An update on bloodborne viruses among people who inject drugs in South Asia.

Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.

Introduction: Injecting drug use is a public health concern due to its clinical, social, economic, and legal consequences. Objective: (1) To evaluate the prevalence of infections associated with injecting drug use; and (2) To assess the social profile of substance users and high-risk behaviors among people who inject drugs (PWID) receiving opioid substitution therapy (OST). Materials and Methods: A cross-sectional study was conducted among 100 PWID who were deemed eligible using inclusion and exclusion criteria. Data were collected through an interviewer-administered structured questionnaire after obtaining informed written consent. Results: The results revealed that 14% of PWID had human immunodeficiency virus (HIV), 7% had tuberculosis, and 2% had hepatitis B virus (HBV). None of the PWID self-reported hepatitis C virus (HCV) infection. Importantly, 71% of PWID were living on the streets (i.e. homeless), and 41% of PWID had a history of sharing needles with other users in the preceding 3 months. Unmarried or single PWID had significantly increased risk of homelessness (χ2 = 4.570; P = 0.032) and reported high-risk sexual practices with commercial sexual partners in the preceding 3 months (χ2 = 4.163; P = 0.041). Homeless PWID had significantly increased frequency of injecting practices (P = 0.020). Conclusion: Despite the higher global prevalence of HCV compared with HBV and HIV among PWID, HCV testing is not currently conducted at most OST centers in India. Access to free needles and syringes should be enhanced to reduce the morbidity associated with injecting drug use.

The new direct-acting antiretroviral drugs for treating hepatitis C have generated considerable momentum for treating HCV infection among people who inject drugs and perhaps ‘ending the HCV epidemic’. There are, however, important epidemiological and behavior research problems that need to be addressed before ‘ending the HCV epidemic’ will be possible. The development of direct-acting antivirals (DAAs) that cure HCV infection in more than 90% of patients with minimal side effects has led to calls for ‘eliminating HCV infection’ or ‘ending HCV epidemics’ among people who inject drugs (PWID) 1. Some of the calls for eliminating HCV infection have included substantial allocations of new funds, e.g. New York State 2. Grebely et al. 3 have estimated the number and prevalence of people with a recent history (within past year) of injecting drug use who are living with hepatitis C virus (HCV) viremia and the proportion of people with recent injecting drug use among all people living with HCV infection at the global, regional and national levels. A major value of this study is its potential contribution as a baseline for ‘eliminating HCV’. While DAAs and the lessons from successfully controlling HIV among PWID in many areas 4 should certainly be useful in controlling HCV among PWID, the data presented in Grebely et al. illustrate that there is still a major amount of epidemiological and behavioral science that will be needed before ‘eliminating’ (or even ‘controlling’) HCV among PWID can be accomplished. First, what would ‘elimination/ending the epidemic’ of HCV among PWID look like? From early in the HIV epidemic among PWID, we had multiple examples, e.g. Glasgow, Scotland, Lund, Sweden, Sydney, Australia and Tacoma, WA, USA, where large-scale implementation of syringe access programs have kept HIV prevalence stable at less than 5% 5. The Grebely et al. data do not provide many (if any) examples of areas where HCV viremia has been stabilized at ‘ending the epidemic’ levels. Would 5% viremia in the local PWID population be a realistic goal? What sort of HCV combined prevention and care programs would be needed to stabilize HCV at 5% or less in a PWID population? Such a system would need to detect and treat existing cases of HCV infection as rapidly as new infections were occurring. Secondly, how will we develop better estimates of the size of PWID populations and the percentage of PWID who are HCV viremic? The uncertainty intervals in the Grebely et al. estimates are rather large, typically almost as large as the estimates themselves. Uncertainty in the estimates of the PWID population size and the percentage of PWID who are HCV viremic would create difficult problems for local officials who would have the task of allocating resources and planning logistical operations for rapidly scaling-up treatment for HCV-infected PWID. Thirdly, what new interventions can be developed to reduce HCV transmission behavior among viremic PWID? One of the important factors in HIV prevention was that PWID who learned that they were HIV-seropositive greatly reduced transmission behavior (passing their used needles and syringes to others) well before antiretroviral therapy (ART) was available 6. We have not yet seen the equivalent reductions in transmission behaviors among PWID who know that they are HCV-seropositive 7. How do we successfully encourage HCV viremic PWID to reduce transmission behavior? Fourthly, what interventions can be developed and implemented to reduce the very high HCV incidence rates among people who have recently begun injecting drugs 8? Many new injectors typically do not identify as ‘drug injectors’, and thus do not utilize HIV/HCV safer injection programs 9. Fifthly, what interventions will be implemented to reduce the rates that drug users transition to injecting drug use? There have been calls for more research on this topic 10, and there are current research studies addressing this subject. However, the objective should be to develop an evidence base for reducing initiation into injecting drug use that is comparable to the evidence base for medication assisted treatment and for syringe access programs. The new DAAs certainly give us the capability of treating very large numbers of HCV infected people who use drugs and greatly reduce morbidity and mortality, and programs to provide access to HCV treatment should be scaled-up in high-, middle- and low-income countries as quickly as feasible, and the additional research needed to learn how to ‘end HCV epidemics’ among PWID should be funded. Finally, and perhaps most importantly, while the above may be considered scientific tasks, it is important to emphasize that the research should be conducted in full collaboration with PWID and drug-user organizations. Such collaboration should not only greatly improve the quality of the research, but also greatly improve the likelihood that the findings will be incorporated into public health programs that could ‘end the HCV epidemic’ among people who use drugs. None.

Incidence, risk factors, and prevention of hepatitis C reinfection: a population-based cohort study

We announce a new series for Addiction on HCV (hepatitis C virus). This is prompted by the changing treatment and prevention landscape and syndemic of HCV and drug use, specifically concerning people who inject drugs (PWID). In some developing countries more than 80% of HCV is among people with a history of drug injection; globally, almost 40% of HCV burden is attributable to injecting drug use and in many countries one in two PWID are likely to be living with HCV 1-3. HCV is an important cause of liver disease, along with alcohol, hepatitis B virus (HBV) and metabolic causes, and the only one that can be cured easily 4. There is no vaccine available for HCV. However, new HCV anti-viral drugs—so-called direct-acting anti-virals (DAAs)—are highly tolerable, of short duration (8–12 weeks) and can cure the disease in the vast majority of cases, with trials involving PWID reporting more than 90% cure rates 5-7. These advancements have raised excitement around the possibility of using HCV treatment as Prevention (TasP). Globally, however, very few PWID are treated for their HCV. Although the cost of DAA therapies can be high, health economic models suggest that prioritizing PWID for early HCV treatment because of the prevention benefits is likely to be cost-effective 8. In addition, there is strengthening empirical evidence that primary prevention interventions such as opioid substitution treatment (OST) and needle and syringe programmes (NSP) can reduce HIV and HCV 9-12. However, theoretical model projections suggest that substantial reductions in HCV transmission among PWID will require both traditional harm reduction/primary prevention and HCV treatment scale-up 13, 14. The ease of administration of these new DAA therapies means that they could be delivered by non-specialists in the community and within drug treatment services, leading to the recommendation that HCV treatment, drug treatment and prevention services should be integrated, which may have advantages and disadvantages in the way that drug treatment services are delivered 15. International clinical guidelines recommend that people at risk of transmitting HCV are treated for HCV 16-18. The World Health Organization Global Health Sector Strategy (GHSS) on Viral Hepatitis has set a challenging goal of eliminating viral hepatitis as a major public health threat by 2030, reducing new chronic infections by 90% and mortality by 65%. In most countries these targets can be achieved only through scaling-up both OST, NSP and HCV treatment for PWID, as highlighted in a recent paper (the first in our series) on HCV in Greece 19. Another model study in our series shows that managing HCV in prisons can make a substantial contribution to reducing transmission in the community 20. Several countries, such as Australia, France, Georgia and Portugal, have already announced and started national HCV elimination campaigns, increasing the number of HCV treatments available and removing any restrictions on access 21, 22. There are great opportunities, therefore, to generate robust evidence on how to prevent HCV transmission and HCV-related morbidity in PWID and in the population. We expect, therefore, as a Commentary in this issue argues, to move from the ‘the theoretical to the empirical sphere’ 23. While these are ambitious goals, success is not guaranteed. Reaching and engaging people with HCV are key challenges, given the prohibition surrounding illicit and injecting drug use and the resultant stigma and discrimination concerns and possible mistrust of health services. Community and peer involvement is likely to be critical to the success of HCV prevention programmes. It has also been hypothesized by some clinicians and researchers that successful treatment of HCV can improve recovery and engagement with drug treatment services 24. The purpose of our new series will be to highlight and document the best new evidence emerging from around the world on the syndemic of HCV and drug use. We are interested in receiving systematic reviews, trials and other evaluations, ethnographic and modelling studies that inform and test how HCV can be prevented in people who use and inject drugs.

Introduction: Drug addiction one of the greatest challenges face across the glob. The parenterally transmitted viruses like Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) occur more frequently in this high-risk group of population as compared with the general population. Aim: To find the prevalence of HBV, HCV and HIV in People Who Inject Drugs (PWIDs) attending a tertiary care hospital in Kashmir valley, India. Materials and Methods: A prospective descriptional study was conducted from October 2017 to October 2020 in the Department of Microbiology of a tertiary care hospital in Kashmir. Subjects included 200 (PWIDs) who voluntarily presented themselves at the drug clinic. Participants were tested for HBV, HCV and HIV infections. For HBV, surface antigen was detected using Enzyme-linked Immunosorbent Assay (ELISA), HCV was detected by HCV antibody test using ELISA and HIV was detected using combination of three rapid kits, COMBAIDS-RS ADVANTAGE ST, MERISCREEN HIV 1-2 WB and TREDRO HIV 1-2 Ab. Demographic data was collected from all the PWIDs. Results: Among 200 PWIDs,138 (69%) were in the age group of 16-25 years and none of them was more than 35 years of age. The mean age of PWIDs was 22.9 years. Out of 200, 20(10%) PWIDS had HCV antibodies, 7 (3.5%) were positive for HBV, and 1 (0.5%) had anti-HIV antibodies. A 73.5% of PWIDs belonged to urban Kashmir and majority of them (62.5%) were college going students. Conclusion: From present study, authors report a high prevalence of hepatitis C and B in PWIDs of Kashmir. It is also the fact that these figures are just the tip of the iceberg. Targeted intervention programs should make HBV/HCV testing, prevention and care more accessible for PWIDs.

Hepatitis C treatment as prevention among HIV-infected men who have sex with men: Feasible?

BackgroundInfections of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are leading contributors to Indonesia’s disease burden, particularly among prisoners with limited access to care. This study investigates the prevalence and risk factors of these infections in prisoners of Semarang.Design and methodsA cross-sectional study at Kedungpane prison, Semarang, Central Java, Indonesia included informed consent, questionnaires about awareness and risk factors, and blood tests. HBV and HCV were determined through rapid serological methods, whereas HIV was confirmed with three rapid tests.ResultsAmong 1,642 prisoners (mean age 35.1 years), HBV, HCV and HIV prevalence was 3.3%, 1.5% and 0.9%, respectively. Significant risk factors for HCV included commercial sex workers (p = 0.009), people who inject drugs (PWID) (p = 0.000), blood transfusions (p = 0.025), drug use (p = 0.007), and multiple partners (p = 0.005). For HIV, key factors were being a transgender women (p = 0.037) and PWID (p = 0.001). Although 94.3% of prisoners had HIV screening, only 12 out of 15 HIV-positive prisoners understood their diagnosis and received treatment. The awareness levels were higher for HIV (76%) than for HBV (35.3%) and HCV (30.7%), with most information from media (51.2%) and counseling (30.4%). In the multivariate analysis, confirmed using exact logistic regression, only PWID remained independently associated with HCV infection, while both PWID and being a transgender woman were independently associated with HIV infection. These associations were strong but should be interpreted cautiously due to limited event counts.ConclusionsPrisoners had the highest prevalence of HBV, followed by HCV and HIV, with HCV rates higher than WHO data. Risk behaviors involved drug use and multiple sexual partners, and knowledge of HIV was higher than that of HBV and HCV mainly from social media and television.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-025-25781-8.

Injecting drug use is an important public health issue, causing significant morbidity and mortality worldwide. The contemporary drug market setting in Australia is defined by a lower prevalence and frequency of heroin injection among regular people who inject drugs (PWID) compared with in the past, and changing patterns of polydrug use, with some evidence of increasing use of pharmaceutical opioids. Our understanding of patterns of drug use and related risk behaviours among contemporary PWID is limited by the fact that much research has captured samples of predominantly older, long-term PWID, many of whom are on opioid substitution therapy (OST) and may use drugs only infrequently. The aim of the research presented in this thesis was to generate comprehensive information about patterns of drug use and associated risk behaviours among PWID who are active in contemporary settings, including understudied populations such as younger PWID, out-of-treatment PWID and PWID from culturally and linguistically diverse backgrounds. The Melbourne Injecting Drug User Cohort Study (MIX) is a prospective cohort of 688 community-recruited regular PWID. The median age of the cohort is 27.6 years and only 35% of participants were prescribed OST at baseline. Over 70% of the cohort completed a follow-up interview at 12 months post-baseline, demonstrating that it is possible to successfully retain a cohort of community-recruited PWID. Despite the uniqueness of this cohort, patterns of drug use by MIX participants were relatively similar to those displayed by sentinel samples of older, longer-term PWID. There were few differences in injecting initiation experiences between MIX participants who initiated injecting in contemporary settings and those who initiated in earlier settings and, although this had some ongoing impact, the relationship was not strongly related to current drug use patterns. Pharmaceutical opioid use was a key component of polydrug use among MIX participants, with 20% of the cohort reporting using illicitly-obtained pharmaceutical opioids in the month preceding baseline interview. Use of pharmaceutical opioids was however not sustained over time. The relationship between age and engagement in risk behaviours was examined using 10 years of data from the Australian Illicit Drug Reporting System, a national repeat cross-sectional survey of regular PWID recruited through needle and syringe programs, drug treatment and community settings. Older age was associated with decreased likelihood of engagement in a range of injecting-related and criminogenic risk behaviours. Injecting drug use among young people of African ethnicity was examined using MIX data and an additional qualitative study. Findings showed that injecting drug use (and substance use more broadly) and mental health are emerging issues among this community. Findings from this body of research inform the provision of harm reduction services which take into the account the key populations and patterns of drug use in the contemporary setting. Priority areas for future research include further research examining pharmaceutical opioid use among PWID, studies of substance use and mental health among resettled refugee youth, research into interventions to reduce injecting-related risk behaviours among younger PWID and additional longitudinal studies of PWID with a broader geographic focus.

Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and liver cancer, is curable in most people. Injecting drug use currently accounts for 80 % of new HCV infections with a known transmission route in the European Union (EU). HCV has generally received little attention from the public or policymakers in the EU, with major gaps in national-level strategies, action plans, guidelines and the evidence base. Specifically, people who inject drugs (PWID) are often excluded from treatment owing to various patient, healthcare provider and health system factors.All policymakers responsible for health services in EU countries should ensure that prevention, treatment, care and support interventions addressing HCV in PWID are developed and implemented. According to current best practice, PWID should have access to comprehensive, evidence-based multiprofessional harm reduction (especially opioid substitution therapy and clean needles and syringes) and support/care services based in the community and modified with community involvement to accommodate this hard-to-reach population. Other recommended components of care include vaccination against hepatitis B and other infections; peer support interventions; HIV testing, prevention and treatment; drug and alcohol services; psychological care as needed; and social support services. HCV testing should be performed regularly in PWID to identify infected persons and engage them in care. HCV-infected PWID should be considered for antiviral treatment (based on an individualised assessment and delivered within multidisciplinary care/support programmes) both to cure infected individuals and prevent onward transmission. Modelling data suggest that the HCV disease burden can only be cut substantially if antiviral treatment is scaled up together with prevention programmes. Measures should be taken to reduce stigma and discrimination against PWID at the provider and institutional levels.In conclusion, strategic action at the policy level is urgently needed to increase access to HCV prevention, testing and treatment among PWID, the group at highest risk of HCV infection. Such action has the potential to substantially reduce the number of infected persons, along with the disease burden and related care costs.

People who inject drugs (PWID) comprise one of the major transmission risk groups for human immunodeficiency virus (HIV) and hepatitis C virus (HCV). In 2011, Athens experienced a large HIV outbreak among PWID. Significant public health interventions were implemented in response to the HIV outbreak. The aims of this study were to estimate the indirect effects of the HIV interventions on HCV infection and to evaluate the concept of the association between HCV and HIV infections in the case of Athens. A dynamic, stochastic, individual-based model was developed to simulate HCV transmission among PWID. We calibrated the model to reproduce the observed HCV prevalence among PWID in Greece. Two years prior to the HIV outbreak, an undetected HCV outbreak has occurred. In 2009, the incidence of HCV infection increased from 640 (495, 842) cases in 2008 to 1260 (1060, 1500). The mean time from initiation of injecting drug use to HCV acquisition decreased from 29months in 2008 to 13months in 2009. After HIV interventions, HCV incidence declined by 64.8% in 2012, compared to 2009. The averted HCV incidence cases attributed to the HIV-implemented interventions were 2200 (1950, 2480), during 2012-2015. The cumulative number incident HCV cases in Athens during 2002-2015 was about 9900 (7800, 12100). Our results highlight that before the 2011 HIV outbreak in Athens, an HCV outbreak occurred in 2009. Prevention measures for HIV that took place in the Athens metropolitan area in 2012 reduced significantly the incidence of HCV.

Correlates of Hepatitis C Positivity Among People Who Inject Drugs in Ukraine OBJECTIVE: The study explores the possible correlates of Hepatitis C Virus (HCV) positivity in a sample of people who inject drugs (PWID) in Ukraine. BACKGROUND:The HCV epidemic in Ukraine is one of the most severe in the WHO European Region (Hope, Eramova, Capurro, & Donoghoe, 2014).Globally, PWID represent a vulnerable population exposed to multiple blood-borne diseases, including HCV.In Ukraine, PWID are affected by HCV infection mainly due to injection risk behaviors. METHODS:We used data from a cross-sectional integrated bio-behavioral study conducted in 29 Ukrainian cities in 2013.Participants were recruited using respondent driven sampling.In total, 9,502 PWID were surveyed and tested for HCV.Univariate, bivariate and multivariate logbinomial modelling analyses were used to assess HCV associations among these PWID.An alpha of 0.1 was used. RESULTS: HCV prevalence in this sample was 57%.Correlates of HCV included residential region -Central/North (adjusted prevalence ratio [aPR])=2.06,90% Confidence Interval [CI]=1.85,2.29), South (aPR=1.69,CI=1.50, 1.89) and East (aPR=1.25,CI=1.09, 1.44) in reference to Western Ukraine; being unemployed (aPR=1.19,CI=1.05, 1.32), lifetime drug use (3-5 years: aPR=1.77,CI=1 .44,2.17;[6][7][8][9][10] CI=1.99, 2.92; 11> years: aPR=4.19,CI= 3.47, 5.04 in reference to 2 years), ever overdosed (aPR=1.63,CI=1.37, 1.94), use of common containers for drug preparation and distribution (aPR=1.15,CI=1.06, 1.25), incarceration history (aPR=1.75, CI=1.59, 1.92), and HIV positivity (aPR=3.20,CI=2.81, 3.64).iii CONCLUSIONS: HCV prevalence of 57% in this sample points to a potentially high prevalence among the general population of PWID in Ukraine.Residents of East, South and Central/North Ukraine are at increased risk of HCV, as well as having been incarcerated, a longer duration of injecting drug use, and being unemployed.Among risky injecting practices, common container use represented the biggest risk of HCV infection.Combined efforts to enhance access to needle sharing programs, opioid substitution therapy, and new interferon-free medications could be a solution of the HCV transmission elimination among PWID in Ukraine.

Model projections on the impact of HCV treatment in the prevention of HCV transmission among people who inject drugs in Europe

Hepatitis C virus treatment in people who inject drugs (PWID) in Bangladesh

Commentary on Barré et al. (2020): Identifying remaining barriers to hepatitis C treatment in the DAA era.