Hepatitis C Virus Incidence Rate Research Articles

Modeling the impact of a supervised consumption site on HIV and HCV transmission among people who inject drugs in three counties in California, USA

Supervised consumption sites (SCS) have been shown to reduce receptive syringe sharing among people who inject drugs (PWID) in the United States and elsewhere, which can prevent HIV and hepatitis C virus (HCV) transmission. PWID are at risk of disease transmission and may benefit from SCS, however legislation has yet to support their implementation. This study aims to determine the potential impact of SCS implementation on HIV and HCV incidence among PWID in three California counties. A dynamic HIV and HCV joint transmission model among PWID (sexual and injecting transmission of HIV, injecting transmission of HCV) was calibrated to epidemiological data for three counties: San Francisco, Los Angeles, and San Diego. The model incorporated HIV and HCV disease stages and HIV and HCV treatment. Based on United States data, we assumed access to SCS reduced receptive syringe sharing by a relative risk of 0.17 (95 % CI: 0.04-1.03). This model examined scaling-up SCS coverage from 0 % to 20 % of the PWID population within the respective counties and assessed its impact on HIV and HCV incidence rates after 10 years. By increasing SCS from 0 % to 20 % coverage among PWID, 21.8 % (95 % CI: -1.2-32.9 %) of new HIV infections and 28.3 % (95 % CI: -2.0-34.5 %) of new HCV infections among PWID in San Francisco County, 17.7 % (95 % CI: -1.0-30.8 %) of new HIV infections and 29.8 % (95 % CI: -2.1-36.1 %) of new HCV infections in Los Angeles County, and 32.1 % (95 % CI: -2.8-41.5 %) of new HIV infections and 24.3 % (95 % CI: -1.6-29.0 %) of new HCV infections in San Diego County could be prevented over ten years. Our models suggest that SCS is an important intervention to enable HCV elimination and could help end the HIV epidemic among PWID in California. It could also have additional benefits such facilitating pathways into drug treatment programs and preventing fatal overdose.

Distribution of hepatitis C virus in eastern China from 2011 to 2020: a Bayesian spatiotemporal analysis.

This study aimed to evaluate the spatiotemporal distribution of patients with hepatitis C virus (HCV) and the factors influencing this distribution in Jiangsu Province, China, from 2011 to 2020. The incidence of reported HCV in Jiangsu Province from 2011 to 2020 was obtained from the Chinese Information System for Disease Control and Prevention (CISDCP). R and GeoDa software were used to visualize the spatiotemporal distribution and the spatial autocorrelation of HCV. A Bayesian spatiotemporal model was constructed to explore the spatiotemporal distribution of HCV in Jiangsu Province and to further analyze the factors related to HCV. A total of 31,778 HCV patients were registered in Jiangsu Province. The registered incidence rate of HCV increased from 2.60/100,000 people in 2011 to 4.96/100,000 people in 2020, an increase of 190.77%. Moran's I ranged from 0.099 to 0.354 (P < 0.05) from 2011 to 2019, indicating a positive spatial correlation overall. The relative risk (RR) of the urbanization rate, the most important factor affecting the spread of HCV in Jiangsu Province, was 1.254 (95% confidence interval: 1.141-1.376), while other factors had no significance. The reported HCV incidence rate integrally increased in the whole Jiangsu Province, whereas the spatial aggregation of HCV incidence was gradually weakening. Our study highlighted the importance of health education for the floating population and reasonable allocation of medical resources in the future health work.

Human immunodeficiency virus, hepatitis C virus and hepatitis B virus incidence in blood donors from 2000 to 2020 in France: Trends and lessons from haemovigilance surveillance.

Data from 21 years (2000-2020) of haemovigilance were used to assess human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) incidence rates in repeat blood donors and the occurrence of transfusion-transmitted (TT) viral infections. Blood donors who converted for HIV, HCV or HBV markers within serial three-year analysis periods were included. Epidemiological and virological data were retrieved from the national epidemiological donor database and were supplemented with information on blood components and the infection status of recipients of the previous negative donation (D.N-1) of donors who seroconverted. Incidence rates declined from 1.27 to 0.35/100,000 person-years for HIV, from 0.59 to 0.19 for HCV and from 1.66 to 0.18 for HBV. Risk factors and lookback for 232 HIV, 90 HCV and 74 HBV seroconversions were investigated. The main risk factor identified at post-donation interview was having sex with men (47.8% of males) for HIV and a sexual risk for HCV (30.6%) and HBV (37.1%). The viral loads and sequences were retrospectively tested in 191 HIV, 74 HCV and 62 HBV D.N-1 archived samples. Six (five HBV and one HIV-1) were positive all low viral loads. Two recipients were infected by red blood cells from two HBV seroconverting donors before the introduction of HBV-nucleic acid testing. HIV, HCV and HBV incidence rates in blood donors declined over the two past decades in France. There is a very small risk of a blood component that tests negative entering the blood supply resulting in TT infections, especially after introduction of molecular assays in donor screening.

Annual trends of hepatitis C virus infection in Manitoba between 1998 and 2018: A focus on special populations.

Hepatitis C virus (HCV) infection is a major cause of liver-related morbidity and mortality worldwide. Epidemiological data of HCV infection in the Canadian province of Manitoba are limited. A population-based retrospective study was conducted using data from the Manitoba Centre for Health Policy repository. Using the test results provided by the Cadham provincial laboratory, individuals in Manitoba with a diagnosis of HCV infection were identified. Annual prevalence and incidence rates (crude and standardized) were calculated for the overall population and stratified by sex, regional health authority (RHA), residence area, income quintile, and special population groups (children, older adults, and pregnant persons). A total of 8,721 HCV cases were diagnosed between 1998 and 2018 in Manitoba. Overall crude HCV incidence and prevalence were estimated as 0.03% and 0.37% during the study period, respectively. No significant change was observed in the standardized HCV incidence rate (per 100,000) during the study period (54.3 in 1998 and 54.8 in 2018). However, the standardized HCV prevalence (per 100,000) increased from 52.5 (95% CI 39.2-68.7) in 1998 to 655.2 (95% CI 605.9-707.3) in 2018. An overall average incidence rate based on sex, RHA, region, income, and special population groups was observed to be higher in males (40.1), Winnipeg RHA (42.7), urban region (42.3), low-income quintiles (78.5), and pregnant persons (94.3), respectively. Although incidence rates of HCV infection in Manitoba appeared to have initially declined, rates showed an upward trend by the end of the study period while prevalence increased steadily.

Modelling the contribution of incarceration and public health oriented drug law reform to HCV transmission and elimination among PWID in Tijuana, Mexico.

Incarceration is associated with increased risk of hepatitis C virus (HCV) among people who inject drugs (PWID). Mexico's previous attempt in implementing a public health-oriented drug law reform resulted in minimal impact on incarceration among PWID. However, implementation of reforms alongside Mexico's HCV elimination program has the potential to reshape the HCV epidemic among PWID in the next decade. We use data from a cohort of PWID in Tijuana, Mexico, to inform epidemic modeling to assess the contribution of incarceration and fully implemented drug reform on HCV transmission and elimination among PWID. We developed a dynamic, deterministic model of incarceration, HCV transmission and disease progression among PWID. The model was calibrated to data from Tijuana, Mexico, with 90% HCV seroprevalence among 10,000 PWID. We estimated the 10-year population attributable fraction (PAF) of incarceration to HCV incidence among PWID and simulated, from 2022, the potential impact of the following scenarios: 1) decriminalization (80% reduction in incarceration rates); 2) fully implemented drug law reform (decriminalization and diversion to opiate agonist therapy [OAT]); 3) fully implemented drug law reform with HCV treatment (direct-acting antivirals [DAA]). We also assessed the number DAA needed to reach the 80% incidence reduction target by 2030 under these scenarios. Projections suggest a PAF of incarceration to HCV incidence of 5.4% (95% uncertainty interval [UI]:0.6-11.9%) among PWID in Tijuana between 2022-2032. Fully implemented drug reforms could reduce HCV incidence rate by 10.6% (95%UI:3.1-19.2%) across 10 years and reduce the number of DAA required to achieve Mexico's HCV incidence reduction goal by 14.3% (95%UI:5.3-17.1%). Among PWID in Tijuana, Mexico, incarceration remains an important contributor to HCV transmission. Full implementation of public health-oriented drug law reform could play an important role in reducing HCV incidence and improve the feasibility of reaching the HCV incidence elimination target by 2030.

Progress on global hepatitis elimination targets.

In 2016, the World Health Assembly adopted a Global Health Sector Strategy on viral hepatitis, with targets set for the years 2020 and 2030 to achieve hepatitis elimination. The main target of hepatitis elimination strategy is to reduce the incidence of hepatitis B virus (HBV) and hepatitis C virus (HCV) by 90% and mortality by 65% in 2030. In last 5 years, the number of people receiving HCV treatment has increased from 1 million to 9.4 million; however, this number is far from the 2030 target of 40 million people receiving HCV treatment. HBV and HCV incidence rates are down from 1.4 million to 1.1 million annual deaths but this is far from the 2030 target of < 0.5 million deaths. The coronavirus disease 2019 pandemic has severely affected the efforts in the fight against hepatitis. No major donor has committed to investing in the fight against hepatitis. Time is running out. There is a need to speed up efforts in the fight against hepatitis to achieve hepatitis elimination by 2030.

Hepatitis C virus (HCV) incidence among men who have sex with men (MSM) living with HIV: results from the French Hospital Database on HIV (ANRS CO4-FHDH) cohort study, 2014 to 2017.

BackgroundDespite the availability of highly effective direct-acting antivirals (DAAs) and the expected treatment as prevention (TasP) effect, transmission of hepatitis C virus (HCV) persists in men who have sex with men (MSM) who engage in high-risk sexual behaviours.AimWe aimed to estimate the incidence of primary HCV infection among MSM living with HIV in France when DAA was readily available.MethodsWe used data from a large French hospital cohort of persons living with HIV (ANRS CO4-FHDH) prospectively collected between 2014 and 2017. HCV incidence rates were calculated using person-time methods for HCV-negative MSM at inclusion who had serological follow-up from 1 January 2014 to 31 December 2017. Sensitivity analyses were performed by varying the main assumptions to assess their impact on the results.ResultsOf 14,273 MSM living with HIV who were initially HCV-seronegative, 330 acquired HCV during follow-up over 45,866 person-years (py), resulting in an overall estimated incidence rate of 0.72/100 py (95% CI: 0.65–0.80). HCV incidence significantly decreased from 0.98/100 py (95% CI: 0.81–1.19) in 2014 to 0.45/100 py (95% CI: 0.35–0.59) in 2017 (54% decrease; 95% CI: 36–67). This trend was confirmed by most of the sensitivity analyses.ConclusionThe primary incidence of HCV was halved for MSM living with HIV between 2014 and 2017. This decrease may be related to unrestricted DAA availability in France for individuals living with HIV. Further interventions, including risk reduction, are needed to reach HCV micro-elimination in MSM living with HIV.

Modeling Hepatitis C Elimination Among People Who Inject Drugs in New Hampshire

The success of direct-acting antiviral therapies for chronic hepatitis C virus (HCV) infection led the World Health Organization to set elimination targets by 2030. For the United States to achieve these benchmarks, public health responses must target high-risk populations, such as people who inject drugs (PWID), a group with high rates of HCV incidence and low rates of treatment uptake. To evaluate potential improvements in the HCV care cascade among PWID, focusing on improved testing, treatment uptake, and access to harm reduction. This decision analytic model used a differential equation-based dynamic transmission model based on data from New Hampshire, an illustrative state with a large number of PWID and limited HCV treatment infrastructure. Surveillance data through 2020 was used for model parameterization, and the final analysis was conducted in May 2021. Model forecasts of chronic HCV cases and advanced-stage HCV outcomes from 2022 to 2045. A total of 6 scenarios were tested: (1) the base case, (2) improved harm reduction, (3) improved testing, (4) improved treatment, (5) improved testing and treatment, and (6) improved testing, treatment, and harm reduction. All scenarios with improved testing, treatment uptake, and/or access to harm reduction were associated with decreases in forecasted HCV prevalence and HCV-associated mortality compared with the base case. Improving harm reduction, testing, and treatment individually were forecast to reduce prevalence of HCV in 2045 from 69.7% in the base case to 62.8%, 45.7%, and 35.5%, respectively. Combining treatment and testing improvements was associated with a 2045 prevalence of 0.3%; adding harm reduction improvements was associated with further reductions in prevalence forecasts (to 0.2%), with fewer total treatments (10 960 vs 13 219 from 2022-2045). In this modeling study, no single intervention was projected to achieve World Health Organization HCV elimination targets. Scenarios with improvements in both testing and treatment were associated with a prevalence of less than 3% by 2030 and achieved elimination targets. Adding improvements in harm reduction was associated with faster reductions in prevalence and fewer treatments.

The Relationship Between Hepatitis C Virus Rates and Office-Based Buprenorphine Access in Ohio.

BackgroundThe United States is experiencing an epidemic of hepatitis C virus (HCV) infections due to injection drug use, primarily of opioids and predominantly in rural areas. Buprenorphine, a medication for opioid use disorder, may indirectly prevent HCV transmission. We assessed the relationship of HCV rates and office-based buprenorphine prescribing in Ohio.MethodsWe conducted an ecological study of the county-level (n = 88) relationship between HCV case rates and office-based buprenorphine prescribing in Ohio. We fit adjusted negative binomial models between the county-level acute and total HCV incidence rates during 2013–2017 and 1) the number of patients in each county that could be served by office-based buprenorphine (prescribing capacity) and 2) the number served by office-based buprenorphine (prescribing frequency) from January–March, 2018.ResultsFor each 10% increase in acute HCV rate, office-based buprenorphine prescribing capacity differed by 1% (95% CI: –1%, 3%). For each 10% increase in total HCV rate, office-based buprenorphine prescribing capacity was 12% (95% CI: 7%, 17%) higher. For each 10% increase in acute HCV rate, office-based buprenorphine prescribing frequency was 1% (95% CI: –1%, 3%) higher. For each 10% increase in total HCV rate, office-based buprenorphine prescribing frequency was 14% (95% CI: 7%, 20%) higher.ConclusionsRural counties in Ohio have less office-based buprenorphine and higher acute HCV rates versus urban counties, but a similar relationship between office-based buprenorphine prescribing and HCV case rates. To adequately prevent and control HCV rates, certain rural counties may need more office-based buprenorphine prescribing in areas with high HCV case rates.

1053. The Ecological Relationship Between County-Level HCV Case Rates and Office-Based Buprenorphine in Ohio

BackgroundThe United States is experiencing an epidemic of hepatitis C virus (HCV) infections due to injection drug use, especially in rural areas. Counties may be expanding access to buprenorphine, an evidence-based treatment that has been shown to reduce injection drug use, to control the HCV epidemic. We assessed the county-level relationship between HCV rates in 2013-2015 and office-based buprenorphine prescribing in 2018 in Ohio. We also assessed if this relationship varied between rural and urban counties.MethodsWe fit crude and adjusted negative binomial models to assess the relationship between HCV incidence rates in 2013-2015 and office-based buprenorphine prescribing capacity and frequency in Ohio in 2018. We examined effect measure modification of this relationship by rural-urban status using an interaction term.ResultsWe found that a 1% higher acute HCV rate was associated with an 18% (95% Confidence Interval [CI]: -3%, 44%) higher office-based buprenorphine prescribing capacity and an 22% (95% CI: -4%, 55%) higher office-based buprenorphine prescribing frequency. We found that a 1% higher total HCV rate was associated with a 239% (95% CI: 179%, 317%) higher office-based buprenorphine prescribing capacity and a 273% (95% CI: 183%, 405%) higher office-based buprenorphine prescribing frequency. We found no evidence of effect measure modification by rural-urban status.ConclusionCounties across Ohio may have expanded access to office-based buprenorphine in response to high rates of total HCV. Expansion of office-based buprenorphine may be less associated with acute HCV rates due to the low frequency with which these cases are seen in outpatient settings.Disclosures All Authors: No reported disclosures

A Treatment-as-Prevention Trial to Eliminate Hepatitis C Among Men Who Have Sex With Men Living With Human Immunodeficiency Virus (HIV) in the Swiss HIV Cohort Study.

In 2016, the World Health Organization (WHO) introduced global targets for the elimination of hepatitis C virus (HCV) by 2030. We conducted a nationwide HCV micro-elimination program among men who have sex with men (MSM) living with human immunodeficiency virus (HIV) from the Swiss HIV Cohort Study (SHCS) to test whether the WHO goals are achievable in this population. During phase A (10/2015-06/2016), we performed a population-based and systematic screening for HCV-RNA among MSM from the SHCS. During phase B (06/2016-02/2017) we offered treatment with HCV direct-acting antiviral (DAA) agents to MSM identified with a replicating HCV infection. During phase C (03/2017-11/2017), we offered rescreening to all MSM for HCV-RNA and initiated DAA treatment in MSM with replicating infections. We screened 3715/4640 (80%) MSM and identified 177 with replicating HCV infections (4.8%); 150 (85%) of whom started DAA treatment and 149 (99.3%) were cured. We rescreened 2930/3538 (83%) MSM with a prior negative HCV-RNA and identified 13 (0.4%) with a new HCV infection. At the end of the micro-elimination program, 176/190 MSM (93%) were cured, and the HCV incidence rate declined from .53 per 100 patient-years (95% CI, .35-.83) prior to the intervention to .12 (95% CI, .03-.49) by the end of 2019. A systematic, population-based HCV micro-elimination program among MSM living with HIV was feasible and resulted in a strong decline in HCV incidence and prevalence. Our study can serve as a model for other countries aiming to achieve the WHO HCV elimination targets. NCT02785666.

Prevalence of Transfusion Transmissible Infections (HBV, HCV, HIV and Treponema pallidum in Volunteer Blood Donors in Shirajganj District

Blood and its components are essential for life and often required to be transfused in critical health condition. However, such transfusion is reported to be associated with the risk of transfusion transmissible infections (TTIs) with notable pathogens e.g. Hepatitis B virus (HBV), Hepatitis C virus (HCV), Human immunodeficiency virus (HIV) and Treponema pallidum. These pathogens are of major public health concern especially in developing countries like Bangladesh. Increase in the number of TTIs is found to be associated with improper management of safe blood transfusion protocol (SBTP) and unethical practices. This study focuses on the prevalence of such TTIs in volunteers’ blood collected between October and December 2018 from Sakhawath Memorial and Avicina Hospitals in Shirajgong district. Prevalence rate of HIV, HBsAg, HCV and Treponema pallidum were 1.2%, 6.8%, 0.8% and 1.6%, respectively. Among the infected individuals, 75% HIV positive cases were professionals, 70% HCV infected cases wwere from other professional groups and 50% of syphilis infected were homemakers. Male donors showed higher incidence rate of HBV (65%), HCV (72%) and HIV (85%) compared to the female donors. Although the findings of the study showed prevalence of TTIs in volunteer blood donors (VBDs) at an alarming rate, most of the infected individuals were not aware of their infections and potential risk of transmission from them. It is necessary to create awareness among blood donors about possible causes of transmission and prevention of infection . Such initiative from both governmental and non-governmental organizations can help reduce TTIs among VBDs.&#x0D; Bangladesh J Microbiol, Volume 36 Number 2 December 2019, pp 105-109

Combined treatment and prevention strategies for hepatitis C virus elimination in the prisons in New South Wales: a modelling study.

Australia is currently on track to meet the World Health Organization (WHO) global hepatitis C virus (HCV) elimination goals by 2030, reflecting universal subsidized access to testing and direct-acting antiviral (DAA) treatment. In New South Wales, DAA treatment in prisons has scaled-up substantially, with 1000 prisoners treated in 2017. However, HCV prevalence and incidence in this setting is high, which could undermine elimination efforts. This study aimed to test the preventative effects of DAA treatment scale-up, opiate substitution treatment (OST) and needle and syringe programme (NSP) strategies for prisons. Modelling study using an individual-based mathematical model of a typical prison setting. The model was calibrated against Australian epidemiological data sets and executed in-prison events for each individual daily, including movements between prisons, changes in risk behaviour and uptake of prevention measures such as OST and NSP, as well as DAA treatment. Scenarios were projected from 2018 to 2030. New South Wales prisons. New South Wales prisoners. Variables including prison populations, prevalence and incidence rate were calculated. Prisoners were described by demographic characteristics, HCV infection history, risk behaviours and accessing treatment and prevention measures in varied security settings. Increasing the number of prisoners treated for HCV to 2000 annually was projected to reduce the HCV incidence rate to 8.69 [95% confidence interval (CI) = 8.17, 9.20] per 100 person-years (100 p.y.). Combined treatment and prevention strategies were necessary to reduce the projected incidence rate to 5.22 (95% CI = 5.13, 5.52) per 100 p.y. Considering the expected reductions in the prevalence of chronic HCV in the Australian community, incidence rate was predicted to drop to 0.93 (95% CI = 0.92, 0.98) per 100 p.y. by 2030. This model, which simulates prison scenarios to inform Australia's national hepatitis C virus elimination efforts, suggests that continued direct-acting antiviral (coverage in the community combined with a moderate increase of direct-acting antiviral treatments in prisons, and introduction of improved harm reduction via opiate substitution treatment and/or needle and syringe programmes, makes hepatitis C virus elimination feasible in Australian prisons.

Prevalence, estimated incidence, risk behaviours, and genotypic distribution of hepatitis C virus among people who inject drugs accessing harm-reduction services in Kenya: a retrospective cohort study

Sub-Saharan Africa has a large population of people with hepatitis C virus (HCV) infection, yet little is known about HCV among people who inject drugs this region. We assessed the prevalence of HCV mono-infection and HIV-HCV co-infection, and the estimated incidence, genotypes, and risk behaviours associated with HCV among people who inject drugs in Kenya. People aged 18 years or older who were living in Nairobi, coastal Kenya, or western Kenya, had a history of injection drug use, and had used any illicit drugs in the past 12 months were recruited at needle and syringe programme sites using respondent-driven sampling. Participants were screened for the presence of an anti-HCV antibody. Those who were anti-HCV positive underwent confirmatory HCV RNA testing, and those with detectable HCV RNA were genotyped. Participants were interviewed regarding parenteral risk behaviours and exposure to services received at the needle and syringe programme sites. We examined correlates of HCV infection and HIV-HCV co-infection using bivariate and multivariate regression, and estimated HCV incidence. Of 2188 enrolled participants, 291 (13%) were anti-HCV positive: 183 (22%) of 842 participants in coastal Kenya, 105 (13%) of 817 in Nairobi, and three (1%) of 529 in western Kenya. 284 anti-HCV-positive participants underwent successful HCV RNA testing, of whom 230 (81%) were viraemic. Estimated incidence rates of anti-HCV positivity per 100 person-years were 6·31 in coastal Kenya, 3·19 in Nairobi, and 0·22 in western Kenya. HCV incidence rate was greater in coastal Kenya compared with Nairobi (incidence rate ratio 1·97 [95% CI 1·35-2·93], p=0·0001) and the western region (28·17 [7·55-236·58], p<0·0001). In the coastal region, history of incarceration, more years injecting, more injections in the past month, and receptive cooker sharing were associated with increased risk of HCV, while female sex, more years injecting, more injections in the past month, and regular use of a syringe with a detachable needle were associated with HCV risk in Nairobi. HCV prevalence among HIV-positive participants was 50% (66 of 131 participants) in coastal Kenya, 35% (42 of 121) in Nairobi, and 4% (one of 23) in western Kenya. Risk factors for HIV-HCV co-infection were similar to those observed for HCV mono-infection. The prevailing genotypes were 1a (51%), 4a (47%), and mixed (2%; three 1a/4a and one 1a/2b). HCV prevalence, estimated incidence, and risk behaviours among people who inject drugs in Kenya vary with region, with the highest estimated incidence observed in coastal Kenya. These findings should be used to inform focused strategies to reduce HCV transmission, such as expansion of needle and syringe programmes, upscaling of opioid agonist therapy, and treatment as prevention in regions affected by injection drug use and HCV. National Institute on Drug Abuse.

Hepatitis C virus prevalence and incidence estimates among Chinese blood donors.

Hepatitis C virus (HCV) is an important transfusion-transmitted virus with global significance. The objective of this study was to evaluate the HCV prevalence and incidence among Chinese blood donors from 2013 to 2016. Whole blood and apheresis platelet donations collected from five Chinese blood centers from June 1, 2013, to December 31, 2016, were screened in parallel by two different enzyme-linked immunosorbent assays for anti-HIV 1/2, hepatitis B surface antigen, anti-HCV, and syphilis. Screening-reactive samples were further confirmed by western blot. Confirmatory positive rates among first-time and repeat donors were used to estimate the prevalence and incidence rates. Multivariable logistic regression modeling was used to examine factors associated with HCV infection. A total of 1,276,544 donations were collected from five Chinese blood centers, of which an estimated 1203 were confirmed HCV positive. The overall HCV prevalence among first-time donors was 166.56 per 100,000 donors (95% confidence interval, 156.04-177.08). The HCV incidence rate was estimated to be 15.21 (95% confidence interval, 11.83-19.56) per 100,000 person-years among repeat donors. Multivariable logistic regression results showed that increased age, lower educational levels, ethnicity, and occupation were all important factors associated with HCV confirmatory status among first-time donors (p < 0.01). HCV infection is still an important concern for transfusion safety in China. Our findings indicate that continued strong efforts are needed to monitor and control the risk of transfusion-transmitted HCV infection in China. Moreover, to reduce unnecessary donor loss, HCV donor screening procedures should be improved by incorporating confirmatory testing into routine blood center operations.

Commentary on Grebely et al. (2019): Ending HCV epidemics among people who inject drugs.

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 and spontaneous clearance of hepatitis C virus (HCV) in people who inject drugs at the Stockholm Needle Exchange-Importance for HCV elimination.

The major transmission route for hepatitis C virus (HCV) is through sharing of unsterile injection equipment among people who inject drugs (PWID). The WHO strategy for HCV elimination by 2030 proposes increased efforts to treat PWID populations that drive the HCV epidemic. Among participants in the Stockholm needle exchange programme (NEP), the HCV prevalence is 60%. We aimed to study HCV incidence, spontaneous HCV clearance rate, and predictors associated with new HCV infections and reinfections in NEP participants. All 2320 patients enrolled in the programme between 8 April 2013 and 23 September 2016 were tested for HCV at baseline, and responded to a questionnaire regarding sociodemographic data and injection risk behaviour. Tests for HCV were repeated at an interval of 3-6months. The anti-HCV prevalence in the NEP participants at baseline was 77%, and the prevalence of HCV RNA was 57%. 24% of the anti-HCV positive were HCV RNA negative with a spontaneously cleared HCV infection. The overall HCV incidence rate was 22/100 PY. The HCV incidence rate in the HCV naive group was 26/100 PY, and in the spontaneously cleared group 19/100. Although there were no significant differences in becoming HCV infected between the two groups (31% vs 29%), the rate of spontaneous HCV clearance was significantly lower in the HCV naive group, 20% vs 44%, (P<0.05). A high HCV incidence rate was noted among the PWID indicating that treatment needs to be scaled up in conjunction with harm reduction measures to achieve HCV elimination goals set by WHO. This includes high coverage needle exchange programmes and effective addiction treatment for substance users, including opiate substitution treatment.

Effectiveness and cost‐effectiveness of interventions targeting harm reduction and chronic hepatitis C cascade of care in people who inject drugs: The case of France

Direct-acting antivirals (DAAs) represent an opportunity to improve hepatitis C virus (HCV) care cascade. This combined with improved harm reduction interventions may lead to HCV elimination especially in people who inject drugs (PWID). We assessed the effectiveness/cost-effectiveness of improvements in harm reduction and chronic hepatitis C (CHC) care cascade in PWID in France. We used a dynamic model of HCV transmission and CHC natural history and evaluated the following: improved needle/syringe programmes-opioid substitution therapies, faster diagnosis/linkage to care, earlier treatment initiation, alone and in combination among active PWID (mean age=36). Outcomes were as follows: life expectancy in discounted quality-adjusted life years (QALYs); direct lifetime discounted costs; incremental cost-effectiveness ratio (ICER); number of infections/reinfections. Under the current practice, life expectancy was 15.846 QALYs, for a mean lifetime cost of €20762. Treatment initiation at F0 fibrosis stage alone was less effective and more costly than faster diagnosis/linkage to care combined with treatment initiation at F0, which increased life expectancy to 16.694 QALYs, decreased new infections by 37%, with a ICER=€5300/QALY. Combining these interventions with harm reduction improvements was the most effective scenario (life expectancy=16.701 QALYs, 41% decrease in new infections) but was not cost-effective (ICER=€105600/QALY); it became cost-effective with higher initial HCV incidence rates and lower harm reduction coverage than in our base-case scenario. This study illustrated the high effectiveness, and cost-effectiveness, of a faster diagnosis/linkage to care together with treatment from F0 with DAAs. This "Test and treat" strategy should play a central role both in improving the life expectancies of HCV-infected patients, and in reducing HCV transmission.

The Effect of Female Sex on Hepatitis C Incidence Among People Who Inject Drugs: Results From the International Multicohort InC3 Collaborative.

The objective of this study was to assess differences in hepatitis C virus (HCV) incidence by sex in people who inject drugs (PWID), using a large international multicohort set of pooled biological and behavioral data from prospective observational studies of incident human immunodeficiency virus (HIV) and HCV infections in high-risk cohorts (the InC3 Collaborative). HCV infection date was estimated based on a hierarchy of successive serological (anti-HCV), virological (HCV RNA), and clinical (symptoms and/or liver function tests) data. We used a Cox proportional hazards model to calculate the crude and adjusted female to male (F:M) hazard ratio (HR) for HCV incidence using biological sex as the main exposure. A total of 1868 PWID were observed over 3994 person-years of observation (PYO). Unadjusted F:M HR was 1.38 (95% confidence interval [CI], 1.15-1.65) and remained significant after adjusting for behavioral and demographic risk factors (1.39 [95% CI, 1.12-1.72]). Although syringe and equipment sharing were associated with the highest HCV incidence rate in women (41.62 and 36.83 PYO, respectively), we found no sex differences attributed to these risk factors. Our findings indicate that women who inject drugs may be at greater risk of HCV acquisition than men, independent of demographic characteristics and risk behaviors. Multiple factors, including biological (hormonal), social network, and differential access to prevention services, may contribute to increased HCV susceptibility in women who inject drugs.

State HCV Incidence and Policies Related to HCV Preventive and Treatment Services For Persons Who Inject Drugs — United States, 2015–2016

Hepatitis C is associated with more deaths in the United States than 60 other infectious diseases reported to CDC combined. Despite curative hepatitis C virus (HCV) therapies and known preventive measures to interrupt transmission, new HCV infections have increased in recent years (1,2). Injection drug use is the primary risk factor for new HCV infections (2). One potential strategy to decrease the prevalence of HCV is to create and strengthen public health laws and policies aimed specifically at reducing transmission risks among persons who inject drugs. To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.