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Zhu J, Takeh BT, David J, Sang J, Moore DM, Hull M, Grennan T, Wong J, Montaner JS, Lima VD. Impact of screening and doxycycline prevention on the syphilis epidemic among men who have sex with men in British Columbia: a mathematical modelling study. LANCET REGIONAL HEALTH. AMERICAS 2024; 33:100725. [PMID: 38590322 PMCID: PMC11000203 DOI: 10.1016/j.lana.2024.100725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/07/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
Background Men who have sex with men (MSM) in British Columbia (BC) are disproportionately affected by infectious syphilis and HIV. In this study, we developed a co-interaction model and evaluated the impact and effectiveness of possible interventions among different MSM subgroups on the syphilis epidemic. Methods We designed a deterministic compartmental model, which stratified MSM by HIV status and HIV pre-exposure prophylaxis (HIV-PrEP) usage into (1) HIV-negative/unaware MSM (HIV-PrEP not recommended, not on HIV-PrEP), (2) HIV-negative/unaware MSM with HIV-PrEP recommended (not on HIV-PrEP), (3) HIV-negative/unaware MSM actively on HIV-PrEP, and (4) MSM diagnosed with HIV. We estimated the effect of scaling up syphilis testing frequency from Status Quo to six-, four-, and three-months, increasing the percentage of MSM using doxycycline prevention (Doxy-P) to 25%, 50%, and 100% of the target level, and a combination of both among subgroups (2)-(4). We also assessed the impact of these interventions on the syphilis incidence rates from 2020 to 2034 in comparison to the Status Quo scenario where no intervention was introduced. Findings Under the Status Quo scenario, with the expansion of the HIV-PrEP program to improve syphilis testing, the syphilis incidence rate was estimated to peak at 16.1 [Credible Interval (CI):14.2-17.9] per 1,000 person-years (PYs) in 2023 and decrease to 6.7 (CI:3.8-10.9) per 1,000 PYs by 2034. The syphilis incidence rate in 2034 was estimated at 0.7 (0.3-1.3) per 1,000 PYs if MSM diagnosed with HIV could be tested every four months, and at 1.5 (0.7-3.0) per 1,000 PYs if HIV-negative/unaware MSM actively on HIV-PrEP could be tested every three months. By achieving 100% of the target coverage of Doxy-P, the syphilis incidence rate was estimated at 1.4 (0.5-3.4) if focusing on MSM diagnosed with HIV, and 2.6 (1.2-5.1) per 1,000 PYs if focusing on HIV-negative/unaware MSM actively on HIV-PrEP. Under the combined interventions, the syphilis incidence rate could be as low as 0.0 (0.0-0.1) and 0.8 (0.3-1.8) per 1,000 PYs, respectively. Interpretation The HIV-PrEP program in BC plays a crucial role in increasing syphilis testing frequency among high-risk MSM and reducing syphilis transmission among this group. In addition, introducing Doxy-P can be an effective complementary strategy to minimize syphilis incidence, especially among MSM diagnosed with HIV. Funding This work was funded by the Canadian Institutes of Health Research.
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Affiliation(s)
- Jielin Zhu
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Bronhilda T. Takeh
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jummy David
- Laboratory for Industrial and Applied Mathematics, Department of Mathematics and Statistics, York University, Toronto, ON, Canada
| | - Jordan Sang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - David M. Moore
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mark Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Troy Grennan
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Julio S.G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Viviane D. Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Bouzanis K, Joshi S, Lokker C, Pavalagantharajah S, Qiu Y, Sidhu H, Mbuagbaw L, Qutob M, Henedi A, Levine MAH, Lennox R, Tarride JE, Kalina D, Alvarez E. Health programmes and services addressing the prevention and management of infectious diseases in people who inject drugs in Canada: a systematic integrative review. BMJ Open 2021; 11:e047511. [PMID: 34556508 PMCID: PMC8461723 DOI: 10.1136/bmjopen-2020-047511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID. DESIGN This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada. RESULTS This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction. CONCLUSIONS These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care. PROSPERO REGISTRATION NUMBER CRD42020142947.
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Affiliation(s)
- Katrina Bouzanis
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Joshi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Cynthia Lokker
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Yun Qiu
- School of Health Sciences, Jiangsu Institute of Commerce, Nanjing, Jiangsu, China
| | - Hargun Sidhu
- Department of Undergraduate Medical Education, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Majdi Qutob
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Alia Henedi
- Faculty of Pharmacy, Eastern Mediterranean University, Famagusta, North Cyprus, Cyprus
| | - Mitchell A H Levine
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robin Lennox
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Dale Kalina
- Department of Infectious Diseases, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
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Lima VD, Zhu J, Card KG, Lachowsky NJ, Chowell-Puente G, Wu Z, Montaner JSG. Can the combination of TasP and PrEP eliminate HIV among MSM in British Columbia, Canada? Epidemics 2021; 35:100461. [PMID: 33984688 DOI: 10.1016/j.epidem.2021.100461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/09/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In British Columbia (BC), the HIV epidemic continues to disproportionally affect the gay, bisexual and other men who have sex with men (MSM). In this study, we aimed to evaluate how Treatment as Prevention (TasP) and pre-exposure prophylaxis (PrEP), if used in combination, could lead to HIV elimination in BC among MSM. METHODS Considering the heterogeneity in HIV transmission risk, we developed a compartmental model stratified by age and risk-taking behaviour for the HIV epidemic among MSM in BC, informed by clinical, behavioural and epidemiological data. Key outcome measures included the World Health Organization (WHO) threshold for disease elimination as a public health concern and the effective reproduction number (Re). Model interventions focused on the optimization of different TasP and PrEP components. Sensitivity analysis was done to evaluate the impact of sexual mixing patterns, PrEP effectiveness and increasing risk-taking behaviour. RESULTS The incidence rate was estimated to be 1.2 (0.9-1.9) per 1000 susceptible MSM under the Status Quo scenario by the end of 2029. Optimizing all aspects of TasP and the simultaneous provision of PrEP to high-risk MSM resulted in an HIV incidence rate as low as 0.4 (0.3-0.6) per 1000 susceptible MSM, and an Re as low as 0.7 (0.6-0.9), indicating that disease elimination was possible when TasP and PrEP were combined. Provision of PrEP to younger MSM or high-risk and younger MSM resulted in a similar HIV incidence rate, but an Re with credible intervals that crossed one. CONCLUSION Further optimizing all aspects of TasP and prioritizing PrEP to high-risk MSM can achieve the goal of disease elimination in BC. These results should inform public health policy development and intervention programs that address the HIV epidemic in BC and in other similar settings where MSM are disproportionately affected.
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Affiliation(s)
- Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Jielin Zhu
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Kiffer G Card
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Nathan J Lachowsky
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Gerardo Chowell-Puente
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA
| | - Zunyou Wu
- Division of HIV Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Pitcher AB, Borquez A, Skaathun B, Martin NK. Mathematical modeling of hepatitis c virus (HCV) prevention among people who inject drugs: A review of the literature and insights for elimination strategies. J Theor Biol 2019; 481:194-201. [PMID: 30452959 PMCID: PMC6522340 DOI: 10.1016/j.jtbi.2018.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023]
Abstract
In 2016, the World Health Organization issued global elimination targets for hepatitis C virus (HCV), including an 80% reduction in HCV incidence by 2030. The vast majority of new HCV infections occur among people who inject drugs (PWID), and as such elimination strategies require particular focus on this population. As governments urgently require guidance on how to achieve elimination among PWID, mathematical modeling can provide critical information on the level and targeting of intervention are required. In this paper we review the epidemic modeling literature on HCV transmission and prevention among PWID, highlight main differences in mathematical formulation, and discuss key insights provided by these models in terms of achieving WHO elimination targets among PWID. Overall, the vast majority of modeling studies utilized a deterministic compartmental susceptible-infected-susceptible structure, with select studies utilizing individual-based network transmission models. In general, these studies found that harm reduction alone is unlikely to achieve elimination targets among PWID. However, modeling indicates elimination is achievable in a wide variety of epidemic settings with harm reduction scale-up combined with modest levels of HCV treatment for PWID. Unfortunately, current levels of testing and treatment are generally insufficient to achieve elimination in most settings, and require further scale-up. Additionally, network-based treatment strategies as well as prison-based treatment and harm reduction provision could provide important additional population benefits. Overall, epidemic modeling has and continues to play a critical role in informing HCV elimination strategies worldwide.
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Affiliation(s)
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, USA
| | - Britt Skaathun
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, USA.
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Gicquelais RE, Foxman B, Coyle J, Eisenberg MC. Hepatitis C transmission in young people who inject drugs: Insights using a dynamic model informed by state public health surveillance. Epidemics 2019; 27:86-95. [PMID: 30930214 DOI: 10.1016/j.epidem.2019.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 12/18/2018] [Accepted: 02/18/2019] [Indexed: 12/12/2022] Open
Abstract
Increasing injection of heroin and prescription opioids have led to increases in the incidence of hepatitis C virus (HCV) infections in US young adults since the early 2000s. How best to interrupt transmission and decrease HCV prevalence in young people who inject drugs (PWID) is uncertain. We developed an age-stratified ordinary differential equation HCV transmission model of PWID aged 15-64, which we fit to Michigan HCV surveillance data among young PWID aged 15-29. We used Latin hypercube sampling to fit to data under 10,000 plausible model parameterizations. We used the best-fitting 10% of simulations to predict the potential impact of primary (reducing injection initiation), secondary (increasing cessation, reducing injection partners, or reducing injection drug use relapse), and tertiary (HCV treatment) interventions (over the period 2017-2030) on acute and chronic HCV cases by the year 2030. Treating 3 per 100 current and former PWID per year could reduce chronic HCV by 27.3% (range: 18.7-30.3%) and acute HCV by 23.6% (range: 6.7-29.5%) by 2030 among PWID aged 15-29 if 90% are cured (i.e. achieved sustained virologic response [SVR] to treatment). Reducing the number of syringe sharing partners per year by 10% was predicted to reduce chronic HCV by 15.7% (range: 9.4-23.8%) and acute cases by 21.4% (range: 14.2-32.3%) among PWID aged 15-29 by 2030. In simulations of combinations of interventions, reducing injection initiation, syringe sharing, and relapse rates each by 10% while increasing cessation rates by 10% predicted a 27.7% (range: 18.0-39.7%) reduction in chronic HCV and a 38.4% (range: 28.3-53.3%) reduction in acute HCV. Our results highlight the need for HCV treatment among both current and former PWID and the scale up of both primary and secondary interventions to concurrently reduce HCV prevalence and incidence in Michigan.
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Affiliation(s)
- Rachel E Gicquelais
- University of Michigan School of Public Health, Department of Epidemiology, 1415 Washington Heights, Ann Arbor, MI 48109, United States; Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe St, Baltimore, MD 21205, United States.
| | - Betsy Foxman
- University of Michigan School of Public Health, Department of Epidemiology, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Joseph Coyle
- Michigan Department of Health and Human Services, 320 S Walnut St, Lansing, MI 48933, United States.
| | - Marisa C Eisenberg
- University of Michigan School of Public Health, Department of Epidemiology, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
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Nouch S, Gallagher L, Erickson M, Elbaharia R, Zhang W, Wang L, Bacani N, Kason D, Kleban H, Knebel L, Hall D, Barrios R, Hull M. Factors associated with lost to follow-up after hepatitis C treatment delivered by primary care teams in an inner-city multi-site program, Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 59:76-84. [DOI: 10.1016/j.drugpo.2018.06.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 12/12/2022]
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Martin NK, Skaathun B, Vickerman P, Stuart D. Modeling Combination HCV Prevention among HIV-infected Men Who Have Sex With Men and People Who Inject Drugs. AIDS Rev 2017; 19:97-104. [PMID: 28534885 PMCID: PMC5560483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
People who inject drugs (PWID) and HIV-infected men who have sex with men (MSM) are key risk groups for HCV transmission. Mathematical modeling studies can help elucidate what level and combination of prevention intervention scale-up is required to control or eliminate epidemics among these key populations. We discuss the evidence surrounding HCV prevention interventions and provide an overview of the mathematical modeling literature projecting the impact of scaled-up HCV prevention among PWID and HIV-infected MSM. Harm reduction interventions, such as opiate substitution therapy and needle and syringe programs, are effective in reducing HCV incidence among PWID. Modeling and limited empirical data indicate that HCV treatment could additionally be used for prevention. No studies have evaluated the effectiveness of behavior change interventions to reduce HCV incidence among MSM, but existing interventions to reduce HIV risk could be effective. Mathematical modeling and empirical data indicate that scale-up of harm reduction could reduce HCV transmission, but in isolation is unlikely to eliminate HCV among PWID. By contrast, elimination is possibly achievable through combination scale-up of harm reduction and HCV treatment. Similarly, among HIV-infected MSM, eliminating the emerging epidemics will likely require HCV treatment scale-up in combination with additional interventions to reduce HCV-related risk behaviors. In summary, elimination of HCV will likely require combination prevention efforts among both PWID and HIV-infected MSM populations. Further empirical research is required to validate HCV treatment as prevention among these populations, and to identify effective behavioral interventions to reduce HCV incidence among MSM.
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Affiliation(s)
- Natasha K. Martin
- Division of Global Public Health, University of California San Diego, California, USA
- School of Social and Community Medicine, University of Bristol, UK
| | - Britt Skaathun
- Division of Global Public Health, University of California San Diego, California, USA
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, UK
| | - David Stuart
- Chelsea and Westminster Foundation NHS Trust, London, UK
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