWID), who are increasingly from suburban communities and predominantly non-Hispanic white.

METHODS

We conducted a cross-sectional personal network (egocentric) and geographic study of young PWID and their drug-using, sexual, and support network members in 2012-13 in metropolitan Chicago, Illinois, U.S.

RESULTS

We enrolled 164 young (median age=26), mostly male (65%), non-Hispanic white PWID (71%), with a self-reported HCV prevalence of 13%. Many (59%) reported multiple residences (i.e., were transient) in the past year, 45% of whom reported living in both urban and suburban places (i.e., were cross-over transients). In multivariable analyses that adjusted for participant and network member characteristics, (1) large injection networks were more common among homeless participants; and (2) syringe sharing was (a) highest among cross-over transients compared to suburban (OR=4.19 95% CI 1.69-10.35) and urban only residents (OR=2.91 95% CI 1.06-8.03), (b) higher among HCV-unknown compared HCV-negative participants (OR=4.62 95% CI 1.69-10.35), (c) more likely with network members who were cross-over transients compared to urban (OR=4.94, 95% CI 2.17-11.23) and (d) less likely with network members with HCV-unknown compared to HCV-negative status (OR=0.4 95% CI 0.19-0.84).

CONCLUSIONS

We identified homelessness as a significant risk factor for large networks and cross-over transience as a significant risk factor for syringe sharing. Further research is needed to understand the role of geographic factors promoting higher risk among these crossover transient PWID.

High regional variability of HIV, HCV and injecting risks among people who inject drugs in Poland: comparing a cross-sectional bio-behavioural study with case-based surveillance

Background

People who inject drugs (PWID) are an important group at risk of blood borne infections in Poland. However, robust evidence regarding the magnitude of the problem and geographical variation is lacking, while coverage of prevention remains low. We assessed the potential of combining bio-behavioural studies and case-based surveillance of PWID to gain insight into preventive needs in Poland.

Methods

Results of a bio-behavioural human immunodeficiency virus (HIV) and hepatitis C virus (HCV) prevalence study among ever injectors in six regions in Poland were compared with HIV case-based surveillance trends from 2000 to 2012. Logistic regression was used for multivariable analyses in the prevalence study. The case surveillance data were correlated with prevalence data, by region, to determine surveillance validity and identify any recent trends.

Results

HIV seroprevalence (18% overall) differed more than ten-fold across regions (2.4% to 32%), but HCV seroprevalence and the proportion of PWID sharing needles/syringes in the past 12 months were similar, 44% to 68% and 22% to 29%, respectively. In multivariable models accounting for socio-demographic factors, duration of injecting history and needle sharing practices, regional differences were significant for both HIV and HCV seroprevalence with adjusted odds ratios varying up to a factor of 12.6 for HIV and 3.8 for HCV. The number of new cases of HIV diagnosed in each region during the bio-behavioural study period was strongly correlated (r = 0.93) with HIV prevalence. There was an overall decreasing trend in the number of new diagnoses of HIV over time. However, a transient increase in three regions was preceded by a higher proportion of people with short injecting history (≤5 years) and a high prevalence of HCV coinciding with a low prevalence of HIV in the bio-behavioural study.

Conclusions

Bio-behavioural and case-based data were consistent with respect to the regional distribution of HIV and also provided complementary information, with the proportion of new injectors and high HCV prevalence predicting increases in HIV case rates. We identified three regions in Poland that appear to be at increased need for preventive measures. Data point to the need for a stronger investment in harm reduction programmes in Poland.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0828-9) contains supplementary material, which is available to authorized users.

Ending hepatitis C in the United States: the role of screening

The US faces at least two distinct epidemics of hepatitis C virus infection (HCV), and due largely to revised screening recommendations and novel therapeutic agents, corresponding opportunities. As only 49%-75% of HCV-infected persons in the US are aware of their infection, any chance of addressing HCV in the US is dependent upon screening to identify undiagnosed infections. Most HCV in the US consists of longstanding infections among persons born during 1945-1965 who are suffering escalating rates of liver-related morbidity and mortality. Mathematical modeling supports aggressive action to reach and treat these persons to minimize the subsequent burden of advanced liver disease on patients and the health care system. Incident infection is primarily among persons who inject drugs, less than 10% of whom have been treated for HCV. Expanded screening and treatment of active persons who inject drugs raises the prospect of utilizing "treatment as prevention" to stem the tide of incident HCV infections in this population. HIV-positive men who have sex with men (MSM) represent a population at risk for sexually transmitted HCV who may also benefit from adjusted screening guidelines to identify both acute and chronic infections. Prisoners also represent a critical population for aggressive screening and treatment. Finally, the two-stage testing algorithm for HCV diagnosis is problematic and difficult for patients and providers to navigate. While emerging therapeutics raise the prospect of reducing HCV-related morbidity and mortality, as well as eliminating new infections, major barriers remain with regard to identifying infections, improving access to treatment, and ensuring payer coverage of costly new therapeutic regimens.

Enhancing assessment and treatment of hepatitis C in the custodial setting

Acute and chronic hepatitis C (HCV) infections are prevalent in custodial settings worldwide, yet provision of antiviral therapies is uncommon. This disparity between the burden of disease and hepatitis service delivery reflects the marginalized patient population, which features high rates of injection drug use and poor mental health. In addition, the prison environment is intended for deprivation of liberty and not healthcare. Screening for HCV infections is provided in most jurisdictions, but uptake rates remain low. Assessment and treatment of inmates is often provided only by community-based services. Despite these challenges, assessment and treatment of inmates with chronic HCV via prison-based services has been shown to be feasible and effective. These services offer the potential to substantively increase HCV treatment uptake and reduce the burden of disease for the community at large. Improvements in the efficacy of HCV therapies via direct-acting antivirals, which also offer reduced treatment duration and decreased toxicities, mean that prison health services will be well placed for the treatment of large numbers of people with HCV who do not access health services in the community.

Socio-Economic Status Determines Risk of Receptive Syringe Sharing Behaviors among Iranian Drug Injectors; A National Study

BACKGROUND

Although needle and syringe sharing is one of the main routs of transmission of HIV in several countries in the middle east, very little is known about how socio-economic status of injecting drug users (IDUs) is linked to the receptive syringe sharing behaviors in these countries.

AIM

To study socio-economic correlates of receptive needle and syringe sharing among IDUs in Iran.

METHODS

The study used data from the Unhide Risk Study, a national survey of IDUs. This study sampled 636 IDUs (91% male) via snowball sampling from eight provinces in Iran in 2009. Socio-demographic and drug use characteristics were collected. We used a logistic regression to determine factors associated with receptive needle and syringe sharing during the past 6 months.

RESULTS

From 636 IDUs enrolled in this study, 68% (n = 434) reported receptive needle and syringe sharing behaviors in the past 6 months. Odds of receptive needle and syringe sharing in the past 6 months was lower among IDUs who were male [odds ratios (OR) = 0.29, 95% confidence interval (CI) = 0.12-0.70], had higher education (OR = 0.74, 95% CI = 0.64-0.86) but higher among those who were unemployed (OR = 4.05, 95% CI = 1.50-10.94), and were single (OR = 1.47, 95% CI = 1.02-2.11).

CONCLUSION

This study presented factors associated with risk of receptive needle and syringe sharing among Iranian IDUs. This information may be used for HIV prevention and harm reduction purposes. Socio-economic status of Iranian IDUs may be closely linked to high-risk injecting behaviors among them.

Hepatitis-C multimedia prevention program in poor Hispanic HIV-infected injecting drug users: six months after intervention

BACKGROUND

In order to prevent the spread of the hepatitis C virus (HCV) amongst Hispanic injection drug users (IDUs), we developed, validated, and implemented a multimedia educational intervention program.

METHODS

A pre-post intervention study design was used to evaluate long-lasting knowledge and behavior changes in a group of 88 low-income Hispanic HIV-infected IDUs. Pre-intervention data was compared with data measured six months after the intervention.

RESULTS

A significant increase in the awareness regarding HCV clinical manifestations, HCV risky behaviors, HCV prevention practices, and HIV/HCV co-infection synergisms was observed in the group six months post-intervention.

CONCLUSION

Our study confirms the long-lasting benefits of multimedia based intervention programs for disseminating HCV prevention strategies in IDUs. Preventive educational approaches that use images, figures, and animations tools can be recommended to target and tailor interventions for vulnerable populations.

Descriptive Aspects of Injection Drug Users in Iran's National Harm Reduction Program by Methadone Maintenance Treatment

BACKGROUND

The Ministry of Health, Treatment and Medical Education of Iran has recently announced an estimated figure of 200,000 injecting drug users (IDUs). The aim of this study was to pilot a national program using demographics, types of drug abuse and prevalence of blood-borne infections among IDUs.

METHODS

In order to elicit data on demographics, types of drug abuse and prevalence of blood-borne infections among IDUs, a questionnaire was designed in the Bureau of Mental-Social Health and Addiction in collaboration with Iran's Drug Control Headquarters of the Police Department. Therapeutical alliance of addiction in Shafagh Center was based on Methadone Maintenance Therapy (MMT).

RESULTS

Among 402 reported IDUs most of them were male, single and in age range of 20 to 39 years old with 72.7% history of imprisonment. Most of them had elementary and high school education and a history of addiction treatment. The majority were current users of opioid, heroin and crack. The prevalence of blood-borne infections was 65.9% and 18.8% for HCV and HIV/AIDS infections, respectively.

CONCLUSION

Prevention programs about harm reduction, treatment and counseling should include young IDUs as a core focus of their intervention structure.

Risk factors for and incidence of acute hepatitis C after the achievement of blood supply safety in Italy: results from the national surveillance system

Surveillance systems for acute hepatitis C allow monitoring of disease incidence trends and transmission patterns. This study aimed to describe the epidemiological profile of reported cases of symptomatic acute hepatitis C in Italy after the achievement of blood supply safety. The incidence of symptomatic acute hepatitis C since 1991 was estimated. Risk factors for acute hepatitis C were analyzed for the period 2003-2010 through a case-control study within a population-based surveillance for acute viral hepatitis. From 1991 to 2010, the incidence decreased from 2 to 0.2 per 100,000, with a more evident decrease among persons aged 15-24 years. During 2003-2010, 1,053 cases were reported. Intravenous drug use (adjusted odds ratio [(adj) OR], 30.5; 95% confidence interval [CI], 18.9-49.1), cohabitation or sexual partnership with an hepatitis C virus (HCV) carrier ((adj) OR, 11.2; 95% CI, 6.6-19.2), nosocomial exposure ((adj) OR, 6.6; 95% CI, 4.6-9.4); unsafe sexual practices ((adj) OR, 3.1; 95% CI, 1.9-5.2), and cosmetic treatments with percutaneous exposure ((adj) OR, 1.7; 95% CI, 1.2-2.4) were independently associated with acute hepatitis C. Population attributable risk estimates indicated nosocomial exposure (39.6%) and intravenous drug use (30.5%) as responsible for most cases. In conclusion, the incidence of symptomatic acute hepatitis C is declining in Italy. Currently, the most important risk factors are: having an HCV-positive household or sexual partner, unsafe sexual practices, cosmetic percutaneous treatments, intravenous drug use, and nosocomial exposure; the latter two factors are responsible for most cases. Effective prevention programs for intravenous drug users and strict adherence to universal precautions in healthcare settings are needed.

A multilevel approach for assessing the variability of hepatitis C prevalence in injection drug users by their gathering places

OBJECTIVES

The aim of this study was to investigate the variation in hepatitis C virus (HCV) prevalence in injection drug users (IDUs) by their gathering places, using a multilevel approach.

METHODS

IDUs recruited from their gathering places were invited to respond to a questionnaire on demographics, drug use history, injection behaviors, and methadone treatment. Dried blood spots were collected for HCV antibody testing by ELISA. Factors associated with the anti-HCV test result were explored by linear logistic regression, followed by the evaluation of heterogeneity between gathering places by multilevel analysis.

RESULTS

A total of 622 respondents from 19 gathering places in Hong Kong, recruited between August and September 2011, were evaluated. Anti-HCV seroprevalence was 81.7% (95% confidence interval 78.6-84.7%), ranging from 67% to 100% by gathering place. HCV infection was associated with current practice of injection, needle-sharing, and midazolam injection. On multilevel analysis, there was a modest but significant variation in HCV antibody prevalence by gathering place, adjusted by midazolam injection (adjusted odds ratio (AOR) 3.91) and current injection (AOR 2.88) or injection over a long duration (AOR 3.17).

CONCLUSIONS

There was heterogeneity in HCV antibody prevalence in IDUs by gathering place, while the influence of injection behaviors varied, suggesting interactivity between factors at the individual and group levels.

Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings

AIMS

To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs).

DESIGN

Hepatitis C virus HCV transmission modelling using U.K. estimates for effect of OST and 100%NSP on individual risk of HCV infection.

SETTING

Range of chronic HCV prevalent (20/40/60%) settings with no OST/100%NSP, and U.K. setting with 50% coverage of both OST and 100%NSP.

PARTICIPANTS

Injecting drug users.

MEASUREMENTS

Decrease in HCV prevalence after 5-20 years due to scale-up of OST and 100%NSP to 20/40/60% coverage in no OST/100%NSP settings, or from 50% to 60/70/80% coverage in the U.K. setting.

FINDINGS

For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCV prevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ≥80%.

CONCLUSIONS

Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

Developing and validating a scoring tool for identifying people who inject drugs at increased risk of hepatitis C virus infection

Objectives To develop and validate a scoring tool based on demographic and injecting risk behaviours to identify those who require additional, non-routine serological screening for hepatitis C virus (HCV) by assessing their personal risk. Design Cross-sectional and prospective cohorts. Setting People who inject drugs (PWID) and attended Needle and Syringe Programs (NSP) in Australia during the period from 1998 to 2008. Participants Cross-sectional data included 16 127 PWID who attended NSP in Australia. Prospective data included 215 HCV-negative PWID who were recruited through street-based outreach, methadone clinics in Australia. Primary and secondary outcome measures HCV seroprevalence in the cross-sectional and HCV seroconversions in the prospective data sets. Results Current study included 16 127 PWID who attended NSP in Australia. Type of drug last injected, frequency and duration of injecting, sharing needles and syringes or other injecting equipment and imprisonment history were associated with HCV infection in all age groups. Strong relationships between an individual's 'HCV score' and their risk of testing HCV antibody positive were observed. An estimated 78% (95% CI 75% to 81%), 82% (95% CI 80% to 84%), 80% (95% CI 78% to 82%) and 80% (95% CI 77% to 82%) of HCV infections across the age groups (<25, 25-29, 30-39 and ≥40 years) would be avoided if participants in the upper four quintiles of HCV scores fell instead into the lowest quintile. Conclusions Knowledge of HCV status has important implications for public health and care and treatment. Risk assessment strategies may assist in alerting PWID who are at increased risk of HCV infection to present for testing.

Prevalence and correlates of hepatitis C infection among male injection drug users in detention, Tehran, Iran

For the benefit of planning for the future care and treatment of people infected with hepatitis C virus (HCV) and to help guide prevention and control programs, data are needed on HCV seroprevalence and associated risk factors. We conducted a cross-sectional sero-behavioral survey of injection drug users (IDU) detained for mandatory rehabilitation during a police sweep of Tehran, Iran, in early 2006. During the study period, a consecutive sample comprising 454 of 499 (91.0%) men arrested and determined to be IDU by urine test and physical examination consented to a face-to-face interview and blood collection for HCV antibody testing. Overall, HCV prevalence was 80.0% (95% confidence interval (CI) 76.2-83.6). Factors independently associated with HCV infection included history of incarceration (adjusted OR 4.35, 95% CI 1.88-10.08), age of first injection < or =25 years (OR 2.72, 95% CI 1.09-6.82), and history of tattooing (OR 2.33, 95% CI 1.05-5.17). HCV prevalence in this population of IDU upon intake to jail was extremely high and possibly approaching saturation. Findings support that incarceration is contributing to the increased spread of HCV infection in Iran and calls for urgent increased availability of HCV treatment, long-term preparation for the care of complications of chronic infection, and rapid scale-up of programs for the primary prevention of parenterally transmitted infections among drug users.

Hepatitis C infection among injecting drug users in England and Wales (1992-2006): there and back again?

Changes in hepatitis C virus (HCV) prevalence from 1992 to 2006 were examined by using 24,311 records from unlinked anonymous surveillance of injecting drug users in England and Wales. Bayesian logistic regression was used to estimate annual prevalence, accounting for changing recruitment patterns (age, gender, injecting duration, geographic region, interactions) and the sensitivity and specificity of different oral fluid testing devices. After controlling for these differences, the authors found that the adjusted HCV prevalence decreased from 70% (95% credible interval: 62, 78) in 1992 to 47% (95% credible interval: 43, 51) in 1998 before rising again to 53% (95% credible interval: 48, 58) in 2006. Women injecting drug users had a higher HCV risk than did men (odds ratio = 1.50, 95% credible interval: 1.31, 1.73). Two regions (London and North West) had a markedly higher HCV prevalence than did the rest of England and Wales. Among individuals who had injected for less than 1 year, the adjusted HCV prevalence in 2006 was higher than that in 1992 (28% vs. 19%, respectively). HCV infection can be prevented. The public health challenge in England and Wales is to increase action in order to regain a downward trend in HCV risk and the benefit that has been lost since 1998.