Abstract
Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents—a scenario quite different from the open, mobile populations known to most health agencies. This paper uses data from the Centers for Disease Control’s National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated. Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.
Highlights
In the United States, hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with approximately 60% having chronic infection, and incidence of infection among new injectors varying between 15-35 per 100 person-years of observation [1]
The tabulated results show that the effects of syringe access (SA)/medically assisted treatment (MAT) treatment marginally enhance the effectiveness of direct acting antiviral (DAA) treatment in lowering chronic HCV prevalence in an open population, but have little effect on HCV-related advance liver disease, with roughly linear effects due to scale for HCV prevalence
Combined interventions that match lower-cost syringe access and medicine assisted addiction treatments with direct acting antiviral treatments can have a large effect on HCV incidence, cirrhosis incidence, and overall HCV prevalence, even among highly mobile PWID populations
Summary
In the United States, hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with approximately 60% having chronic infection, and incidence of infection among new injectors varying between 15-35 per 100 person-years of observation [1]. A systematic review and meta-analysis showed that PWID who receive medically assisted substance use treatment (SA/MAT) and participate in high-coverage syringe access programs may reduce their risk of HCV infection by 70% [9]. This raises the possibility that such strategies could be employed alongside DAA treatment to lower downstream cases of HCV-related severe liver diseases. Previous modeling studies have reported that scaling up MAT, high-coverage syringe access programs, and HCV treatment over time can reduce new infections and disease burden, and advance toward HCV elimination [10]. This paper extends that work by exploring the impact of treating chronically infected PWID at all HCV stages, and describing the anticipated benefits of combining DAA treatment with intensive SA/MAT
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