Incidence of HIV and hepatitis C virus among people who inject drugs, and associations with age and sex or gender: a global systematic review and meta-analysis

Towards an HCV vaccine: an overview of the immunization strategies for eliciting an effective B-cell response

INTRODUCTION

Fifty-eight million people worldwide are chronically infected with hepatitis C virus (HCV) and are at risk of developing cirrhosis and hepatocellular carcinoma (HCC). Direct-acting antivirals are highly effective; however, they are burdened by high costs and the unchanged risk of HCC and reinfection, making prophylactic countermeasures an urgent medical need. HCV high genetic diversity is one of the main obstacles to vaccine development. The protective role of the humoral response directed against the HCV E2 glycoprotein is well established, and broadly neutralizing antibodies play a crucial role in effective viral clearance.

AREAS COVERED

This review explores the HCV targets and the different vaccination approaches, encompassing different expression systems, antigen selection strategies, and delivery methods, focusing on those aimed at eliciting a broad and effective humoral response. Our search criteria included the keywords 'HCV,' 'Hepatitis C,' and 'vaccine' using publicly available databases. Following the screening, 54 papers were selected.

EXPERT OPINION

The investigation of novel vaccine platforms beyond traditional approaches is necessary. While progress has been made in this direction, continued investigations on the HCV virology, immunology, and vaccinology are essential to surmount associated obstacles, heling in the development of an HCV vaccine that can benefit the global public health.

Considerations for equitable distribution of digital healthcare for people who use drugs

BACKGROUND

Telehealth holds the potential to expand healthcare access for people who use drugs (PWUD). However, limited data exist on their digital infrastructure access, a prerequisite for telehealth participation. We studied digital healthcare accessibility among PWUD.

METHODS

We employed respondent-driven sampling to recruit 162 PWUD in Athens, Greece to assess current internet and computer access and telemedicine experience via a structured questionnaire. Participants were at least 18 years with an injection drug use (IDU) history. We utilized logistic regression to evaluate sociodemographic associations.

RESULTS

Participants' mean (SD) age was 45.9 (8.8) years, 84.0% were male, 90.1% Greek, 77.8% reported IDU within the past year, 85.2% were not linked to opioid treatment, and 50.0% were experiencing homelessness. Only 1.9% had telemedicine experience. Internet and computer access were reported by 66.0% and 31.5%, respectively. Most (77.9%) used mobile phones for internet access. Compared to participants with secure housing, those experiencing homelessness reported decreased internet (50.6% vs. 81.5%, p < 0.001) and computer access (11.1% vs. 51.9%, p < 0.001). Multivariable analyses revealed that older age (per 1-year increase: OR = 0.94, 95% CI [0.89, 0.99], p = 0.03)), IDU within the past year (0.29 [0.10, 0.88], p = 0.03), and homelessness (0.29, [0.13, 0.65], p = 0.003) were associated with lower odds of internet access.

CONCLUSIONS

Two-thirds of PWUD accessed the internet, mainly via mobile phones, while only one-third gained access through a computer. Very few PWUD used telemedicine. Homelessness, recent IDU, and older age may further limit digital infrastructure access and should be considered when designing equitable digital healthcare solutions for PWUD.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov (ID: NCT05794984, Protocol: STUDY00007088, Date: 2023-04-03).

Global, regional, and national estimates of hepatitis C virus (HCV) infection incidence among people who inject drugs and number of new annual HCV infections attributable to injecting drug use: a multi-stage analysis

BACKGROUND

Measuring progress towards the WHO 2030 target for hepatitis C virus (HCV) elimination among people who inject drugs (PWID)-an incidence of two or fewer infections per 100 person-years-has been challenging due to insufficient data. We aimed to estimate HCV incidence among PWID before and since 2015, progress towards the 2030 target, and the number of new annual HCV infections attributable to injecting drug use since 2015.

METHODS

Four sequential steps were taken to estimate country-specific HCV incidence. First, we estimated HCV incidence from HCV antibody prevalence by duration of injecting using force-of-infection (FOI) modelling. Second, using Bayesian random-effects meta-analysis, we pooled FOI-derived estimates with any direct HCV incidence estimates from a published global meta-analysis, by country. Third, for countries with no FOI-derived or direct HCV incidence data, we applied incidence estimates from a published multi-country dynamic mathematical model. Fourth, for countries for which incidence could not be estimated using any of the aforementioned methods but that had data on overall HCV antibody prevalence (ie, not stratified by duration of injecting), we used a regression model to predict incidence based on prevalence and average duration of injecting. WHO regional and global HCV incidence, incidence rate ratios (IRRs) for 2015-21 versus pre-2015, and relative decline needed to achieve the 2030 WHO target were derived and weighted by the country-specific number of PWID at risk (ie, those who were HCV RNA-negative), provided that data from at least five countries were available within a WHO region. New annual HCV infections attributable to injecting drug use were estimated by multiplying country-specific HCV incidence for the 2015-21 period by the number of HCV RNA-negative PWID; for countries with no HCV incidence data but with evidence of an existing PWID population, incidence was imputed using the corresponding WHO regional incidence.

FINDINGS

For the pre-2015 period, 146 HCV incidence estimates from 81 countries were included: 52 (36%) direct, 61 (42%) FOI-derived, and 33 (23%) regression-based estimates. For 2015-21, 114 estimates from 97 countries were included: 20 (18%) direct, 18 (16%) FOI-derived, 68 (60%) dynamic model-derived, and eight (7%) regression-based. Globally, pooled HCV incidence was 13·9 per 100 person-years (95% uncertainty interval [UI] 11·9-16·4) for pre-2015 and 8·6 per 100 person-years (7·1-10·7) for 2015-21. Based on a subset of countries with data for both periods, incidence was lower in the Western Pacific (IRR 0·32 [95% UI 0·23-0·50]), Eastern Mediterranean (0·67 [0·50-0·89]), and European (0·79 [0·63-1·02]) regions in 2015-21 versus pre-2015, but no difference was observed in the Americas. Insufficient data prevented comparisons over time for the African and South-East Asia regions and globally. Based on 2015-21 HCV incidence, the global decline needed to meet the 2030 WHO target is 76·7% (95% UI 71·8-81·3), while the global number of new annual HCV infections attributable to injecting drug use was 833 760 (95% UI 493 716-1 544 395) among the 187 countries with documented evidence of a population of PWID.

INTERPRETATION

A substantial increase in HCV treatment and prevention is needed globally to achieve the WHO 2030 HCV elimination target for incidence among PWID.

FUNDING

WHO and the Wellcome Trust.

The association between drug injection duration and hepatitis C prevalence among people who inject drugs in Iran

People who inject drugs (PWID) are at higher risk of hepatitis C virus (HCV) due to their behaviors such as shared injection. Employing appropriate modeling approaches is crucial for accurately evaluating the impact of other variables on outcomes, in this case, HCV seropositivity. This study aimed to assess the non-linear effect of injection duration on HCV seropositivity. From July 2019 to March 2020, 2,684 PWID in Iran were recruited. The binary outcome variable was HCV serostatus (positive vs. negative), determined by detecting HCV antibodies. The non-linear effect of injection duration on HCV seropositivity was assessed using a multilevel Generalized Additive Model in R software, adjusting the effects of other variables in the analysis. We found a non-linear effect of injection duration on HCV seropositivity status (p-value < 0.001). The probability of HCV seropositivity increased with injection duration, though this relationship was non-linear. Initially, the probability rises faster; however, this effect diminishes as the injection duration extends. An initial sharp increase in HCV risk was seen during the first 20 years of injection. HCV seropositivity was notably associated with ever HIV seropositivity (OR [Odds Ratio] = 10.54, 95% CI [Confidence Interval]: 5.39, 20.61, p-value < 0.001), ever having injected methamphetamine (OR = 1.72, 95% CI: 1.33, 2.22, p-value < 0.001), being currently married (OR = 0.67, 95% CI: 0.48, 0.93, p-value = 0.018), ever shared needle/syringe with others (OR = 2.63, 95% CI: 1.32, 5.22, p-value = 0.006), and ever being incarcerated (OR = 1.97, 95% CI: 1.50, 2.58, p-value < 0.001). Our study contributes to the field by demonstrating that a non-linear approach can reveal patterns of risk that linear models might fail to capture. These findings indicate that the relationship between injection duration and HCV seropositivity can be more complex than previously understood, underscoring the importance of employing more advanced modeling techniques in future research.

Gender-based factors associated with hepatitis C testing in people who inject drugs: results from the French COSINUS cohort

OBJECTIVE

We identified factors associated with hepatitis C virus (HCV) testing in the previous 6 months in people who inject drugs (PWID) according to gender.

DESIGN

COSINUS (Cohorte pour l'évaluation des facteurs Structurels et Individuels de l'USage de drogues) is a multisite longitudinal cohort study conducted between June 2016 and May 2019.

SETTING

Harm reduction facilities in two French cities (Marseille and Bordeaux).

PARTICIPANTS

Eligibility criteria were as follows: 18 years of age or older, French speaking, regular use of illegal drugs or of prescribed medication, having injected at least once in the previous month and being able to provide informed consent to participate. We selected data for 298 participants (624 observations).

PRIMARY OUTCOME

Self-reporting HCV testing in the previous 6 months. Gender was defined as self-identifying as a woman, man or transgender person.

RESULTS

Seventy-nine per cent (n=235) of the sample were men, and 63% (n=189) reported HCV testing in the previous 6 months. Our results suggest that men recently incarcerated (OR (95% CI): 3.26 (1.31, 8.12), p=0.011), those regularly attending harm reduction facilities (OR (95% CI): 2.49 (1.47, 4.22), p=0.001), and those with lifetime attempted suicide (OR (95% CI): 2.07 (1.08, 3.95), p=0.028) were more likely to have been tested for HCV in the previous 6 months, whereas older men were less likely (OR (95% CI): 0.46 (0.24, 0.89), p=0.022). Women who had slept in the street (OR (95% CI): 3.95 (1.12, 13.89), p=0.032) were more likely to have been tested for HCV in the previous 6 months, whereas those employed (OR (95% CI): 0.31 (0.12, 0.83), p=0.019) and those with lifetime attempted suicide (OR (95% CI): 0.39 (0.16, 0.97), p=0.044) were less likely.

CONCLUSION

Our results highlight the importance of improving current harm reduction facilities for PWID by adapting them to women's needs and paying special attention to women's mental health. Furthermore, in the context of primary care, improving provider training and reducing injection-related stigma may improve HCV testing uptake in older men and employed women.

Preferential Initiation of Long-Acting Injectable Versus Oral HIV Pre-Exposure Prophylaxis Among Women Who Inject Drugs

Fifty-five of 62 women who inject drugs (WWID) selected long-acting cabotegravir (CAB-LA) over oral PrEP, and 51/55 received a first injection. More recent injection drug use and number of sexual partners were associated with selecting CAB-LA (P < .05). Findings provide preliminary evidence of a strong preference for longer-acting products among WWID.

Social support and HIV management among people who inject drugs: in-depth interviews in Delhi, India

BACKGROUND

People who inject drugs (PWID) experience a higher burden of HIV compared to general populations. Social support has been shown to improve disease management and combat stigma for PWID yet remains unexplored among PWID in low- and middle-income countries.

METHODS

We conducted qualitative in-depth interviews to understand social ties and health management among PWID living with HIV in Delhi, India. The research was nested in a factorial randomized controlled trial comparing same-day treatment and community-based care with standard-of-care. Interviews were conducted in Hindi in a private room, audio recorded, transcribed in English, and analyzed inductively using Dedoose.

RESULTS

We conducted 22 interviews (30 min-two hours) with PWID living with HIV in Delhi (all men, ages 21-38 years). 10 slept in houses, 11 on public streets, and one in a shelter. Participants often experienced isolation in their lives but identified avenues of positive social support from healthcare staff, families, peers (friends or injecting partners), and authority figures/public contacts. Healthcare staff provided information and respectful encouragement to manage health. Outreach workers provided support to remind and accompany participants to clinic visits. Family members offered financial support, medicine reminders, and trust. Authority figures/public contacts included employers, shopkeepers, and vendors who provided a safe place to sleep or store belongings, which proved crucial to consistently store and take pills. In some cases, specific social connections created barriers to health by enabling injecting drug use and carrying out harmful behaviors such as physical attacks, disrespect, and theft.

CONCLUSION

Social connections can offer PWID positive emotional and logistical support to access health services and help them persevere through societal and structural stigmas. However, in some cases they may also contribute negatively to health management challenges. As a harm reduction strategy, public health services can work with PWID to consider untapped opportunities to build positive support and resilience through social ties, as well as how to contend with social connections harmful to health management.

Anonymous Opt-Out HIV and hepatitis C screening at a syringe services program in Florida

This paper outlines the implementation of opt-out HIV and Hepatitis C (HCV) screening at a syringe services program (SSP) in Florida, highlighting its effectiveness in reducing the transmission of these infectious diseases. Historically, many SSPs have utilized opt-in testing models, which require participants to actively choose testing and often result in low participation rates. Recognizing the need for a more effective approach and to comply with Florida's regulatory requirements under the Infectious Disease Elimination Act, we transitioned to an opt-out testing model at our SSP. This model integrates routine, anonymous, and voluntary testing into standard care, normalizing the process and reducing stigma associated with infectious disease screening. Initially, our policy tied testing to access to specific services, including syringe exchange, to meet compliance with Florida Department of Health mandates. However, after feedback from participants, staff, and community members, we revised our approach to allow all participants to access all services, regardless of their decision to participate in testing. Importantly, this policy change did not decrease testing rates, with only 6 out of 226 new enrollments (3%) opting out since the implementation of opt-out screening. By fostering a trusting, non-coercive environment and normalizing screening as part of routine care, we achieved high rates of participation while maintaining participant autonomy. Since transitioning to an opt-out model, we have conducted nearly 3,000 HIV and HCV tests, with seropositivity rates of 3.8% and 54%, respectively. These efforts have facilitated early detection, rapid linkage to care, and reduced transmission within the community. Our findings underscore the importance of comprehensive, repeat testing in high-risk populations and demonstrate the potential for opt-out models to serve as a scalable framework for SSPs nationwide. This approach not only fulfills regulatory and public health objectives but also strengthens the role of SSPs as critical interventions in combating HIV and HCV transmission.

Reprint of: Monitoring HIV, HCV and HBV among people who use drugs in France. A reflective feed-back on a 25-year experiment based on mixed methods. The ANRS-Coquelicot survey

The ANRS-Coquelicot survey has been carried out in France for 25 years, to monitor trends in infectious diseases (HIV and hepatitis B and C) among people who use drugs. In this article, we propose to open the black box of this monitoring experience, by describing and analysing some methodological, ethical and political issues involved in this type of survey. The ANRS-Coquelicot survey has carried out on five occasions in France (from 2002 to 2023) in several cities (from 1 to 27) among people who use drugs recruited in a large diversity of services including drug treatment centres, harm reduction facilities, residential services as well as outreach teams. The survey design included a Time Location Sampling combined with the Generalized Weight Share Method and was guided by a previous anthropological survey. Over time, some methodological challenges have been addressed such as convincing harm reduction providers and drug treatment professionals to welcome this sero-prevalence survey that was first envisioned as a form social control of people who use drugs as well as an evaluation of their professional practices. The implementation of a previous socio-anthropological phase played a major role in favouring the acceptability of the survey as well as in the improvement of the quantitative methodology for choosing the most adequate methodological tools for measuring risk exposure as well as allowing participants room to promote their experiences of the survey through self-narration. Conducting sero-prevalence surveys among time is a way to produce scientific knowledge but can also inform drug policies in order to enable more favourable environments for people who use drugs. This article is an opportunity to show the richness of surveillance surveys and how they can both produce new knowledge and be the subject of innovative methodological developments, as well as enabling the evaluation and orientation of harm reduction policies over time.

Supervised Injecting Room Cohort Study (SIRX): study protocol

BACKGROUND

Supervised injecting facilities (SIFs) are designed to reduce the harms associated with injecting drug use and improve access to health and support services for people who need them. The Supervised Injecting Room Cohort Study (SIRX) aims to provide evidence of the effects, including cost-effectiveness, of a SIF embedded within a community health service, the Melbourne Medically Supervised Injecting Room (MSIR), which has a range of integrated harm reduction, health and social support services on-site.

METHODS AND ANALYSIS

The SIRX study design involves two prospective cohort studies that collect behavioural data and retrospectively and prospectively linked administrative data for primary and tertiary health services, criminal justice records, and mortality. The two cohorts are: (1) participants drawn from the existing Melbourne Injecting Drug User Cohort Study (SuperMIX; established in 2008-ongoing) through which participants consent to annual behavioural surveys (including serological testing for HIV and hepatitis B and C viruses) and linkage to administrative data; and (2) the SIRX-Registration Cohort (SIRX-R; established in 2024) comprising registered MSIR clients who consent to a baseline behavioural survey and administrative data linkage including the frequency of SIF use, and the uptake of on-site services. Primary outcomes are aligned to the legislated aims of the Melbourne MSIR, including ambulance-attended non-fatal overdoses and all-cause and drug-related mortality. Using causal inference methods, analyses will estimate the effect of MSIR exposure (frequent use/infrequent use/no use) on these primary outcomes. The SIRX study also has a secondary focus on the effect of MSIR exposure on health service use and related outcomes.

ETHICS AND DISSEMINATION

SuperMIX Study (599/21) and SIRX-R Study (71/23) ethics approvals were obtained from Alfred Hospital Research Ethics Committee. Participants will be assessed for capacity to provide informed consent following a detailed explanation of the study. Participants are informed of their right to withdraw from the study at any time and that withdrawing does not impact their access to services. Aggregated research results will be disseminated via presentations at national and international scientific conferences and publications in peer-reviewed journals. Local-level reports and outputs will be distributed to key study stakeholders and policymakers. Summary findings via accessible outputs (eg, short infographic summaries) for participants will be displayed in relevant services including the Melbourne MSIR and the study van, and distributed via Harm Reduction Victoria.

Monitoring HIV, HCV and HBV among people who use drugs in France. A reflective feed-back on a 25-year experiment based on mixed methods. The ANRS-Coquelicot survey

The ANRS-Coquelicot survey has been carried out in France for 25 years, to monitor trends in infectious diseases (HIV and hepatitis B and C) among people who use drugs. In this article, we propose to open the black box of this monitoring experience, by describing and analysing some methodological, ethical and political issues involved in this type of survey. The ANRS-Coquelicot survey has carried out on five occasions in France (from 2002 to 2024) in several cities (from 1 to 27) among people who use drugs recruited in a large diversity of services including drug treatment centres, harm reduction facilities, residential services as well as outreach teams. The survey design included a Time Location Sampling combined with the Generalized Weight Share Method and was guided by a previous anthropological survey. Over time, some methodological challenges have been addressed such as convincing harm reduction providers and drug treatment professionals to welcome this sero-prevalence survey that was first envisioned as a form social control of people who use drugs as well as an evaluation of their professional practices. The implementation of a previous socio-anthropological phase played a major role in favouring the acceptability of the survey as well as in the improvement of the quantitative methodology for choosing the most adequate methodological tools for measuring risk exposure as well as allowing participants room to promote their experiences of the survey through self-narration. Conducting sero-prevalence surveys among time is a way to produce scientific knowledge but can also inform drug policies in order to enable more favourable environments for people who use drugs. This article is an opportunity to show the richness of surveillance surveys and how they can both produce new knowledge and be the subject of innovative methodological developments, as well as enabling the evaluation and orientation of harm reduction policies over time.

Prevalence of blood-borne virus infections and uptake of hepatitis C testing and treatment in Australian prisons: the AusHep study

Background

Incarcerated people are at high risk of blood-borne virus infections, particularly HCV, and a priority population for elimination efforts. This national bio-behavioural survey evaluated blood-borne virus prevalence and HCV testing-and-treatment uptake amongst people in Australian prisons.

Methods

Randomly-selected participants from 23 representative prisons nationally were offered point-of-care testing for HIV and HCV (anti-HCV) antibodies, hepatitis B surface antigen (HBsAg), and HCV RNA (if anti-HCV positive). Demographic data and previous HCV testing and treatment were collected by structured interview.

Findings

1599 individuals participated (98% participation; 89%male; median age 35 years; 49% ever injected drugs). Prevalence estimates were: 31.7% (95% CI:28.8-34.8) for anti-HCV; 8.0%for HCV RNA (95% CI:6.4-9.9); 0.5% (95% CI:0.2-1.1) for HBsAg, and 0.8% (95% CI: 0.4-1.7) for HIV antibody. Among participants who had ever injected drugs (n = 787), HCV RNA prevalence was highest among those injecting and sharing needles/syringes within the past month [27.9%; adjusted odds ratio (aOR):4.54 (95% CI:2.65-7.77). Among participants (n = 1599), 70.4% (95% CI: 67.4-73.2) had ever been tested for HCV (62.6% in prison). The highest likelihood of having had HCV testing was observed among participants who injected drugs in the past month (aOR = 10.37, 95% CI:5.72-0.18.78). Among those eligible (n = 318), 84.6% (95% CI:79.2-88.7) had ever received HCV treatment (75.0% in prison), and 67.8% (95% CI:61.7-73.4) were cured. The likelihood of HCV treatment was higher among those previously imprisoned, (aOR = 2.67, 95% CI:1.20-5.93).

Interpretation

Despite high overall HCV testing and treatment uptake, the lower uptake and substantial ongoing HCV disease burden in some sub-populations highlights the need for continued prison-based elimination efforts with population-specific interventions.

Funding

The AusHep study was funded by the Australian GovernmentDepartment of Health and Aged Care.

HIV incidence and factors associated with HIV risk among people who inject drugs engaged with harm-reduction programmes in four provinces in South Africa: a retrospective cohort study

BACKGROUND

HIV incidence among people who inject drugs in South Africa has never been estimated. We aimed to estimate HIV incidence and associations with risk and protective factors among people who inject drugs engaged with harm-reduction services.

METHODS

For this retrospective cohort study we used programmatic data collected from April 1, 2019, to March 30, 2022, by the Networking HIV and AIDS Community of South Africa, which offers harm-reduction services and HIV testing to people who inject drugs. During this 3-year period, services were delivered through drop-in centres and outreach in four South African provinces: Gauteng, KwaZulu-Natal, Western Cape, and Eastern Cape. Our cohort comprised people who inject drugs who did not self-report being HIV positive, were HIV negative at first testing, and had at least one follow-up test. Data were collected by outreach teams. We estimated HIV incidence, assuming seroconversions occurred at the midpoint between the last negative test and first positive test. We assessed associations between HIV seroconversion risk and several factors with Cox regression models, including sociodemographic characteristics, primary drugs used, uptake of interventions (ie, number of harm-reduction packs and opioid agonist treatment [OAT]), and HIV testing interval.

FINDINGS

Of 31 182 people who inject drugs accessing harm-reduction services, 20 955 (including 3409 self-reporting being HIV positive) were not tested for HIV. Of 10 227 people who tested at least once, 8152 were HIV negative at first test and of these, 2402 had at least two tests and formed the study cohort. Overall, 283 (11·8%) people who inject drugs acquired HIV over 2306·1 person-years. HIV incidence was higher in Gauteng (16·7 per 100 person-years; 95% CI 14·5-19·1) and KwaZulu-Natal (14·9 per 100 person-years; 11·3-19·3), than in the Eastern Cape (5·0 per 100 person-years; 2·3-9·6) and Western Cape (3·2 per 100 person-years; 1·9-4·9). In multivariable Cox models, HIV acquisition risk varied by race, primary drugs used, and interval between HIV tests. Additionally, people who injected drugs and received OAT in the past year had lower HIV risk (adjusted hazard ratio 0·48; 95% CI 0·22-1·03) than people who did not receive OAT, although the 95% CI was wide and crossed the null.

INTERPRETATION

Our study highlights a pressing need for scale-up of HIV prevention strategies, particularly opioid agonist treatment, for people who inject drugs in South Africa. Dedicated investments are needed to develop monitoring systems for HIV incidence, risk behaviours, and uptake of interventions to ensure effective and equitable programmes.

FUNDING

Wellcome Trust, Canadian Institutes of Health Research, and Global Fund to Fight AIDS, Tuberculosis and Malaria.

Elimination of HCV Infection: Recent Epidemiological Findings, Barriers, and Strategies for the Coming Years

Hepatitis C is a disease for which in approximately 30 years we have gone from the discovery of the causative agent in 1989, to the introduction of direct-acting antiviral (DAAs) therapies starting from 2011, and to a proposal for its elimination in 2016, with some countries being on track for this goal. Elimination efforts, in the absence of a vaccine, rely on prevention measures and antiviral therapies. However, treatment rates have declined in recent years and are not considered adequate to achieve this goal at a global level. This poses a great epidemiological challenge, as HCV in many countries still causes a significant burden and most infected people are not yet diagnosed. Consequently, efforts are needed at different levels with common purposes: to facilitate access to screening and diagnosis and to improve linkage to care pathways. In this review, we discuss the latest epidemiological findings on HCV infection, the obstacles to its elimination, and strategies that are believed to be useful to overcome these obstacles but are applied unevenly across the world.

Latent factors affecting safer injection practices that can reduce infections and how education can improve them

BACKGROUND

The incidence of healthcare-associated infections, particularly injection-related infections, can increase patient comorbidities even in countries with adequate medical resources. Although there are clear guidelines for injection practices to prevent infections, their application in clinical settings is insufficient. Therefore, the objective of this study was to identify factors affecting injection practices associated with reduced infections by conducting surveys targeting practicing healthcare providers involved in administering injections at each healthcare organization and performing data analysis.

METHODS

We administered a survey to healthcare providers responsible for injection practices at each healthcare organization that included items related to infection-safe injection practice guidelines. All survey questions were reviewed by an expert panel of infectious disease and infection control nurses. Survey contents were subjected to exploratory factor analysis (EFA), confirmatory factor analysis, and multivariable robust regression tests to determine the impact of each factor and their correlations.

RESULTS

A total of 842 questionnaires were analyzed. Each questionnaire was classified into four factors: reuse and contamination, compliance with aseptic technique, exchange of infusion set, and use of multidose vials. Nurses with higher careers showed more compliance. Education within one year and awareness of each item of the questionnaire had positive associations with proper injection practice.

CONCLUSIONS

Education is thought to be the most important factor in good injection practices that could reduce infections. Relevant knowledge through timely training is expected to have a positive impact on performance and compliance related to safe injections.

Risk of Dementia in Parkinson's Disease: A Systematic Review and Meta-Analysis

Estimates of the risk of dementia in Parkinson's disease (PDD) vary widely. We aimed to review the incidence of PDD and in a meta-analysis estimate the pooled annual incidence and relative risk of PDD while also exploring factors that may contribute to heterogeneity between studies. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed and MEDLINE and EMBASE were searched for articles reporting the number of cases of dementia in a population, followed longitudinally, with a minimum of 100 dementia-free Parkinson's disease (PD) patients at baseline. Meta-analyses and meta-regressions were used to estimate the pooled incidence rate of PDD and the relative risk of PDD versus healthy controls (HC). A total of 32 studies were identified, 25 reporting the incidence of PDD and 10 reporting the relative risk of PDD versus HC. The pooled incidence rate of PDD was 4.45 (95% confidence interval [CI], 3.91-4.99) per 100 person-years at risk, equating to a 4.5% annual risk of dementia in a PD prevalent population. The relative risk of PDD was estimated to be 3.25 (95% CI, 2.62-4.03) times greater than HC. Factors contributing to study heterogeneity and disparities in the estimated risk of PDD include the age of patients, year of recruitment, and study location. Significant gaps remain with no studies identified in several geographical regions. Future studies should stratify by age and standardize reporting to reduce overall heterogeneity. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Prevalence of HCV Infection Among People Experiencing Homelessness in Madrid, Spain

Importance

Hepatitis C virus (HCV) microelimination aims to detect and treat hidden infections, especially in at-risk groups, like people experiencing homelessness (PEH) with alcohol or drug use disorders. Point-of-care HCV RNA testing and peer support workers are crucial for identifying and preventing HCV infection among marginalized populations, contributing to overall elimination goals.

Objective

To assess risk factors, prevalence, and trends of active HCV infection among PEH in Madrid, Spain (2019-2023).

Design, Setting, and Participants

This cross-sectional study was conducted between 2019 and 2023 in PEH, defined as people who lacked a fixed, regular, and adequate night residence, screened on the street or in homeless shelters via mobile unit using rapid HCV antibody testing, followed by HCV-RNA testing in Madrid, Spain. Data were analyzed from January to June 2024.

Main Outcomes and Measures

Active HCV infection among PEH was the main outcome. Risk factors analyzed included being born outside of Spain, alcohol misuse, lacking financial income, benzodiazepine use, injection drug use (IDU; including nonactive IDU and active IDU within the last year), opioid substitution therapy participation, and sexual behavior patterns. Data were analyzed using logistic regression. P values were adjusted for multiple testing using the false discovery rate (q-values).

Results

A total of 4741 individuals were screened for HCV infection, of whom 2709 (mean [SD] age, 42.2 [12.7]; 1953 [72.2%] men) were PEH and included in analysis. A total of 363 PEH (13.4%) had test results positive for HCV antibodies, of whom 172 (47.4%) had test results positive for HCV-RNA, and 148 of these (91.9%) started HCV treatment. Overall, active HCV infection prevalence was 6.3%, and the main risk factors associated with active HCV infection included IDU, encompassing both nonactive IDU (adjusted odds ratio [aOR], 10.9; 95% CI, 6.1-19.4; q < .001) and active IDU in the last year (aOR, 27.0; 95% CI, 15.2-48.0; q < .001); a lack of financial income (aOR, 1.8; 95% CI, 1.1-2.9; q = .03); and alcohol misuse (aOR, 1.8; 95% CI, 1.3-2.6; q = .008). There was a significant decrease between 2019 and 2023 in active HCV infection prevalence across the entire population, from 7.2% to 3.4% (P = .04).

Conclusions and Relevance

In this cross-sectional study of PEH in Madrid, IDU, lack of income, and alcohol misuse were primary risk factors associated with HCV infection. The significant decline in HCV rates observed across all risk groups during the study period suggests preventive policies were effective in reducing HCV prevalence among the homeless population.

Microbes Causing Spinal Epidural Infection in Patients Who Use Drugs

Background

The incidence of spine infections has increased due to the surge in injection drug use driven by the opioid epidemic. Few recent studies have evaluated the microbiology of spinal epidural infections among people who inject drugs compared to the microbiology of such infections among the general population.

Methods

We performed a retrospective chart review to identify patients with a spinal epidural abscess or phlegmon unrelated to recent spine surgery between 2015 and 2023.

Results

Of 346 initial records, 277 met inclusion criteria for demographic analyses. Of the 229 patients with microbiologic results, details regarding possible drug use were available in 227 patients. Patients with no documented history of drug use were categorized as non-PWUD, while patients who use drugs (PWUD) were separated based on whether drug use was active or not. Patients with prior histories of injection or noninjection drug use were categorized as nonactive PWUD, while those with injection or snorting drug use reported in the past 3 months were categorized as active PWUD. Thirty-nine percent of patients with spinal epidural infection had substance use disorder. Most patients with monomicrobial cultures were infected with gram-positive, aerobic bacteria (86%). Active PWUD were more likely to have methicillin-resistant Staphylococcus aureus compared to non-PWUD (36% vs 13%, respectively, P = .002). Nonactive PWUD were more likely to have non-Escherichia coli gram-negative bacterial infections than non-PWUD (18% and 4.4%, respectively, P = .01).

Conclusions

More than 1 in 3 patients with a spinal epidural infection unrelated to recent surgery had substance use disorder. These patients are more likely to have infections due to MRSA and gram-negative bacteria other than E coli such as Serratia marcescens.

Persistently high HIV incidence among men who have sex with men and people who inject drugs attending integrated care centres in India: a longitudinal assessment of clinic-based data

INTRODUCTION

Globally, there have been significant declines in HIV incidence over the past two decades, but this decline is slowing, and in some settings, declines have stalled or are growing-particularly where epidemics are concentrated in key populations (KPs). Understanding temporal changes in HIV incidence among KP is critical yet, due to logistical constraints, there are few sources of longitudinal incidence data, particularly among KP.

METHODS

We present HIV incidence rates from June 2014 to December 2022 among cisgender men who have sex with men (MSM) and people who inject drugs (PWID) attending community-based integrated care centres (ICCs) in 15 Indian cities. ICCs, established between 2014 and 2017, provide HIV testing and other services to MSM (eight sites) or PWID (eight sites). Client HIV testing data were included in the analysis if they had ≥2 tests and were not positive on the first test. We calculated incidence rates per 100 person-years (PY), stratified by KP, city/site and year. Poisson regression explored associations of incidence with time, age, gender (PWID only) and ICC use.

RESULTS

From June 2014 to December 2022, 13,501 clients (5722 MSM, 7779 PWID) had ≥2 HIV tests over a median of 1.8 years. There were a total of 1093 incident HIV acquisitions. Overall incidence rates for MSM and PWID were 1.9/100 PY (95% CI: 1.7-2.2) and 4.1 (3.9-4.4), respectively. Among MSM sites, incidence ranged from 0.4 to 3.5 and in PWID sites from 0.6 to 17.9. From adjusted models, incidence increased by 17% annually among MSM. Among PWID, incidence increased by 11% annually up until 2020 and then decreased by 29% after 2020; when excluding the outlier of New Delhi, incidence was stable among PWID. MSM and PWID 21-25 years old had the highest risk of HIV and among PWID, those more consistently engaged in medication for opioid use disorder were at the lowest risk.

CONCLUSIONS

While there was substantial geographic variability, MSM and PWID engaged in a free community-based clinic experienced persistently high HIV incidence (>2/100 PY). KP in low- and middle-income countries should be a focus when considering novel strategies such as long-acting pre-exposure prophylaxis to curtail incidence.

The Prevalence and Genotype Distribution of Hepatitis C Virus in Kenya: A Systematic Review and Meta-Analysis

BACKGROUND

Hepatitis C (HCV) is a virus that causes chronic liver disease, end-stage cirrhosis, and liver cancer, yet most infected individuals remain undiagnosed or untreated. Kenya is a country located in Sub-Saharan Africa (SSA) where the prevalence of HCV remains high but with uncertain disease burden due to little population-based evidence of the epidemic. We aimed to highlight the HCV disease burden in Kenya with a summary of the available data.

METHODS

The study was performed as per the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched publications reporting HCV prevalence and genotypes in Kenya between January 2000 to December 2022. The effect size, i.e., the HCV prevalence, was defined as the proportion of samples testing positive for HCV antibody. Study quality was assessed by the Joanna Briggs Institute (JBI) critical appraisal checklist. Due to high study heterogeneity, the studies were categorized into low-, intermediate-, and high-risk for HCV infection. The pooled estimate prevalence per category was determined by the random effects model. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023401892).

RESULTS

A total of 29 studies with a sample size of 90,668 met our inclusion criteria, a third of which were from the capital city Nairobi (34.5%). Half of the studies included HIV-infected individuals (31%) or injection drug users (20.7%). HCV genotype 1 was the most common, with genotype 4 only slightly less common, and together they accounted for 94% of cases. The pooled prevalence for the low-, intermediate- and high-risk groups were 2.0%, 3.4%, and 15.5%, respectively. Over 80% of the studies had a score of > 6 on the JBI scale, indicating a low risk of bias in terms of study design, conduct and analysis.

CONCLUSION

Our findings demonstrate that there is a higher prevalence of HCV in key populations such as HIV-infected individuals and drug users than in the general population in Kenya. We found that HCV genotypes 1 and 4 were the most common genotypes. More data from the general population is required in order to establish baseline data on the prevalence and genotypes of HCV in Kenya.

Incidence of primary hepatitis C infection among people who inject drugs during 2012-2020 in Athens, Greece

One of the World Health Organization's targets for the 2030 viral hepatitis elimination strategy is to reduce new hepatitis C (HCV) infections. In Athens, Greece, people who inject drugs (PWID) have a high HCV prevalence, with increasing trends since the 2000s. This analysis aims to assess primary HCV incidence among PWID during 2012-2020. Two community-based interventions were implemented in 2012-2013 and 2018-2020 with repeated sero-behavioural surveys in each period. Participants enrolled in multiple surveys were identified through linkage. To assess trends in HCV transmission, three indicators were estimated: (i) anti-HCV prevalence among 'new' injectors (those injecting ≤2 years), (ii) indirect HCV incidence among 'new' injectors, assuming infection occurred at the midpoint between initiating injection and the first positive test, and (iii) HCV incidence from repeat participants. There were 431 and 125 'new' injectors, respectively, in 2012-2013 and 2018-2020. Αnti-HCV prevalence [95% CI] declined from 53.6% [48.8%, 58.3%] in 2012-2013 to 40.0% [31.3, 49.1%] in 2018-2020 (25.4% reduction, p = .007). The indirect estimate [95% CI] of HCV incidence among 'new' injectors decreased from 56.1 [49.3, 63.8] to 39.0/100 person-years (PYs) [29.6, 51.5] (30.5% reduction, p = .020). HCV incidence [95% CI] based on seroconversions in repeat participants (16/63 in 2012-2013 and 9/55 in 2018-2020) declined from 64.6 [39.6105.4] to 13.8/100 PYs [7.2, 26.5], respectively (78.6% reduction, p < .001). Primary HCV incidence remains high among PWID in Athens. Consistent implementation of combined interventions, including high-coverage harm reduction programs and initiatives tailored to increase access to HCV treatment, is essential to sustain the declining trends documented during 2012-2020.

Prevalence and Modes of Transmission of Hepatitis C Virus Infection: A Historical Worldwide Review

Hepatitis C virus infection affects over 58 million individuals and is responsible for 290,000 annual deaths. The infection spread in the past via blood transfusion and iatrogenic transmission due to the use of non-sterilized glass syringes mostly in developing countries (Cameroon, Central Africa Republic, Egypt) but even in Italy. High-income countries have achieved successful results in preventing certain modes of transmission, particularly in ensuring the safety of blood and blood products, and to a lesser extent, reducing iatrogenic exposure. Conversely, in low-income countries, unscreened blood transfusions and non-sterile injection practices continue to play major roles, highlighting the stark inequalities between these regions. Currently, injection drug use is a major worldwide risk factor, with a growing trend even in low- and middle-income countries (LMICs). Emerging high-risk groups include men who have sex with men (MSM), individuals exposed to tattoo practices, and newborns of HCV-infected pregnant women. The World Health Organization (WHO) has proposed direct-acting antiviral (DAA) therapy as a tool to eliminate infection by interrupting viral transmission from infected to susceptible individuals. However, the feasibility of this ambitious and overly optimistic program generates concern about the need for universal screening, diagnosis, linkage to care, and access to affordable DAA regimens. These goals are very hard to reach, especially in LMICs, due to the cost and availability of drugs, as well as the logistical complexities involved. Globally, only a small proportion of individuals infected with HCV have been tested, and an even smaller fraction of those have initiated DAA therapy. The absence of an effective vaccine is a major barrier to controlling HCV infection. Without a vaccine, the WHO project may remain merely an illusion.

HCV prevalence and phylogenetic characteristics in a cross-sectional, community study of young people who inject drugs in New York City: Opportunity for and threats to HCV elimination

Background and Aims

In the United States, the opioid epidemic has led many young people who use opioids to initiate injection drug use, putting them at risk for hepatitis C virus (HCV) infection. However, community surveys to monitor HCV prevalence among young people who inject drugs (YPWID) are rare.

Methods

As part of Staying Safe (Ssafe), a trial to evaluate an HCV-prevention intervention, a community-recruited sample of 439 young people who use opioids (ages 18-30) in New York City (NYC) were screened from 2018 to 2021. Screening procedures included a brief verbal questionnaire, a visual check for injection marks, onsite urine drug testing, rapid HCV antibody (Ab) testing, and dried blood spot (DBS) collection. DBS specimens were sent to a laboratory for HCV RNA testing and phylogenetic analysis to identify genetic linkages among HCV RNA-positive specimens. Multivariable logistic regression was used to assess associations between HCV status (Ab and RNA) and demographics and drug use patterns.

Results

Among the 330 participants who reported injecting drugs (past 6 months), 33% (n = 110) tested HCV Ab-positive, 58% of whom (n = 64) had HCV RNA-positive DBS specimens, indicating active infection. In multivariable analysis, visible injection marks (AOR = 3.02; p < 0.001), older age (AOR = 1.38; p < 0.05), and female gender (AOR = 1.69; p = 0.052) were associated with HCV Ab-positive status. Visible injection marks were also associated with HCV RNA-positive status (AOR = 5.24; p < 0.01). Twenty-five percent of RNA-positive specimens (14/57) were genetically linked.

Conclusion

The relatively low prevalence of active infection suggests the potential impact of treatment-as-prevention in reducing HCV prevalence among YPWID. Targeted community serosurveys could help identify actively infected YPWID for treatment, thereby reducing HCV incidence and future transmissions.

Applying a stigma and time framework to facilitate equitable access to hepatitis C care among women who inject drugs: The ETHOS Engage Study

BACKGROUND

Women who inject drugs are significantly less likely to initiate hepatitis C virus (HCV) treatment than men. Concerted efforts are needed to minimise gender-based inequalities in care. The study aim was to use a stigma and time framework to investigate how women who inject drugs experienced HCV care in healthcare settings.

METHODS

Semi-structured, in-depth interviews were conducted with 34 participants from the ETHOS Engage Cohort (n = 1,443) in Australia. Inclusion criteria were aged ≥18 years, history of injection drug use, and persons who injected in the prior six months or were currently receiving opioid agonist treatment. Drawing on the original qualitative dataset (n = 34), we conducted a secondary analysis focused on women participants' experiences of receiving HCV related care (n = 21/34). Utilising thematic analysis, we applied Earnshaw's theoretical framework, which incorporates time into stigma and health research via three "timescales" - historical context, human development, and status course.

RESULTS

Among the 21 women interviewed (mean age 42 years, 5 are Aboriginal, 11 received HCV treatment), the majority were currently receiving opioid agonist treatment and over half injected drugs in the past month. For historical context, most participants were diagnosed with HCV during the interferon era (1990s-2014). Participants had to navigate a sociomedical landscape not only largely bereft of adequate HCV medical knowledge, appropriate support, and adequate treatments, but were also generally assessed as "unsuitable" for treatment based on their perceived personhood as people who inject drugs. For human development, many participants reported encountering overlapping stigmatizing experiences (layered stigma) while receiving their HCV diagnosis in prenatal care and early postpartum. Under status course, participants acutely recognised the intersection of HCV infection, injection drug use, and gender, and reported concerns about being judged more harshly from healthcare providers as a result.

CONCLUSION

A stigma and time framework illuminated multiple overlapping stigmatizing experiences for women who inject drugs in HCV care and in turn, can help to inform tools and interventions to counter their impact.

Using an intersectionality lens to explore barriers and enablers to hepatitis C point-of-care testing: a qualitative study among people who inject drugs and service providers

BACKGROUND

Hepatitis C virus (HCV) infection is a significant global health burden, particularly among people who inject drugs. Rapid point-of-care HCV testing has emerged as a promising approach to improve HCV detection and linkage to care in harm reduction organizations such as needle and syringe programs. The objective of this study was to use an intersectionality lens to explore the barriers and enablers to point-of-care HCV testing in a needle and syringe program.

METHODS

A qualitative study was conducted using semi-structured interviews with clients (people who inject drugs) and service providers in a large community organization focused on the prevention of sexually transmitted and blood borne infections and harm reduction in Montreal, Canada. An intersectionality lens was used alongside the Theoretical Domains Framework to guide the formulation of research questions as well as data collection, analysis, and interpretation.

RESULTS

We interviewed 27 participants (15 clients, 12 providers). For clients, four themes emerged: (1) understanding and perceptions of HCV testing, (2) the role of an accessible and inclusive environment, (3) the interplay of emotions and motivations in decision-making, and (4) the impact of intersectional stigma related to HCV, behaviors, and identities. For providers, five themes emerged: (1) knowledge, skills, and confidence for HCV testing, (2) professional roles and their intersection with identity and lived experience, (3) resources and integration of services, (4) social and emotional factors, and (5) behavioral regulation and incentives for HCV testing. Intersectional stigma amplified access, emotional and informational barriers to HCV care for clients. In contrast, identity and lived experience acted as powerful enablers for providers in the provision of HCV care.

CONCLUSION

The application of an intersectionality lens provides a nuanced understanding of multilevel barriers and enablers to point-of-care HCV testing. Findings underscore the need for tailored strategies that address stigma, improve provider roles and communication, and foster an inclusive environment for equitable HCV care. Using an intersectionality lens in implementation research can offer valuable insights, guiding the design of equity-focused implementation strategies.

Sex and gender differences in hepatitis C virus risk, prevention, and cascade of care in people who inject drugs: systematic review and meta-analysis

Background

People who inject drugs (PWID) are a priority population in HCV elimination programming. Overcoming sex and gender disparities in HCV risk, prevention, and the cascade of care is likely to be important to achieving this goal, but these have not yet been comprehensively reviewed.

Methods

Systematic review and meta-analysis. We searched Pubmed, EMBASE and the Cochrane Database of Systematic Reviews 1 January 2012-22 January 2024 for studies of any design reporting sex or gender differences among PWID in at least one of: sharing of needles and/or syringes, incarceration history, injection while incarcerated, participation in opioid agonist treatment or needle and syringe programs, HCV testing, spontaneous HCV clearance, direct-acting antiviral (DAA) treatment initiation or completion, and sustained virological response (SVR). Assessment of study quality was based on selected aspects of study design. Additional data were requested from study authors. Data were extracted in duplicate and meta-analysed using random effects models. PROSPERO registration CRD42022342806.

Findings

9533 studies were identified and 92 studies were included. Compared to men, women were at greater risk for receptive needle and syringe sharing (past 6-12 months: risk ratio (RR) 1.12; 95% confidence interval (CI) 1.01-1.23; <6 months: RR 1.38; 95% CI 1.09-1.76), less likely to be incarcerated (lifetime RR 0.64; 95% CI 0.57-0.73) more likely to be tested for HCV infection (lifetime RR 1.07; 95% CI 1.01, 1.14), more likely to spontaneously clear infection (RR1.58; 95% CI 1.40-1.79), less likely to initiate DAA treatment (0.84; 95% CI 0.78-0.90), and more likely to attain SVR after completing DAA treatment (RR 1.02; 95% CI 1.01-1.04).

Interpretation

There are important differences in HCV risk and cascade of care indicators among people who inject drugs that may impact the effectiveness of prevention and treatment programming. Developing and assessing the effectiveness of gender-specific and gender-responsive HCV interventions should be a priority in elimination programming.

Funding

Réseau SIDA-MI du Québec.

Changes in hepatitis C virus prevalence and incidence among people who inject drugs in the direct acting antiviral era

BACKGROUND

The World Health Organization (WHO) has set a goal to eliminate hepatitis C virus (HCV) infection by 2030, including a 90% reduction of HCV incidence. With the introduction of a needle syringe program (NSP) in Stockholm, Sweden, and unrestricted availability of direct acting antiviral (DAA) treatment, we investigate the change of prevalence and incidence of HCV infection among people who inject drugs (PWID) over time.

METHODS

All persons attending the Stockholm NSP 2013-2021 (n=4,138) were included. The prevalence of viremic HCV infection was investigated yearly. For incidence analysis, PWID at risk with at least one follow-up test were included. Participants were divided into naive defined as anti-HCV negative (n=791), and exposed, defined as anti-HCV positive with a negative HCV RNA (n=1,030). Risk factors for HCV infection were analyzed using parametric exponential proportional hazards regression models.

RESULTS

The prevalence of viremic HCV infection decreased from 62% to 30% year 2013-2021 while the prevalence of cured after treatment increased from 0 to 22%, corresponding to 42% cured after treatment out of eligible in 2021. The overall incidence rate in naive was 16.9 (95% CI 15.0-19.0) and in exposed 12.8 (95% CI 11.6-14.2) per 100 person years (PY) and was not significantly reduced years 2013-2015 to 2020-2021 in either group. Risk factors for incident HCV infection in multivariable analysis were sharing needles/syringes, younger age, custody/prison past year, and homelessness, whereas opioid agonist treatment was protective.

CONCLUSION

The prevalence of HCV was halved in PWID as unrestricted DAA treatment became available and NSP was established in Stockholm. However, overall incidence was not reduced. To meet the WHO incidence goal, targeting PWID with high injection risk behaviors for testing and treatment is essential, along with engagement in harm reduction services.

Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial

Importance

Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers.

Objective

To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral.

Design, Setting, and Participants

Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023.

Intervention

Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312).

Main Outcomes and Measures

The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis.

Results

Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high.

Conclusions and Relevance

Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections.

Trial Registration

ClinicalTrials.gov Identifier: NCT02933970.

Epidemiology of acute hepatitis C and hepatitis C virus-related cirrhosis in reproductive-age women, 1990-2019: An analysis of the Global Burden of Disease study

BACKGROUND

The current study uniquely focuses on the global incidence and temporal trends of acute hepatitis C (AHC) and hepatitis C virus (HCV)-related cirrhosis among women of reproductive age (15-49 years) from 1990-2019. The risk of vertical transmission and adverse perinatal outcomes associated with HCV infection underscores the importance of prioritising these women in HCV prevention efforts.

METHODS

Leveraging the Global Burden of Disease 2019 data, we calculated age-standardised incidence rates (ASIR) and assessed temporal trends via the average annual percent change from joinpoint regression. The age-period-cohort model was employed to understand further the effects of age, period, and birth cohort.

RESULTS

Over the 30 years, global incidences of AHC and HCV-related cirrhosis in reproductive-age women increased by 46.45 and 72.74%, respectively. The ASIR of AHC was highest in low sociodemographic index regions but showed a declining trend. Conversely, the ASIR of HCV-related cirrhosis displayed unfavourable trends in low, low-middle, and high sociodemographic index regions. Special attention is necessary for sub-Saharan Africa, high-income North America, Eastern Europe, and Central Asia due to their high incidence rates or increasing trends of AHC and HCV-related cirrhosis. Notably, the age-period-cohort model suggests a recent resurgence in AHC and HCV-related cirrhosis risk.

CONCLUSIONS

The current study is the first to thoroughly evaluate the trends of AHC and HCV-related cirrhosis among reproductive-age women, shedding light on previously unexplored aspects of HCV epidemiology. Our findings identify critical areas where health care systems must adapt to the changing dynamics of HCV infection. The detailed stratification by region and nation further enables the development of localised prevention and treatment strategies.

The Epidemiology of Chronic Hepatitis C: Where We Are Now

One of the main objectives of the World Health Organization is the eradication of viral hepatitis by 2030 by identifying subjects before disease progression. In 2019, only 21% of the 58 million people chronically infected with hepatitis C virus (HCV) had been diagnosed, while overall 13% had been treated. The key recommendation of international screening programs is to reach the people at major risk of viral hepatitis and the general population. National plans, including that in Italy, have dedicated budget lines to support efforts to achieve the objective of elimination. The Italian program involves free screening for HCV in the general population born between 1969 and 1989 and also for all persons in the care of addiction services (Ser.D) and prisoners. The screening programs differed slightly among regions in Italy. In particular, referring to the screening for people born in the period of 1969–1989, in Tuscany, these people received an invitation by SMS to undergo a HCV antibody test. If the test results were positive, the subject was registered on a regional platform and required to undergo HCV RNA testing, prescribed by their GP. In the case of testing positive for HCV RNA, the linkage to care (i.e., patient entry into specialist care after diagnosis) is guaranteed. A strong effort is currently required to eliminate HCV effectively. This review highlights the most recent changes to the epidemiological scenario at the global, European, Italian, and regional (Tuscany) levels.

A call to create integrated services to better address the needs of migrants who use drugs in Europe

Each year, thousands of migrants enter the EU. Data on drug use in migrant populations are scarce and inconclusive. However, several risk factors make them particularly vulnerable to engaging in problematic drug use. In this perspective, we summarize the limited information that is available on migrants who use drugs and make a case as to why it is essential to improve access to health and social services, including harm reduction services, for this population. With this aim, we call for the co-creation of integrated services that better address the needs of migrants who use drugs in Europe.

New HIV Infections Among Key Populations and Their Partners in 2010 and 2022, by World Region: A Multisources Estimation

BACKGROUND

Previously, The Joint United Nations Programme on HIV/AIDS estimated proportions of adult new HIV infections among key populations (KPs) in the last calendar year, globally and in 8 regions. We refined and updated these, for 2010 and 2022, using country-level trend models informed by national data.

METHODS

Infections among 15-49 year olds were estimated for sex workers (SWs), male clients of female SW, men who have sex with men (MSM), people who inject drugs (PWID), transgender women (TGW), and non-KP sex partners of these groups. Transmission models used were Goals (71 countries), AIDS Epidemic Model (13 Asian countries), Optima (9 European and Central Asian countries), and Thembisa (South Africa). Statistical Estimation and Projection Package fits were used for 15 countries. For 40 countries, new infections in 1 or more KPs were approximated from first-time diagnoses by the mode of transmission. Infection proportions among nonclient partners came from Goals, Optima, AIDS Epidemic Model, and Thembisa. For remaining countries and groups not represented in models, median proportions by KP were extrapolated from countries modeled within the same region.

RESULTS

Across 172 countries, estimated proportions of new adult infections in 2010 and 2022 were both 7.7% for SW, 11% and 20% for MSM, 0.72% and 1.1% for TGW, 6.8% and 8.0% for PWID, 12% and 10% for clients, and 5.3% and 8.2% for nonclient partners. In sub-Saharan Africa, proportions of new HIV infections decreased among SW, clients, and non-KP partners but increased for PWID; elsewhere these groups' 2010-to-2022 differences were opposite. For MSM and TGW, the proportions increased across all regions.

CONCLUSIONS

KPs continue to have disproportionately high HIV incidence.

On-site testing and treatment of sexually transmitted infections among female sex workers using molecular point-of-care testing integrated into harm reduction services in Madrid, Spain

INTRODUCTION

This study aimed to evaluate the feasibility of molecular point-of-care testing for STIs, the prevalence of STIs and associated factors, and testing and treatment uptake among street-based female sex workers (FSWs) attending a mobile harm reduction unit in Madrid, Spain.

METHODS

This was a prospective, longitudinal study. From August 15th to December 6th, 2022, participants were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis using molecular testing (Xpert) on self-collected urine samples at a mobile harm reduction unit. Additionally, rapid tests were used to screen participants for HIV, hepatitis C virus (HCV), and syphilis. On-site same-day results and treatment for those infected were offered.

RESULTS

Among 77 FSWs included the median age was 40 (range, 33-48), 64 % were homeless, and 84 % reported drug use in the past six months. Four participants self-reported having HIV, of whom all were on antiretroviral therapy, and 14 (18 %) had HCV antibodies, including three with current infection. The prevalence of at least one STI was 66 %. When categorized by type of STI, the prevalences were as follows: 15 % for CT, 15 % for NG, 51 % for TV, and 21 % for syphilis. Notably, the prevalence of STIs was higher among FSW with recent drug use, with no cases of CT or NG detected among FSWs who did not recently use drugs. In adjusted analysis, drug use was associated an increased odds of having an STI (adjusted odds ratio, 10.47; 95 % CI: 1.67-65.42). All participants consented to screening, and all but one received on-site result-based linkage to treatment.

CONCLUSIONS

This study demonstrates the feasibility, high STI prevalence, and high linkage to testing and treatment following point-of-care molecular testing among street-based FSWs who have recently used drugs in Madrid, Spain.

Hepatitis C Cascade of Care in the Direct-Acting Antivirals Era: A Meta-Analysis

INTRODUCTION

The hepatitis C virus (HCV) epidemic remains a public health problem worldwide. A systematic review and meta-analysis were conducted to provide evidence of outcomes attained across the HCV care cascade in the era of direct-acting antivirals.

METHODS

Studies from North America, Europe, and Australia (January 2014 through March 2021) reporting on HCV care cascade outcomes (screening to cure) were included. When calculating the proportions of individuals completing each step, the numerator for Steps 1-8 was the number of individuals completing each step; the denominator was the number of individuals completing the previous step for Steps 1-3 and Step 3 for Steps 4-8. In 2022, random effects meta-analyses were conducted to estimate pooled proportions with 95% CIs.

RESULTS

Sixty-five studies comprising 7,402,185 individuals were identified. Among individuals with positive HCV ribonucleic acid test results, 62% (95% CI=55%, 70%) attended their first care appointment, 41% (95% CI=37%, 45%) initiated treatment, 38% (95% CI=29%, 48%) completed treatment, and 29% (95% CI=25%, 33%) achieved cure. HCV screening rates were 43% (95% CI=22%, 66%) in prisons or jails and 20% (95% CI=11%, 31%) in emergency departments. Linkage to care rates were 62% (95% CI=46%, 75%) for homeless individuals and 26% (95% CI=22%, 31%) for individuals diagnosed in emergency departments. Cure rates were 51% (95% CI=30%, 73%) in individuals with substance use disorder and 17% (95% CI=17%, 17%) in homeless individuals. Cure rates were lowest in the U.S.

DISCUSSION

Despite the availability of effective all-oral direct-acting antiviral therapies, persistent gaps remain across the HCV care cascade, especially among traditionally marginalized populations. Public health interventions targeting identified priority areas (e.g., emergency departments) may improve screening and healthcare retention of vulnerable populations with HCV infection (e.g., substance use disorder populations).

Progress of immunotherapies in gestational trophoblastic neoplasms

BACKGROUND

Different from other malignant gynecologic tumors, gestational trophoblastic neoplasms (GTNs) exhibit an exceptionally high cure rate primarily through chemotherapeutic interventions. However, there exists a small subset of refractory GTNs that do not respond to conventional chemotherapies. In such cases, the emergence of immunotherapies has demonstrated significant benefits in managing various challenging GTNs.

PURPOSE

This article aims to provide a comprehensive and systematic review of the immune microenvironment and immunotherapeutic approaches for GTNs. The purpose is to identify potential biomarkers that could enhance disease management and summarize the available immunotherapies for ease of reference.

METHODS

We reviewed the relevant literatures toward immunotherapies of GTNs from PubMed.

CONCLUSION

Current immunotherapeutic strategies for GTNs mainly revolve around immune checkpoint inhibitors (ICIs) targeting programmed death receptor 1 (PD-1) and programmed cell death ligand 1 (PD-L1). Prominent examples include avelumab, pembrolizumab, and camrelizumab. However, existing researches into the underlying mechanisms are still limited.

Hepatitis C

Hepatitis C virus (HCV) is a hepatotropic RNA virus that can cause acute and chronic hepatitis, with progressive liver damage resulting in cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In 2016, WHO called for the elimination of HCV infection as a public health threat by 2030. Despite some progress, an estimated 57 million people were living with HCV infection in 2020, and 300 000 HCV-related deaths occur per year. The development of direct-acting antiviral therapy has revolutionised clinical care and generated impetus for elimination, but simplified and broadened HCV screening, enhanced linkage to care, and higher coverage of treatment and primary prevention strategies are urgently required.

Insights from a national survey in 2021 and from modelling on progress towards hepatitis C virus elimination in the country of Georgia since 2015

BackgroundBetween May 2015 and February 2022, 77,168 hepatitis C virus (HCV)-infected people in Georgia have been treated through an HCV elimination programme. To project the programme's long-term impacts, an HCV infection model was initially developed, based on data from surveys among people who inject drugs and a national serosurvey in 2015.AimAccounting for follow-up surveys in 2021, we validate and update projections of HCV infection prevalence and incidence.MethodWe assessed the initial model projections' accuracy for overall prevalence, by age, sex, and among people who ever injected drugs, compared with 2021 serosurvey data. We used 2021 results to weight model fits and to recalculate the national programme's impact leading up to March 2022 on HCV infection incidence rates. Cases and deaths averted were estimated. The impact of reduced treatment rates during the COVID-19 pandemic was assessed.ResultsThe original model overpredicted adult (≥ 18 years old) chronic HCV infection prevalence for 2021 (2.7%; 95% credible interval (CrI): 1.9-3.5%) compared with a 2021 serosurvey (1.8%; 95% confidence interval (CI): 1.3-2.4%). Weighted model projections estimated a 60% decrease in HCV infection incidence by March 2022, with an absolute incidence of 66 (95% CrI: 34-131) per 100,000 person-years (overall population). Between May 2015 and March 2022, 9,186 (95% CrI: 5,396-16,720) infections and 842 (95% CrI: 489-1,324) deaths were averted. The COVID-19 pandemic resulted in 13,344 (95% CrI: 13,236-13,437) fewer treatments and 438 (95% CrI: 223-744) fewer averted infections by March 2022.ConclusionResults support the programme's high effectiveness. At current treatment rate (406/month), 90% reductions in prevalence and incidence in Georgia are achievable by 2030.