CommentaryResearch priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs
Introduction
Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection (The Polaris Observatory, 2017), including an estimated 7.5 million people who have recently injected drugs (PWID) (Nelson et al., 2011). There is an additional large, but unquantified, burden among those PWID who have ceased injecting (Hajarizadeh, Grebely, & Dore, 2013; Nelson et al., 2011). The incidence of HCV infection among current PWID also remains high in many settings (Morris et al., 2017a; Page, Morris, Hahn, Maher, & Prins, 2013). Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase (Hajarizadeh et al., 2013), despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95% (Dore & Feld, 2015). 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 and those who have ceased injecting.
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 of Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the epidemiology, 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.
Section snippets
Epidemiology of injecting drug use, HCV, and HIV among PWID
People with a history of injecting drug use include those who report injecting an illicit drug at least once in their life. This population includes people who have permanently ceased injecting; “current” or “recent” injectors (with definitions for “recent” varying in the literature from one month to one year); as well as people who may be considered “occasional” injectors (including people in treatment for drug use disorders, some may be receiving opioid substitution therapy (OST), who have
Prevention of primary HCV infection
HCV incidence remains high in many settings (Hagan, Pouget, Des Jarlais, & Lelutiu-Weinberger, 2008; Morris et al., 2017a, Page et al., 2013, Wiessing et al., 2014), particularly in the first several years of injecting (Hagan et al., 2008; Roy, Boudreau, & Boivin, 2009), and ongoing HCV transmission is a major issue among PWID, with variations globally.
There is no HCV vaccine, either currently or readily foreseeable. A mathematical model recently suggested that a partially effective vaccine,
HCV testing
Simple, tolerable, and effective DAA HCV therapies have eliminated interferon as a major barrier to HCV scale-up in PWID and dramatically simplified diagnostic and monitoring needs (Cohn, Roberts, Amorosa, Lemoine, & Hill, 2015). However, in order for these therapies to have an effect at a population level (Grebely & Dore, 2014), targeted interventions to enhance HCV testing, linkage to care, and treatment (“the HCV care cascade”) are needed.
Globally, HCV testing and diagnosis remains
Linkage to HCV care and treatment
Linkage to HCV care and treatment also remains inadequate internationally (Bruggmann et al., 2014, Liakina et al., 2015, Saraswat et al., 2015). Simplified HCV testing, including dried blood spot testing (McAllister et al., 2014) and point-of-care HCV testing (Bottero et al., 2015, Morano et al., 2014) has been shown to facilitate linkage to HCV care. Other strategies that have been demonstrated to facilitate linkage to HCV care and treatment include, non-invasive liver disease screening using
DAA treatment for HCV infection
The availability of tolerable, highly effective all-oral DAA regimens has overcome the barrier posed by poor tolerability of interferon-based therapy, providing an important tool to achieve scale-up of HCV therapy in PWID.
Among people receiving OST with no recent illicit drug use, post-hoc analyses of phase II and III trials of DAA therapy have demonstrated that treatment completion, adherence, and sustained virological response (SVR) are similar to those not receiving OST (Dore et al., 2016,
Reinfection following successful treatment
Ongoing risk behaviours following successful HCV therapy and lack of adequate coverage of harm reduction interventions (e.g. NSP and OST) may lead to reinfection and compromised treatment outcomes (Cunningham, Applegate, Lloyd, Dore, & Grebely, 2015; Midgard et al., 2016). The incidence of HCV reinfection following successful interferon-based treatment among PWID ranges from 0.0 to 5.3/100 person-years (Aspinall et al., 2013, Cunningham et al., 2015, Midgard et al., 2016, Pineda et al., 2015;
Approach to these research priorities
A further consideration is the methods chosen to address these identified research priorities. This expert panel identified that a multi-disciplinary and multi-method approach is appropriate for these research priorities. In particular, the expertise and insight that can be drawn from social science and from direct involvement of the affected communities was highlighted as best and appropriate practice to optimise investment in HCV research.
Each of the research priorities posed across topics
Conclusion
The high burden of HCV infection among populations of PWID poses challenges for the implementation of evidence-based, best practice guidelines to shape the priorities that are identified for research. A key underpinning to research in each area of epidemiology, prevention, testing, linkage to care, treatment outcomes and reinfection is the prohibition that surrounds injecting drug use around the globe. Hence, a research question that is relevant to each area is the impact of policies and
Financial support
The Kirby Institute is funded by the Australian Government Department of Health. The National Drug and Alcohol Research Centre at UNSW Australia is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund. The views expressed in this publication do not necessarily represent the position of the Australian Government. JG is supported by a National Health and Medical Research Council Career Development Fellowship. LD is supported
Disclosures
JG is a consultant/advisor and has received research grants from Abbvie, Bristol Myers Squibb, Cepheid, Gilead Sciences and Merck. PB has served as advisor and speaker for, and has received project and research grants from AbbVie, BMS, Gilead, Merck, and Mundipharma. JVL is a consultant/advisor for Gilead Sciences and MSD and has received research grants from AbbVie and Gilead Sciences. MaHe received investigator initiated research grant support from Abbvie, Bristol Myers Squibb, and Gilead
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2021, International Journal of Drug PolicyCitation Excerpt :Recent epidemiological evidence indicates that PWID have both a high degree of willingness to undergo DAA treatment and can be cured of HCV at rates comparable to other populations (>90%) (Alimohammadi, Holeksa, Thiam, Truong, & Conway, 2018; Mah et al., 2017; Socías et al., 2017). Accordingly, a growing body of social and implementation science research has identified priorities for action to scale up DAA treatments among PWID, including through healthcare reforms (e.g., removal of clinical and regulatory barriers to treatment; implementation of integrated, decentralized, and peer-led services) and broader socio-structural interventions to address high levels of poverty and the lack of affordable housing, as well as substance use-related criminalization and stigmatization (Day et al., 2019; Ford et al., 2015; Goodyear, Ti, Carrieri, Small, & Knight, 2020; Carla, Grebely, Bruneau, Bruggmann et al., 2017; Grebely, Bruneau, Lazarus et al., 2017; Knight & Ti, 2019). The evolving HCV care landscape signals a pivotal and long-awaited opportunity to reduce the inequitable burden (e.g., incidence, prevalence, impacts) of HCV among PWID.
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2021, International Journal of Drug PolicyCitation Excerpt :In Sweden, reasons for being LTFU has not been studied before, but a study found that WWID at NEP enrolment had higher injection risk behaviours compared to MWID, also reducing their injection risk behaviours faster and proportionally more (Kåberg et al., 2020). Optimization of policy-making and harm reduction programs including NEP should be based on continuously updated gender--specific evidence (Iversen, Page, Madden & Maher, 2015; Karlsson et al., 2017; Rehle, Lazzari, Dallabetta & Asamoah-Odei, 2004) and NEP performance, the lack of which has hindered development of comprehensive policy guidelines, especially targeting women's needs (Grebely et al., 2017; Iversen et al., 2015; Larney et al., 2015; Roberts et al., 2010). Consequently, the aim of this study was to analyze the NEP continuum of care from a gender--perspective i.e., to better understand WWID and MWID subgroup characteristics associated with injection- and sexual risk behaviour at NEP enrolment, being LTFU, and retention in the NEP.
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