Hepatitis C virus infection among drug injectors in St Petersburg, Russia: social and molecular epidemiology of an endemic infection

Prevalence of resistance-associated substitutions (RAS) in hepatitis C virus in the Former Soviet Union countries

OBJECTIVE

The emergence of resistance-associated substitutions (RASs) poses a significant challenge to the effective treatment of hepatitis C virus (HCV) infection using direct-acting antivirals. This study's objective was to observe the prevalence of HCV genotypes and RAS within the Former Soviet Union (FSU) countries.

METHODS

We analysed 60 NS3, 313 NS5A and 1119 NS5B sequences of HCV deposited in open-access databases from 11 FSU countries for the prevalence of genotypes and the presence of RAS using the Geno2Pheno software.

RESULTS

The following NS3 RASs were revealed through our analyses: 156P/S/T, 168del, 80K, 55A and 174S. The most prevalent NS5A RAS was 30K (12.69%) in genotype 3a, associated with resistance to daclatasvir, elbasvir and ledipasvir, followed by 62S (8.96% in genotype 3a), linked with resistance to daclatasvir, and 93H (3.95% and 6.72% in genotypes 1b and 3a, respectively), conferring resistance to daclatasvir, ombitasvir, elbasvir, ledipasvir and velpatasvir. The NS5B RASs found in this study were 451S and 556G, associated with resistance to dasabuvir.

CONCLUSION

The high prevalence of HCV genotypes 1b and 3a in the FSU region and the presence of specific RASs should be considered when determining the most effective treatment regimen for HCV-infected individuals in the FSU countries.

Molecular and spatial epidemiology of HCV among people who inject drugs in Boston, Massachusetts

Integration of genetic, social network, and spatial data has the potential to improve understanding of transmission dynamics in established HCV epidemics. Sequence data were analyzed from 63 viremic people who inject drugs recruited in the Boston area through chain referral or time-location sampling. HCV subtype 1a was most prevalent (57.1%), followed by subtype 3a (33.9%). The phylogenetic distances between sequences were no shorter comparing individuals within versus across networks, nor by location or time of first injection. Social and spatial networks, while interesting, may be too ephemeral to inform transmission dynamics when the date and location of infection are indeterminate.

'Distribution of Hepatitis C Virus genotypes in northern Greece in the last decade: descriptive analysis and clinical correlations'

Hepatitis C virus (HCV) represents a major public health problem, while the identification of a HCV genotype is clinically very important for therapy prescription. The aim of the present study was to determine the HCV genotype distribution patients from northern Greece with HCV RNA positive viral load and to identify whether there is a shift in this distribution, during 2009-2017. The study was performed on 915 HCV positive patients and according to the results, genotype 3 was the most prevalent genotype (Ν = 395, 43.2%) followed by genotype 1 (Ν = 361, 39.5%). Regarding the gender of the patients, genotype 1 was mostly detected in women. Moreover, genotype 1 was associated with higher viral loads, while genotype 3 was most frequently detected in patients with a history of intravenous drug use. In conclusion, our results show that genotype 3 is the most prevalent genotype in Greece during the last decade as opposed to older epidemiological studies, likely due to intravenous drug use becoming the major source of infection.

Hepatitis C bio-behavioural surveys in people who inject drugs-a systematic review of sensitivity to the theoretical assumptions of respondent driven sampling

BACKGROUND

New, more effective and better-tolerated therapies for hepatitis C (HCV) have made the elimination of HCV a feasible objective. However, for this to be achieved, it is necessary to have a detailed understanding of HCV epidemiology in people who inject drugs (PWID). Respondent-driven sampling (RDS) can provide prevalence estimates in hidden populations such as PWID. The aims of this systematic review are to identify published studies that use RDS in PWID to measure the prevalence of HCV, and compare each study against the STROBE-RDS checklist to assess their sensitivity to the theoretical assumptions underlying RDS.

METHOD

Searches were undertaken in accordance with PRISMA systematic review guidelines. Included studies were English language publications in peer-reviewed journals, which reported the use of RDS to recruit PWID to an HCV bio-behavioural survey. Data was extracted under three headings: (1) survey overview, (2) survey outcomes, and (3) reporting against selected STROBE-RDS criteria.

RESULTS

Thirty-one studies met the inclusion criteria. They varied in scale (range 1-15 survey sites) and the sample sizes achieved (range 81-1000 per survey site) but were consistent in describing the use of standard RDS methods including: seeds, coupons and recruitment incentives. Twenty-seven studies (87%) either calculated or reported the intention to calculate population prevalence estimates for HCV and two used RDS data to calculate the total population size of PWID. Detailed operational and analytical procedures and reporting against selected criteria from the STROBE-RDS checklist varied between studies. There were widespread indications that sampling did not meet the assumptions underlying RDS, which led to two studies being unable to report an estimated HCV population prevalence in at least one survey location.

CONCLUSION

RDS can be used to estimate a population prevalence of HCV in PWID and estimate the PWID population size. Accordingly, as a single instrument, it is a useful tool for guiding HCV elimination. However, future studies should report the operational conduct of each survey in accordance with the STROBE-RDS checklist to indicate sensitivity to the theoretical assumptions underlying the method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019245.

Hepatitis C in Eastern Europe and Central Asia: a survey of epidemiology, treatment access and civil society activity in eleven countries

INTRODUCTION

The 16 countries of the Eastern Europe and Central Asia (EECA) region are home to 6.6 million people in need of treatment for chronic hepatitis C virus (HCV) infection. Because of transformational change in HCV treatment, global efforts to address HCV are accelerating. Given its large regional burden, the EECA needs to ensure its inclusion in and benefit from any new developments.

METHODS

Our 2015-16 survey aimed to collect and report on epidemiology, treatment access (including drug registration and prices, national HCV guidelines and treatment program coverage) and pertinent civil society organization (CSO) activities in 11 countries in the EECA.

RESULTS

Major gaps in epidemiological data exist; reported anti-HCV prevalence ranged from 1.5 to 7.5% for the general population, 22.7 to 70-95% for people who inject drugs (PWID) and 18 to 80% for people living with HIV (PLHIV). Ten countries (91% of the sample) have registered one or more of the second-generation, direct-acting antiviral medications (DAA) for potential interferon-free treatment. However, intellectual property issues and prices limit access to these drugs. In 2014, HCV programs in the surveyed countries covered only 0.15% of the total number of people in need of treatment. CSO-driven, international donor-funded programs are starting to fulfill needs of PWID and PLHIV.

CONCLUSIONS

As feasible curative HCV treatment is now available, and given the significant regional disease burden, EECA countries need to ensure HCV surveillance and DAA availability at affordable prices in order to expand treatment and prevent the onward transmission of the infection. EECA CSOs have demonstrated their capacity to play a crucial role in advancing HCV issues, and they should continue leveraging these issues for the benefit of individual patients and public health in general.

Hepatitis C virus genotype 3A in a population of injecting drug users in Montenegro: Bayesian and evolutionary analysis

Few reports are available on HCV molecular epidemiology among IDUs in Eastern Europe, and none in Montenegro. The aim of this study was to investigate the HCV genotype distribution in Montenegro among IDUs and to perform Bayesian and evolutionary analysis of the most prevalent HCV genotype circulating in this population. Sixty-four HCV-positive IDUs in Montenegro were enrolled between 2013 and 2014, and the NS5B gene was sequenced. The Bayesian analysis showed that the most prevalent subtype was HCV-3a. Phylogenetic data showed that HCV-3a reached Montenegro in the late 1990s, causing an epidemic that exponentially grew between the 1995 and 2005. In the dated tree, four different entries, from 1990 (clade D), 1994 (clade A) to 1999 (clade B) and 2001 (clade C), were identified. In the NS5B protein model, the amino acids variations were located mainly in the palm domain, which contains most of the conserved structural elements of the active site. This study provides an analysis of the virus transmission pathway and the evolution of HCV genotype 3a among IDUs in Montenegro. These data could represent the basis for further strategies aimed to improve disease management and surveillance program development in high-risk populations.

Using respondent-driven sampling (RDS) to recruit illegal poly-substance users in Cape Town, South Africa: implications and future directions

BACKGROUND

South Africa continues to witness an increase in illicit poly-substance use, although a precise measurement continues to be compounded by difficulties in accessing users. In a pilot attempt to use respondent-driven sampling (RDS)-a chain referral sampling method used to access populations of individuals who are 'hard-to-reach'-this article documents the feasibility of the method as recorded in a simultaneously run, multisite, poly-substance study in Cape Town. Here we aim to a) document the piloting of RDS among poly-substance users in the three socio-economic disparate communities targeted; b) briefly document the results; and c) review the utility of RDS as a research tool.

METHODS

Three cross-sectional surveys using standard RDS procedures were used to recruit active poly-substance users and were concurrently deployed in three sites. Formative research was initially conducted to assess the feasibility of the survey. To determine whether RDS could be used to successfully recruit poly-substance users, social network characteristics, such as network size was determined.

RESULTS

A 42.5 % coupon return rate was recorded in total from 12 initial seeds. There were vast differences in the recruitment chains of individual seeds-two generated more than 90 recruits, and 2 of the 10 recruitment chains showing a length of more than 10 waves. Findings include evidence of the use of 3 or more substances in all three sites, high levels of unemployment among users, with more than a third of participants in two sites reporting arrest for drug use in the past 12 months.

CONCLUSIONS

Our results indicate that RDS was a feasible and acceptable sampling method for recruiting participants who may not otherwise be accessible. Future studies can use RDS to recruit such cohorts, and the method could form part of broader efforts to document vulnerable populations.

A Systematic Review of Published Respondent-Driven Sampling Surveys Collecting Behavioral and Biologic Data

Reporting key details of respondent-driven sampling (RDS) survey implementation and analysis is essential for assessing the quality of RDS surveys. RDS is both a recruitment and analytic method and, as such, it is important to adequately describe both aspects in publications. We extracted data from peer-reviewed literature published through September, 2013 that reported collected biological specimens using RDS. We identified 151 eligible peer-reviewed articles describing 222 surveys conducted in seven regions throughout the world. Most published surveys reported basic implementation information such as survey city, country, year, population sampled, interview method, and final sample size. However, many surveys did not report essential methodological and analytical information for assessing RDS survey quality, including number of recruitment sites, seeds at start and end, maximum number of waves, and whether data were adjusted for network size. Understanding the quality of data collection and analysis in RDS is useful for effectively planning public health service delivery and funding priorities.

Hepatitis C in the Russian Federation: challenges and future directions

Hepatitis C virus (HCV) infection is one of the most prevalent health problems in the world. Official registration of HCV infections in the Russian Federation started in 1994. Two clinical forms of infection – acute and chronic hepatitis C – are registered separately. Moreover, the HCV national surveillance system also includes reports from laboratories on results from testing ∼20 population risk groups for antibodies to HCV; approximately 15–16 million tests are performed annually. Modern epidemiological features of HCV infection in the Russian Federation are characterized by low incidence of the acute form of infection (acute HCV; one to two per 100,000) and a dramatic increase in chronic HCV (CHCV) cases. In 2013, the average nationwide rate of newly detected CHCV cases was 39.3/100,000. In the same year, the prevalence of CHCV demonstrating an accumulation of chronically infected patients in the country was much higher – 335.8/100,000. Four risk groups were identified as greatly affected by HCV, which were demonstrated by a high prevalence of antibodies to HCV: newborns from chronically infected women, persons from correctional facilities, patients with chronic liver diseases, and clients from clinics for sexually transmitted disease patients and drug users. It was found that several HCV genotypes circulated in different regions of the country; HCV1b had a prevalence of 55%–80% in almost every part of the country. However, in St Petersburg during the final decade of the last century and from 2001–2005, HCV3a subtype expanded circulation among young people due to increased intravenous drug addiction. Intravenous drug users were the major cause of a higher registration of double infection, with two different virus subtypes, and the appearance in Russia of new recombinant virus RF_2k/1b. It can be concluded that CHCV infection should be a focus of the health care system in Russia because serious epidemics of liver cirrhosis and hepatocellular carcinoma will be seen in the near future that will require urgent preventive and therapeutic measures.

Molecular characterization of HCV in a Swedish county over 8 years (2002-2009) reveals distinct transmission patterns

Background

Hepatitis C virus (HCV) is a major public health concern and data on its molecular epidemiology in Sweden is scarce. We carried out an 8-year population-based study of newly diagnosed HCV cases in one of Sweden's centrally situated counties, Södermanland (D-county). The aim was to characterize the HCV strains circulating, analyze their genetic relatedness to detect networks, and in combination with demographic data learn more about transmission.

Methods

Molecular analyses of serum samples from 91% (N=557) of all newly notified cases in D-county, 2002–2009, were performed. Phylogenetic analysis (NS5B gene, 300 bp) was linked to demographic data from the national surveillance database, SmiNet, to characterize D-county transmission clusters. The linear-by-linear association test (LBL) was used to analyze trends over time.

Results

The most prevalent subtypes were 1a (38%) and 3a (34%). Subtype 1a was most prevalent among cases transmitted via sexual contact, via contaminated blood, or blood products, while subtype 3a was most prevalent among people who inject drugs (PWIDs). Phylogenetic analysis revealed that the subtype 3a sequences formed more and larger transmission clusters (50% of the sequences clustered), while the 1a sequences formed smaller clusters (19% of the sequences clustered), possibly suggesting different epidemics.

Conclusion

We found different transmission patterns in D-county which may, from a public health perspective, have implications for how to control virus infections by targeted interventions.

Survival of Hepatitis C Virus in Syringes Is Dependent on the Design of the Syringe-Needle and Dead Space Volume

Background

Many people who inject drugs (PWID) use syringes with detachable needles, which have high dead space (HDS). Contaminated HDS blood may substantially contribute to the transmission of HIV, hepatitis C (HCV), and other blood-borne viruses within this population. Newly designed low dead space (LDS) syringe-needle combinations seek to reduce blood-borne virus transmission among PWID. We evaluated the infectivity of HCV-contaminated residual volumes recovered from two LDS syringe-needle combinations.

Methods

We tested two different design approaches to reducing the dead space. One added a piston to the plunger; the other reduced the dead space within the needle. The two approaches cannot be combined. Recovery of genotype-2a reporter HCV from LDS syringe-needle combinations was compared to recovery from insulin syringes with fixed needles and standard HDS syringe-needle combinations. Recovery of HCV from syringes was determined immediately following their contamination with HCV-spiked plasma, after storage at 22°C for up to 1 week, or after rinsing with water.

Results

Insulin syringes with fixed needles had the lowest proportion of HCV-positive syringes before and after storage. HCV recovery after immediate use ranged from 47%±4% HCV-positive 1 mL insulin syringes with 27-gauge ½ inch needles to 98%±1% HCV-positive HDS 2 mL syringes with 23-gauge 1¼ inch detachable needles. LDS combinations yielded recoveries ranging from 65%±5% to 93%±3%. Recovery was lower in combinations containing LDS needles than LDS syringes. After 3 days of storage, as much as 6-fold differences in virus recovery was observed, with HCV recovery being lower in combinations containing LDS needles. Most combinations with detachable needles required multiple rinses to reduce HCV infectivity to undetectable levels whereas a single rinse of insulin syringes was sufficient.

Conclusions

Our study, the first to assess the infectivity of HCV in residual volumes of LDS syringes and needles available to PWID, demonstrates that LDS syringe-needle combination still has the greater potential for HCV transmission than insulin syringes with fixed needles. Improved LDS designs may be able to further reduce HCV recovery, but based on the designed tested, LDS needles and syringes remain intermediate between fixed-needle syringes and HDS combinations in reducing exposure to HCV.

Emergence of methadone as a street drug in St. Petersburg, Russia

BACKGROUND

The syndemic of opioid addiction, HIV, hepatitis, tuberculosis, imprisonment, and overdose in Russia has been worsened by the illegality of opioid substitution therapy. As part of on-going serial studies, we sought to explore the influence of opioid availability on aspects of the syndemic as it has affected the city of St. Petersburg.

METHODS

We employed a sequential approach in which quantitative data collection and statistical analysis were followed by a qualitative phase. Quantitative data were obtained in 2013-2014 from a respondent-driven sample (RDS) of people who inject drugs (PWID). Individuals recruited by RDS were tested for antibodies to HIV and interviewed about drug use and injection practices, sociodemographics, health status, and access to medical care. Subsequently, we collected in-depth qualitative data on methadone use, knowledge, and market availability from PWID recruited at nine different locations within St. Petersburg.

RESULTS

Analysis of interview data from the sample revealed the percentage of PWID injecting methadone in the 30 days prior to interview increased from 3.6% in 2010 to 53.3% in 2012-2013. Injection of only methadone, as compared to injecting only heroin or both drugs, was associated with less frequent injection and reduced HIV-related injected risk, especially a lower rate of injecting with a previously used syringe. In-depth questioning of methadone injectors corroborated the finding from serial quantitative surveys of PWID that methadone's black market availability is a recent phenomenon. Spatial analysis revealed widespread methadone availability but no concentration in any specific districts of the city.

CONCLUSION

Despite the prohibition of substitution therapy and demonization of methadone, the drug has emerged to rival heroin as the most commonly available opioid in St. Petersburg. Ironically, its use is associated with reduced injection-related HIV risk even when its use is illegal.

Injecting drug use: A vector for the introduction of new hepatitis C virus genotypes

Hepatitis C virus (HCV) genotypes' monitoring allows real-time insight into the dynamic changes that occur in the global epidemiological picture of HCV infection. Intravenous drug use is currently the primary driver for HCV transmission in developed and developing countries. The distribution of HCV genotypes/subtypes differs significantly between people who inject drugs (PWID) and the general population. HCV genotypes that previously exhibited a limited geographical distribution (3a, 4) are becoming more prevalent in this high-risk group. Immigration from HCV-endemic countries and the evolving networks of HCV transmission in PWID influence HCV genotypes distribution in Europe. Social vulnerabilities (e.g., unemployment, homelessness, and limited access to social and healthcare insurances systems) are important triggers for illicit drug use, which increases the associated risks of HCV infection and the frequent emergence of less prevalent genotypes. Genotype/subtype determination bears important clinical consequences in the progression of liver disease, susceptibility to antiviral therapies and the emergence of resistance-associated variants. An estimated half of the chronically HCV-infected PWID are unaware of their infection, and only one in ten of those diagnosed enter treatment. Nevertheless, PWID exhibit high response rates to new antiviral regimens, and the level of HCV reinfection is unexpectedly low. The focus of the healthcare system must be on the early detection and treatment of infection, to avoid late presentations that are associated with high levels of viremia and liver fibrosis, which may diminish the therapeutic success rate.

Impact of incarceration experiences on reported HIV status and associated risk behaviours and disease comorbidities

BACKGROUND

The Russian human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) originated in Kaliningrad, but research into risk behaviours among PWID has been lacking. The potential for heterosexual spread has not been analysed.

METHODS

A sample of PWID was accrued using two methods. A questionnaire was administered to assess HIV-related risk behaviours for parenteral and sexual transmission, sociodemographic factors, HIV knowledge and attitudes about sexual risks. Data were analysed focusing on the role of imprisonment, factors associated with awareness of being HIV infected and condom use.

RESULTS

More than a quarter of the sample reported having been diagnosed with HIV infection, with higher prevalence among women and those with a history of incarceration. More than half reported having been diagnosed with hepatitis C virus infection. Those reporting being HIV positive were less likely to distribute used syringes to other PWID and more likely to have used a condom the last time they had sex. A history of incarceration was associated with higher rates of receptive syringe sharing among those not having ever received an HIV-positive diagnosis and a lower likelihood of believing that condoms are needed when having sex with a casual partner.

CONCLUSION

Although extensive HIV testing has alerted many PWID to their HIV-positive status, which is associated with less distributive syringe sharing and higher likelihood of condom use, substantial risk for parenteral and especially sexual HIV transmission remains. More active prevention programs will be required to control the heterosexual spread of HIV.

Epidemiology of hepatitis C in Croatia in the European context

We analyzed prevalence, risk factors and hepatitis C virus (HCV) genotype distribution in different population groups in Croatia in the context of HCV epidemiology in Europe, with the aim to gather all existing information on HCV infection in Croatia which will be used to advise upon preventive measures. It is estimated that 35000-45000 of the Croatian population is chronically infected with HCV. Like in other European countries, there have been changes in the HCV epidemiology in Croatia over the past few decades. In some risk groups (polytransfused and hemodialysis patients), a significant decrease in the HCV prevalence was observed after the introduction of routine HCV screening of blood/blood products in 1992. Injecting drug users (IDUs) still represent a group with the highest risk for HCV infection with prevalence ranging from 29% to 65%. Compared to the prevalence in the Croatian general population (0.9%), higher prevalence rates were found in prison populations (8.3%-44%), human immunodeficiency virus-infected patients (15%), persons with high-risk sexual behavior (4.6%) and alcohol abusers (2.4%). Low/very low prevalence was reported in children and adolescents (0.3%) as well as in blood donors (0%-0.009%). In addition, distribution of HCV genotypes has changed due to different routes of transmission. In the general population, genotypes 1 and 3 are most widely distributed (60.4%-79.8% and 12.9%-47.9%, respectively). The similar genotype distribution is found in groups with high-risk sexual behavior. Genotype 3 is predominant in Croatian IDUs (60.5%-83.9%) while in the prison population genotypes 3 and 1 are equally distributed (52.4% and 47.6%). Data on HCV prevalence and risk factors for transmission are useful for implementation of preventive measures and HCV screening.

Genotyping of hepatitis B and C virus Russian isolates for reference serum panel construction

Approximately 2% and 5% of the world human population is estimated to be infected with HCV and HBV, respectively. Reference panels of HCV and HBV serum samples with defined genotypes and serotypes is necessary for monitoring of the specificity and sensitivity of diagnostic test kits. The aim of this study was to determine genotypes/serotypes of HBV and HCV circulating in Russia in order to construct a panel of reference sera containing these HCV genotypes and HBV serotypes. A total of 343 HBsAg-positive and 207 anti-HCV positive serum samples were collected from patients with HBV and HCV infection from different cities between years 2002 and 2010 in St. Petersburg, Krasnodar, Nizhny Novgorod, Novosibirsk, Barnaul, Gorno-Altaisk, and Khabarovsk. HBV DNA was found in 76.4% of HBsAg positive samples by PCR for the S gene and HCV RNA was found in 71.5, 70.0, and 64.7% of anti-HCV positive samples in the 5'UTR, Core, and NS5B regions, respectively. The prevalence and proportion of HBV genotype/serotype associations were as follows: A/adw2, 2.1%; D/ayw2, 54.0%; D/ayw3, 43.1%; D/adw2, 0.7%. A new combination of genotype D and adw2 serotype was discovered. The distribution of HCV genotypes was the following: 43.6%, b; 3.8%, 2a; and 52.6%, 3a. Russian National reference panels of HBV and HCV lyophilized sera were developed to monitor specificity and sensitivity of approved kits and for the certification of newly developed assays.

High-risk behaviors after release from incarceration among people who inject drugs in St. Petersburg, Russia

BACKGROUND

Injection drug use, infectious disease, and incarceration are inextricably linked in Russia. We aimed to identify factors associated with time to relapse (first opioid injection after release from prison) and using a non-sterile, previously used syringe at relapse in a sample of people who inject drugs in St. Petersburg.

METHODS

We collected data on time from release to relapse among individuals with a history of incarceration, a subsample of a larger study among people who inject drugs. Proportional hazards and logistic regression were used to identify factors associated with time to relapse and injection with a non-sterile previously used syringe at relapse, respectively.

RESULTS

The median time to relapse after release was 30 days. Factors that were independently associated with relapsing sooner were being a native of St. Petersburg compared to not being native (AHR: 1.64; 95% CI 1.15-2.33), unemployed at relapse compared to employed (AHR: 4.49; 95% CI 2.96-6.82) and receiving a previous diagnosis of HBV and HCV compared to no previous diagnosis (AHR: 1.49; 95% CI 1.03-2.14). Unemployment at relapse was also significant in modeling injection with a non-sterile, previously used syringe at relapse compared to those who were employed (AOR: 6.80; 95% CI 1.96-23.59).

CONCLUSIONS

Unemployment was an important correlate for both resuming opioid injection after release and using a non-sterile previously used syringe at relapse. Linkage to medical, harm reduction, and employment services should be developed for incarcerated Russian people who inject drugs prior to release.

Epidemiology of hepatitis C in Europe

The advent of potent and safe direct-acting antivirals against the hepatitis C virus has the potential of fulfilling the dream of eliminating this infection and its impact on global public health. However, even if effective drugs are at hand, most patients remain unaware of their infection, which may be recognized only in late stages when dire complications have occurred. Europe is not spared by this scourge, with its estimated 19,000,000 persons infected, and knowledge of the epidemiology of HCV and its drivers is a critical tool in fighting this virus. A thorough review is provided on the extent of the HCV epidemic across Europe, with a discussion of the most important subgroups affected, and of the risk factors of infection, both traditional and new.

Hepatitis C virus seroprevalence among people who inject drugs and factors associated with infection in eight Russian cities

Background

Behavioural surveillance among people who inject drugs (PWID) and testing for hepatitis C virus (HCV) and HIV is needed to understand the scope of both epidemics in at-risk populations and to suggest steps to improve their health.

Methods

PWID were recruited using respondent-driven sampling (RDS) in eight Russian cities. A standardized survey was administered to collect sociodemographic and behavioral information. Blood specimens were obtained for serological testing for HCV and HIV-1. Data across the eight sites were pooled to identify individual-, network-, and city-level factors associated with positive HCV serostatus.

Results

Among 2,596 PWID participating in the study, 1,837 tested positive for HCV (71%). The sample was 73% male and the mean age was 28. Very few PWID reported regular contact with harm reduction programs. Factors associated with testing positive for HCV were longer duration of injection drug use, testing positive for HIV-1, sharing non-syringe injection paraphernalia and water for rinsing syringes, and larger social network size. Factors negatively associated with HCV-positive serostatus were injecting with a used syringe and two city-level factors: longer mean RDS recruitment chain in a city and higher levels of injecting stimulants.

Conclusions

HCV prevalence in all eight Russian cities is at the higher end of the range of HCV prevalence among PWID in Europe, which provides evidence that more resources, better prevention programs, and accelerated treatment targeting PWID are needed to control the HCV epidemic.

Identification of Indian sub-continent as hotspot for HCV genotype 3a origin by Bayesian evolutionary reconstruction

BACKGROUND

Recent emphasis in Hepatitis C virus (HCV) evolutionary biology has focused on analysis using Core, E1/E2 and/or NS5b regions, with limited appreciation of full length genome. While HCV genotypes have been described as endemic in the Indian subcontinent, there has been no confirmation at the molecular evolutionary level of these genotypes. We have attempted here to determine the status of Indian HCV genotype 3a sequences in relation to similar genotypes from other parts of the world.

METHODS

Cloning, sequencing and molecular characterization was performed on 9 Indian sequences and comparative analyses were performed with 46 sequences from other countries. Evolutionary-rate and molecular-clock hypothesis testing was addressed by Bayesian MCMC.

RESULTS

Genetic analysis of full length genome revealed two hypervariable regions (HVR) in E2 region - HVR496 and HVR576, with a variable 5-8 amino-acid insertion sequence and a putative N-glycosylation site. Phylogenetic analysis revealed a divergence resulting in 2 distinct clades: clade-1 represented by HCV 3a subtype and clade-2 represented by other 3 subtype genomes. Clade-2 shows earlier divergence than clade-1. Analysis revealed that genotype 3a genomes from India roots out first (∼99 years ago) in clade1. Bayesian skyline plot analysis revealed an increase in effective number of infections from 1940s to 1990s, followed by a gradual decrease after 2000.

CONCLUSIONS

Genotype 3a sequences appear to have originated in India and later dispersed to United Kingdom around mid 1940s, most likely around the time of Indian independence and World War II.

Transmission of hepatitis C virus among intravenous drug users in the Uppsala region of Sweden

Background

Epidemiology and transmission patterns of hepatitis C virus (HCV) are important subjects as we enter a new era of treatment with directly acting antivirals (DAAs). The highest prevalence of HCV in developed countries is found among intravenous drug users (IDUs), where unsafe needle sharing practices provide the main route of infection. Efforts to prohibit the continuous spread of HCV among these groups have been initiated by the community services and health care providers. Our goal was to understand how HCV was transmitted among IDUs within a limited population group. We provide a retrospective study (2005–2007) of the HCV transmission patterns in a population of IDUs in the Uppsala region of Sweden.

Method

Eighty-two serum samples were collected from IDUs in Uppsala County. Our reverse transcription nested polymerase chain reaction (RT-nested PCR) and sequencing method enabled a comprehensive genetic analysis for a broad spectrum of genotypes of two relatively conserved regions, NS5B and NS3, that encodes for the viral polymerase and protease, respectively. HCV RNA in serum samples was amplified and sequenced with in-house primers. Sequence similarities between individuals and subgroups were analyzed with maximum likelihood (ML) phylogenetic trees. Published HCV reference sequences from other geographic regions and countries were also included for clarity.

Results

Phylogenetic analysis was possible for 59 NS5B (72%) and 29 NS3 (35%) sequences from Uppsala patients. Additionally, we also included 15 NS3 sequences from Örebro patients, making a total of 44 NS3 sequences for the analysis. By analyzing the NS3 sequences, two transmission sets were found between the IDUs (>98% sequence identity), with one set consisting of two individuals and another set consisting of three individuals. In addition, the phylogenetic analysis done with our serum samples displayed clusters that distinguished them from the reference sequences.

Conclusion

Our method seems to enable us to trace the HCV transmission between IDUs. Furthermore, the method is fairly independent of the time of infection because the method uses relatively conserved HCV sequence regions (i.e. NS5B and NS3).

Hepatitis C virus maintains infectivity for weeks after drying on inanimate surfaces at room temperature: implications for risks of transmission

BACKGROUND

Healthcare workers may come into contact with fomites that contain infectious hepatitis C virus (HCV) during preparation of plasma or following placement or removal of venous lines. Similarly, injection drugs users may come into contact with fomites. Hypothesizing that prolonged viability of HCV in fomites may contribute significantly to incidence, we determined the longevity of virus infectivity and the effectiveness of antiseptics.

METHODS

We determined the volume of drops misplaced during transfer of serum or plasma. Aliquots equivalent to the maximum drop volume of plasma spiked with the 2a HCV reporter virus were loaded into 24-well plates. Plates were stored uncovered at 3 temperatures: 4°C, 22°C, and 37°C for up to 6 weeks before viral infectivity was determined in a microculture assay.

RESULTS

The mean volume of an accidental drop was 29 µL (min-max of 20-33 µL). At storage temperatures 4°C and 22°C, we recovered viable HCV from the low-titer spots for up to 6 weeks of storage. The rank order of HCV virucidal activity of commonly used antiseptics was bleach (1:10) > cavicide (1:10) > ethanol (70%).

CONCLUSIONS

The hypothesis of potential transmission from fomites was supported by the experimental results. The anti-HCV activity of commercial antiseptics varied.

Genetic diversity of HCV among various high risk populations (IDAs, thalassemia, hemophilia, HD patients) in Iran

OBJECTIVE

To determine the patterns of distribution of HCV genotypes among high risk population in north of Iran.

METHODS

A cross-sectional study was conducted on 135 HCV RNA-positive high risk individuals including thalassemia, hemophilia, patients under hemodialysis and intravenous drug addicts. HCV genotypes were determined based on amplification with type-specific primers methods.

RESULTS

Among the 187 anti-HCV positive samples, only 135 (72.2%) gave HCV-RNA positvity. Over all, the most identified HCV type was genotype 3a (51.1%) followed by 1a (27.4%), 1b (8.2%). Sixteen (11.9%) out of 135 HCV RNA-positive participants have infected with more than one genotype or subtypes as follow; 1a/1b in 11 (8.2%), 2/3a in 3 (2.2%), and 1a/1b/3a in 2 (1.5%). Stratification of participants revealed that HCV subtype 3a was more prominent in thalassemia, hemophilia and HD patients but 1a and 1b were frequent in intravenous drug addicts.

CONCLUSIONS

This study is the first report on HCV genotypes among Iranian subjects with different exposure categories resided in Mazandaran, where genotype 3a was found to be the most frequent genotype in thalassemia, hemophilia, and hemodialysis patients but not in IDAs. Since the addiction age is decreasing in Iran and a lot of addicts are IDAs, it might change the subtype pattern of HCV in general population.

Moderate/heavy alcohol use and HCV infection among injection drug users in two Russian cities

BACKGROUND

In Russia, injection drug use and transmission of blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are inextricably linked, however the burden of alcohol use remains unexplored among injection drug users (IDUs).

METHODS

Individuals who were 18 years of age and older and had injected drugs in the previous 30 days were recruited in the cities of Novosibirsk and Ivanovo by respondent driven sampling. Consenting individuals were administered a quantitative survey instrument and provided blood samples for serological testing.

RESULTS

In Novosibirsk and Ivanovo, 29% and 35% of respondents were categorized as moderate/heavy drinkers, respectively. Individuals reported problems related to alcohol use that affected their physical health (23%), family (55%), and induced financial hardships (43%). In the multivariate analysis, we found that methamphetamine injection in the past 12 months was a strong and significant correlate of moderate/heavy drinking in Novosibirsk (aOR=5.63 95% CI: [1.01-31.47]) and Ivanovo (aOR=3.81 95% CI: [2.20-6.62]). There was poor agreement between self-reported HCV status and HCV test results (κ=-0.05 and 0.26 in Novosibirsk and Ivanovo, respectively). IDUs who correctly knew their HCV seropositive status in Novosibirsk and IDUs who correctly knew their HCV seronegative status in Ivanovo were significantly more likely to be moderate/heavy drinkers.

CONCLUSION

Alcohol use is problematic among IDUs who are at high risk for HCV. Future interventions should target IDUs who are moderate/heavy drinkers in order to prevent liver complications resulting from HCV infection.

Social network-based recruitment successfully reveals HIV-1 transmission networks among high-risk individuals in El Salvador

OBJECTIVE

HIV in Central America is concentrated among certain groups such as men who have sex with men (MSM) and female sex workers (FSWs). We compared social recruitment chains and HIV transmission clusters from 699 MSM and 787 FSWs to better understand factors contributing to ongoing HIV transmission in El Salvador.

METHODS

Phylogenies were reconstructed using pol sequences from 119 HIV-positive individuals recruited by respondent-driven sampling (RDS) and compared with RDS chains in 3 cities in El Salvador. Transmission clusters with a mean pairwise genetic distance ≤ 0.015 and Bayesian posterior probabilities =1 were identified. Factors associated with cluster membership were evaluated among MSM.

RESULTS

Sequences from 34 (43%) MSM and 4 (10%) FSW grouped in 14 transmission clusters. Clusters were defined by risk group (12 MSM clusters) and geographic residence (only 1 spanned separate cities). In 4 MSM clusters (all n = 2), individuals were also members of the same RDS chain, but only 2 had members directly linked through recruitment. All large clusters (n ≥ 3) spanned >1 RDS chain. Among MSM, factors independently associated with cluster membership included recent infection by BED assay (P = 0.02), sex with stable male partners (P = 0.02), and sex with ≥ 3 male partners in the past year (P = 0.04).

CONCLUSIONS

We found few HIV transmissions corresponding directly with the social recruitment. However, we identified clustering in nearly one-half of MSM suggesting that RDS recruitment was indirectly but successfully uncovering transmission networks, particularly among recent infections. Interrogating RDS chains with phylogenetic analyses may help refine methods for identifying transmission clusters.

Individual-level, network-level and city-level factors associated with HIV prevalence among people who inject drugs in eight Russian cities: a cross-sectional study

OBJECTIVES

To ascertain HIV prevalence among people who inject drug (injection drug users (IDUs)) in the Russian Federation and identify explanations for the disparity in different cities.

DESIGN

Cross-sectional survey with serological testing for HIV and hepatitis C virus prevalent infections.

SETTING

8 Russian cities-Irkutsk, Omsk, Chelyabinsk, Yekaterinburg, Naberezhnye Chelny, Voronezh, Orel and St Petersburg.

PARTICIPANTS

In 2007-2009 active IDUs were recruited by respondent-driven sampling with a target sample size of 300 or more in each city.

MAIN OUTCOME MEASURES

Participants were administered a questionnaire covering sociodemographics, injection risk and protective behaviours, sexual behaviours, HIV knowledge, experiences with drug treatment and harm reduction programmes and social networks. Participants were tested for HIV and hepatitis C by enzyme immunoassay. Data were analysed to identify individual-level, network-level and city-level characteristics significantly associated with HIV prevalence. Factors significant at p≤0.1 were entered into a hierarchical regression model to control for multicollinearity.

RESULTS

A total of 2596 active IDUs were recruited, interviewed and tested for HIV and hepatitis C virus infection. HIV prevalence ranged from 3% (in Voronezh) to 64% (in Yekaterinburg). Although individual-level and network-level variables explain some of the difference in prevalence across the eight cities, the over-riding variable that seems to account for most of the variance is the emergence of commercial, as opposed to homemade, heroin as the predominant form of opioid injected.

CONCLUSIONS

The expansion of commercial heroin markets to many Russian cities may have served as a trigger for an expanding HIV epidemic among IDUs in that country.

Social networks and HCV viraemia in anti-HCV-positive rural drug users

Although social networks are known to play an important role in drug-using behaviours associated with hepatitis C virus (HCV) infection, literature on social networks and HCV is inconsistent. This exploratory study examined HCV RNA distribution within a social network of anti-HCV-positive non-medical prescription opioid users (NMPOUs) in rural Appalachia. Participants were tested serologically for HCV RNA, and behavioural, demographic, and network data were collected using interview-administered questionnaires. Multivariate analyses were performed using logistic regression. Behavioural and demographic characteristics did not differ by RNA status. In the multivariate model, recent injecting drug users (IDUs) were more likely to be RNA positive [odds ratio (OR) 4·06, 95% confidence interval (CI) 1·04-15·83], and turnover into an IDU's drug network was significantly protective (OR 0·15, 95% CI 0·03-0·75). This is the first study to date to examine HCV distribution in rural NMPOUs from a network perspective and demonstrates that network characteristics significantly contribute to the epidemiology of HCV in this understudied, high-risk population.

HEPATITIS C VIRUS GENOTYPES IN INJECTING DRUG USERS FROM ROMANIA

Due to the increasing number of infections related to injecting drug use, both the pattern of hepatitis C virus (HCV) transmission, and the circulating genotypes in Europe have changed. As there are little available data in this respect for Romania, the aim of our study was a preliminary analysis of the distribution of HCV genotypes circulating among injecting drug users (IDUs). Of the 45 IDUs evaluated (86.7% men, mean age - 27.6±3.7 years, mean age at first drug use - 17.5±3.9 years), 88.9% presented anti-HCV antibodies, with higher rates in those with an injecting history of more than 10 years; 57.8% of the subjects had detectable HCV viral load. Only 6.7% had markers of chronic hepatitis B infection, and none had anti-HIV antibodies. While HCV subtype 1b is still prevalent (in 50% of the viraemic subjects), other subtypes begin to emerge, especially in younger patients (1a - in 23.1%, 4 - in 11.5%, 3a - in 7.7% of the cases). These data indicate the possibility of major shifts in the distribution of the dominant subtype, underlining the need for close surveillance of HCV infections in IDUs, who can act as a bridging group toward the general population.

HEPATITIS C VIRUS GENOTYPES IN INJECTING DRUG USERS FROM ROMANIA

Due to the increasing number of infections related to injecting drug use, both the pattern of hepatitis C virus (HCV) transmission, and the circulating genotypes in Europe have changed. As there are little available data in this respect for Romania, the aim of our study was a preliminary analysis of the distribution of HCV genotypes circulating among injecting drug users (IDUs). Of the 45 IDUs evaluated (86.7% men, mean age - 27.6±3.7 years, mean age at first drug use - 17.5±3.9 years), 88.9% presented anti-HCV antibodies, with higher rates in those with an injecting history of more than 10 years; 57.8% of the subjects had detectable HCV viral load. Only 6.7% had markers of chronic hepatitis B infection, and none had anti-HIV antibodies. While HCV subtype 1b is still prevalent (in 50% of the viraemic subjects), other subtypes begin to emerge, especially in younger patients (1a - in 23.1%, 4 - in 11.5%, 3a - in 7.7% of the cases). These data indicate the possibility of major shifts in the distribution of the dominant subtype, underlining the need for close surveillance of HCV infections in IDUs, who can act as a bridging group toward the general population.

Risk Factors and Seroprevalence of Hepatitis C among Patients Hospitalized at Mulago Hospital, Uganda

The emergence of hepatitis C virus (HCV) and its associated sequelae in Africa is a cause for significant concern. Human immunodeficiency virus (HIV) positive patients are at an increased risk of contracting HCV infection due to similar risk factors and modes of transmission. We investigated the seroprevalence of hepatitis C in hospitalized HIV-positive and HIV-negative patients in Mulago Hospital, an academic hospital in Uganda. Blood samples were first tested for HCV antibodies, and positive tests were confirmed with HCV RNA PCR. We enrolled five hundred patients, half HIV-positive and half HIV negative. Overall, 13/500 patients (2.6%) tested positive for HCV antibodies. There was no difference in HCV antibody detection among HIV-positive and HIV-negative patients. Out of all risk factors examined, only an age greater than 50 years was associated with HCV infection. Traditional risk factors for concurrent HIV and HCV transmission, such as intravenous drug use, were exceedingly rare in Uganda. Only 3 of 13 patients with detectable HCV antibodies were confirmed by HCV RNA detection. This result concurs with recent studies noting poor performance of HCV antibody testing when using African sera. These tests should be validated in the local population before implementation.

Contraception use and unplanned pregnancies among injection drug-using women in St Petersburg, Russia

BACKGROUND

This cross-sectional study estimated the prevalence of contraceptive methods and investigated whether abortion rates influence contraceptive behaviour among injection drug-using (IDU) women in St Petersburg, Russia.

METHODOLOGY

A self-administered questionnaire of behaviour in the last 3 months was applied to a convenient sample of IDU women.

RESULTS

Of 80 sexually active participants, 67% had had an abortion. No participant reported using hormonal contraceptives or intrauterine devices (IUDs). The only valid method of contraception used was condoms, which was reported by half of the participants. Consistent condom use was reported by 22% of participants and was no more likely among those who had an abortion. Condom use was significantly associated with having multiple or casual sex partners [prevalence ratio (PR) 1.75, 95% (confidence interval) CI 1.11-2.78, p = 0.01], having an IDU sex partner (PR 0.55, 95% CI 0.36-0.85, p = 0.029) and with a negative attitude toward condoms (PR 0.53, 95% CI 0.33-0.84, p = 0.01). Abortions were less likely among those who had multiple or casual sex partners (PR 0.69, 95% CI 0.49-0.97, p = 0.03).

CONCLUSIONS

Despite the high prevalence of abortions among IDU women, none reported the use of hormonal contraception or IUDs. Having had an abortion was not associated with greater likelihood of using condoms. Participants mostly used condoms with casual or multiple sex partners, suggesting that condoms were used mainly to prevent HIV/sexually transmitted infection transmission and not to prevent pregnancy. Programmes to prevent unwanted pregnancies and reduce abortion-related health risks among this understudied vulnerable group are needed.

Comparing sexual risks and patterns of alcohol and drug use between injection drug users (IDUs) and non-IDUs who report sexual partnerships with IDUs in St. Petersburg, Russia

Background

To date, the great majority of Russian HIV infections have been diagnosed among IDUs and concerns about the potential for a sexual transmission of HIV beyond the IDU population have increased. This study investigated differences in the prevalence of sexual risk behaviors between IDUs and non-IDUs in St. Petersburg, Russia and assessed associations between substance use patterns and sexual risks within and between those two groups.

Methods

Cross-sectional survey data and biological test results from 331 IDUs and 65 non-IDUs who have IDU sex partners were analyzed. Multivariate regression was employed to calculate measures of associations.

Results

IDUs were less likely than non-IDUs to report multiple sexual partners and unprotected sex with casual partners. The quantity, frequency and intensity of alcohol use did not differ between IDUs and non-IDUs, but non-IDUs were more likely to engage in alcohol use categorized as risky per the alcohol use disorders identification test (AUDIT-C). Risky sexual practices were independently associated with monthly methamphetamine injection among IDUs and with risky alcohol use among non-IDUs. Having sex when high on alcohol or drugs was associated with unprotected sex only among IDUs.

Conclusions

Greater prevalence of sexual risk among non-IDUs who have IDU sex partners compared to IDUs suggests the potential for sexual transmission of HIV from the high-prevalence IDU population into the general population. HIV prevention programs among IDUs in St. Petersburg owe special attention to risky alcohol use among non-IDUs who have IDU sex partners and the propensity of IDUs to have sex when high on alcohol or drugs and forgo condoms.

Survival of hepatitis C virus in syringes: implication for transmission among injection drug users

BACKGROUND

We hypothesized that the high prevalence of hepatitis C virus (HCV) among injection drug users might be due to prolonged virus survival in contaminated syringes.

METHODS

We developed a microculture assay to examine the viability of HCV. Syringes were loaded with blood spiked with HCV reporter virus (Jc1/GLuc2A) to simulate 2 scenarios of residual volumes: low void volume (2 microL) for 1-mL insulin syringes and high void volume (32 microL) for 1-mL tuberculin syringes. Syringes were stored at 4 degrees C, 22 degrees C, and 37 degrees C for up to 63 days before testing for HCV infectivity by using luciferase activity.

RESULTS

The virus decay rate was biphasic (t1/2alpha= 0.4 h and t1/2beta = 28 hh). Insulin syringes failed to yield viable HCV beyond day 1 at all storage temperatures except 4 degrees , in which 5% of syringes yielded viable virus on day 7. Tuberculin syringes yielded viable virus from 96%, 71%, and 52% of syringes after storage at 4 degrees, 22 degrees, and 37 degrees for 7 days, respectively, and yielded viable virus up to day 63.

CONCLUSIONS

The high prevalence of HCV among injection drug users may be partly due to the resilience of the virus and the syringe type. Our findings may be used to guide prevention strategies.