April 14, 2013

Hepatology

Accepted Article (Accepted, unedited articles published online and citable. The final edited and typeset version of record will appear in future.)

Natasha K Martin1,2,†,*, Peter Vickerman2, Jason Grebely3, Margaret Hellard4, Sharon J Hutchinson5,6, Viviane D Lima7, Graham R Foster8, John F Dillon9, David J Goldberg5, Gregory J Dore3, Matthew Hickman1

DOI: 10.1002/hep.26431

Copyright © 2013 American Association for the Study of Liver Diseases

Abstract
Background:

Substantial reductions in HCV prevalence among people who inject drugs (PWID) cannot be achieved by harm reduction interventions such as needle exchange and opiate substitution therapy (OST) alone. Current HCV treatment is arduous and uptake low, but new highly effective and tolerable interferon-free direct-acting antiviral (DAA) treatments could facilitate increased uptake. We projected the potential impact of DAA treatments on PWID HCV prevalence in three settings.

Methods

A dynamic HCV transmission model was parameterized to three chronic HCV prevalence settings: Edinburgh, UK (25%); Melbourne, Australia (50%); Vancouver, Canada (65%). Using realistic scenarios of future DAAs (90% sustained viral response, 12 weeks duration, available 2015), we projected the treatment rates required to reduce chronic HCV prevalence by half or three-quarters within 15 years.

Results

Current HCV treatment rates may minimally impact prevalence in Melbourne and Vancouver (<2% relative reductions), but could reduce prevalence by 26% in 15 years in Edinburgh. Prevalence could halve within 15 years with treatment scale-up to 15, 40, or 76 per 1000 PWID annually in Edinburgh, Melbourne, or Vancouver, respectively (2, 13, 15-fold increases, respectively). Scale-up to 22, 54, or 98 per 1000 PWID annually could reduce prevalence by three-quarters within 15 years. Less impact occurs with delayed scale-up, higher baseline prevalence, or shorter average injecting duration. Results are insensitive to risk heterogeneity or restricting treatment to PWID on OST. At existing HCV drug costs, halving chronic prevalence would require annual treatment budgets of USD$3.2 million in Edinburgh and ˜$50 million in Melbourne and Vancouver.

Conclusion:

Interferon-free DAAs could enable increased HCV treatment uptake among PWID, which could have a major preventative impact. However, treatment costs may limit scale-up, and should be addressed. (HEPATOLOGY 2013.)

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