Hepatitis C virus (HCV) related liver fibrosis in people who inject drugs (PWID) at the Stockholm Needle Exchange - evaluated with liver elasticity

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.

A multicomponent holistic care pathway for people who use drugs in Tayside, Scotland

BACKGROUND

People Who Use Drugs (PWUD) are at high risk of non-fatal overdose and other drug-related harms. The United Kingdom drugs policy landscape makes it challenging to support those at risk. Tayside, in East Scotland, has a sizeable population at risk of drug-related harms. In 2021, the National Health Service implemented a care pathway for PWUD to provide multidimensional healthcare interventions. We aimed to quantify drug-related harms; assess wider health and well-being; and understand substance use trends and behaviours, among those engaged in the pathway.

METHODS

Existing community-embedded blood-borne virus pathways were adapted to provide multiple healthcare assessments over three visits. We undertook an observational cohort study to analyse uptake and outcomes for the initial cohort of PWUD engaged at appointment one.

RESULTS

From August 2021-September 2022, 150 PWUD engaged with the pathway. Median age was 39 (34-42) years, 108 (72%) were male, and 124 (83%) lived in deprived areas. Seventy (47%) had been disengaged from healthcare for over a year. Polysubstance use was reported by 124 (83%), 42 (28%) disclosed injecting daily, and 54 (36%) shared equipment. Fifty-four (36%) experienced recent non-fatal overdose, and there were six overdose fatalities (4.1 [1.5-9.0] per 100PY). The offer of take-home naloxone was accepted by 108 (72%). Fourteen (9%) were diagnosed with Hepatitis C and two (1%) with HIV. Renal, hepatological, and endocrine impairment were observed among 30 (20%), 23 (15%), and 11 (7%), people respectively. Ninety-six (65%) had high risk of clinical depression. Forty-eight (32%) declined Covid-19 vaccination.

CONCLUSION

The pathway engaged PWUD with high exposure to recent non-fatal overdose and other drug-related harms, alongside co-morbid health issues. Our results suggest multi-dimensional health assessments coupled with harm reduction in community settings, with appropriate linkage to care, are warranted for PWUD. Service commissioners should seek to integrate these assessments where possible.

Real-world hepatitis C treatment outcomes and reinfections among people who inject drugs at a needle and syringe program in Stockholm, Sweden

BACKGROUND

People who inject drugs (PWID) represent a population with an increased prevalence of hepatitis C (HCV) infections. HCV treatment among PWID is essential to reach the WHO goal of eliminating HCV as a major public health threat by 2030. Despite better understanding of PWID subgroups and changes in risk behaviors over time, more knowledge about HCV treatment outcomes in different HCV prevalence populations and settings is warranted to enhance the continuum of care.

METHODS

All Stockholm Needle and Syringe Program (NSP) participants who initiated HCV treatment between October 2017 and June 2020 were HCV RNA tested at end of treatment and twelve weeks thereafter to confirm cure with a sustained virological response (SVR). All cured participants were prospectively followed from SVR to the last negative HCV RNA test or a subsequent reinfection, until October 31, 2021.

RESULTS

Overall, 409 NSP participants initiated HCV treatment, 162 at the NSP and 247 in another treatment setting. There were a total of 6.4% treatment dropouts (n = 26), 11.7% among participants treated at the NSP and 2.8% among those treated elsewhere (p < 0.001). Stimulant use (p < 0.05) and not being in an opioid agonist treatment program (p < 0.05) was associated with dropout. More participants treated outside the NSP were lost to follow-up between end of treatment and SVR (p < 0.05). During follow-up post-SVR, 43 reinfections occurred, corresponding to a reinfection rate of 9.3/100 PY (95% CI 7.0, 12.3). Factors associated with reinfection were younger age (p < 0.001), treatment while in prison (p < 0.01) and homelessness (p < 0.05).

DISCUSSION

In this high HCV prevalence NSP setting, with a majority of stimulant users, treatment success was high and the level of reinfections manageable. To reach HCV elimination, there is a need to target specific PWID subgroups for HCV treatment, in both harm reduction and adjacent healthcare settings frequented by PWID.

Predictors of Significant Liver Fibrosis in People with Chronic Hepatitis C Who Inject Drugs in the Czech Republic

BACKGROUND AND OBJECTIVES

HCV infection often remains untreated in people who inject drugs (PWID), albeit they may present with advanced liver fibrosis at a young age. We aimed to assess the rate of patients with significant fibrosis in PWID starting anti-HCV therapy and identify the factors associated with severe fibrosis.

METHODS

The cohort of 200 patients was divided into two groups: F0-F2 (N = 154, 77%), patients with liver stiffness measurement (LSM) < 10.0 kPa, and F3-F4 (N = 46, 23%), with LSM ≥ 10.0 kPa, indicating significant liver fibrosis.

RESULTS

In group F3-F4, there were significantly more males, and the patients were older, with a higher BMI. The number of long-term abstaining patients was significantly higher in group F3-F4 compared with group F0-F2, as well as the proportion of patients reporting harmful drinking. Obesity (OR 4.77), long-term abstinence from illicit drugs (OR 4.06), harmful drinking (OR 2.83), and older age (OR 1.17) were significant predictors of advanced fibrosis in PWID starting anti-HCV therapy.

CONCLUSIONS

A quarter of PWID presented with significant liver fibrosis at treatment initiation. Obesity, long-term drug abstinence, harmful drinking, and older age contributed to significant liver fibrosis.

Cohort study: Apparent redundancy of fibrosis assessment in young persons with HCV; development of realistic approaches to break the paradigm

INTRODUCTION AND OBJECTIVES

Hepatitis C Virus (HCV) is a blood-borne, hepatotropic RNA virus causing both acute and chronic infection. Chronic HCV infection predisposes individuals to liver fibrosis, cirrhosis and hepatocellular carcinoma. Staging of fibrosis prior to treatment to determine either treatment choice or required follow up, is standard practice. However, this often acts as a barrier to treatment initiation. We sought to validate the hypothesis that those individuals; mono-infected with HCV, ≤35 years of age; with no additional hepatic insult were unlikely to have significant fibrosis.

METHODS

We performed a retrospective analysis of a Hepatitis C Virus database; with collation of relevant basic demographics including age, sex and baseline Transient Elastography measurements pre-treatment. Additionally, we compared the reliability of biochemical fibrosis scores with corresponding transient elastography scores.

RESULTS

Our results support the hypothesis that those individuals with chronic HCV ≤35 years old, with no additional risk for fibrogenesis did not have significant liver fibrosis within our cohort.

CONCLUSION

Patients ≤35 years old likely do not necessitate fibrosis assessment prior to Direct Acting Antiviral (DAA) treatment in the absence of other significant risk factors for fibrosis. Given the emerging evidence that DAA treatment results in a significant decrease in all-cause mortality and hepatocellular carcinoma development, treatment of those with chronic HCV represents a global priority.

High risk of non-alcoholic liver disease mortality in patients with chronic hepatitis C with illicit substance use disorder

Aims: Hepatitis C virus (HCV) is a slowly progressive disease, often transmitted among people who inject drugs (PWID). Mortality in PWID is high, with an overrepresentation of drug-related causes. This study investigated the risk of death in patients with chronic hepatitis C virus (HCV) infection with or without illicit substance use disorder (ISUD).Methods: Patients with HCV were identified using the Swedish National Patient Registry according to the International Classification of Diseases-10 (ICD-10) code B18.2, with ≤5 matched comparators from the general population. Patients with ≥2 physician visits with ICD-10 codes F11, F12, F14, F15, F16, or F19 were considered to have ISUD. The underlying cause of death was analyzed for alcoholic liver disease, non-alcoholic liver disease, liver cancer, drug-related and external causes, non-liver cancers, or other causes. Mortality risks were assessed using the standardized mortality ratio (SMR) with 95% CIs and Cox regression analyses for cause-specific hazard ratios.Results: In total, 38,186 patients with HCV were included, with 31% meeting the ISUD definition. Non-alcoholic liver disease SMRs in patients with and without ISUD were 123.2 (95% CI, 103.7-145.2) and 69.4 (95% CI, 63.8-75.3), respectively. The significant independent factors associated with non-alcoholic liver disease mortality were older age, being unmarried, male sex, and having ISUD.Conclusions: The relative risks for non-alcoholic liver disease mortality were elevated for patients with ISUD. Having ISUD was a significant independent factor for non-alcoholic liver disease. Thus, patients with HCV with ISUD should be given HCV treatment to reduce the risk for liver disease.