Maintenance Opioid Agonists Protect Against HCV in Injection Drug Users

Judith I. Tsui, MD, MPH^1,2; Jennifer L. Evans, MS³; Paula J. Lum, MD, MPH⁴; Judith A. Hahn, PhD^3,4; Kimberly Page, PhD, MPH⁵

[+-] Author Affiliations

¹Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
²Department of Medicine, Boston Medical Center, Boston, Massachusetts
³Department of Epidemiology and Biostatistics, University of California, San Francisco
⁴Department of Medicine, University of California, San Francisco
⁵Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque

JAMA Intern Med. Published online October 27, 2014. doi:10.1001/jamainternmed.2014.5416

Abstract

Importance Injection drug use is the primary mode of transmission for hepatitis C virus (HCV) infection. Prior studies suggest opioid agonist therapy may reduce the incidence of HCV infection among injection drug users; however, little is known about the effects of this therapy in younger users.

Objective To evaluate whether opioid agonist therapy was associated with a lower incidence of HCV infection in a cohort of young adult injection drug users.

Design, Setting, and Participants Observational cohort study conducted from January 3, 2000, through August 21, 2013, with quarterly interviews and blood sampling. We recruited young adult (younger than 30 years) injection drug users who were negative for anti-HCV antibody and/or HCV RNA.

Exposures Substance use treatment within the past 3 months, including non–opioid agonist forms of treatment, opioid agonist (methadone hydrochloride or buprenorphine hydrochloride) detoxification or maintenance therapy, or no treatment.

Main Outcomes and Measures Incident HCV infection documented with a new positive result for HCV RNA and/or HCV antibodies. Cumulative incidence rates (95% CI) of HCV infection were calculated assuming a Poisson distribution. Cox proportional hazards regression models were fit adjusting for age, sex, race, years of injection drug use, homelessness, and incarceration.

Results Baseline characteristics of the sample (n = 552) included median age of 23 (interquartile range, 20-26) years; 31.9% female; 73.1% white; 39.7% who did not graduate from high school; and 69.2% who were homeless. During the observation period of 680 person-years, 171 incident cases of HCV infection occurred (incidence rate, 25.1 [95% CI, 21.6-29.2] per 100 person-years). The rate ratio was significantly lower for participants who reported recent maintenance opioid agonist therapy (0.31 [95% CI, 0.14-0.65]; P = .001) but not for those who reported recent non–opioid agonist forms of treatment (0.63 [95% CI, 0.37-1.08]; P = .09) or opioid agonist detoxification (1.45 [95% CI, 0.80-2.69]; P = .23). After adjustment for other covariates, maintenance opioid agonist therapy was associated with lower relative hazards for acquiring HCV infection over time (adjusted hazard ratio, 0.39 [95% CI, 0.18-0.87]; P = .02).

Conclusions and Relevance In this cohort of young adult injection drug users, recent maintenance opioid agonist therapy was associated with a lower incidence of HCV infection. Maintenance treatment with methadone or buprenorphine for opioid use disorders may be an important strategy to prevent the spread of HCV infection among young injection drug users.

Source

Researchers look to reduce Hep C infections with "Staying safe intervention" for injecting drug users

February 11, 2014
N-195 2013-14

Despite a number of social/behavioral intervention and educational programs, the spread of hepatitis C (HCV) in people who inject drugs (PWIDs) remains a chronic problem. Now, researchers affiliated with New York University’s Center for Drug Use and HIV Research (CDUHR) are focusing on intervention strategies that highlight the lesser-known dangers of HCV transmission through the sharing of other injection equipment such as cookers, filters, drug-dilution water and water containers.

Their article, “The Staying Safe Intervention: Training People Who Inject Drugs in Strategies to Avoid Injection-Related HCV and HIV Infection,” published in the 2014 March-April issue ofAIDS Education and Prevention, explores the feasibility and efficacy of their “Staying Safe Intervention,” a strengths-based social/behavioral intervention conducted with small groups of PWID, designed to facilitate long-term prevention of HIV and HCV.

“The Staying Safe Intervention seeks to reduce injection risk by intervening upstream in the causal chain of risk behaviors by modeling, training in, and motivating the use of strategies and practices of long-term risk-avoidance,” said Dr. Pedro Mateu-Gelabert, the study’s Principal Investigator, at the NYC-based National Development Research Institutes.

Dr. Mateu-Gelabert and his NDRI-CDUHR team evaluated 68 street-recruited injectors from the Lower East Side of Manhattan. The objective was to reduce participants’ injection risk behaviors, empower and motivate behavioral change, and teach tactics to help reduce drug intake.  The current program was built upon findings of their 2005 study, “Staying Safe,” which looked at the behaviors and strategies of individuals who had injected drugs for long periods of time (8–15 years) but had not contracted HIV or HCV.

“The Staying Safe Intervention does not focus exclusively on the moment of injection,” explains Dr. Mateu-Gelabert, “but on the upstream determinants of risk behavior, such as stigma, risk networks, social support and income, while encouraging injectors to plan ahead in order to better manage the drug-related risk contexts they are likely to face.”

The social/behavioral intervention showed substantial improvement in motivation and planning to avoid injection-related risks, increased use of stigma management strategies, and decreases in drug withdrawal episodes (known to reduce safe injection practices) and number of weekly injections. The research team also noted that participants in the study have been spreading the word on safer drug use within their communities.

The Centers for Disease Control and Prevention estimate that not only do nine percent of new HIV infections originate from drug use, but 18 percent of PWID are HIV positive and up to 70-77 percent of PWIDs have HCV.

“Given the substantial reductions observed among Staying Safe participants in key injection-related risk behaviors associated with HCV transmission, the Staying Safe Intervention may have the potential to contribute to sufficient additional risk reduction to help address the seemingly intractable rates of HCV transmission among PWID,” said Dr. Mateu-Gelabert.

Currently, Dr. Mateu-Gelabert’s team is researching HCV and HIV risk associated with nonmedical prescription opioid use. Future research will evaluate the effectiveness of the Staying Safe Intervention in preventing HIV and hepatitis C infection among young prescription opioid users who have transitioned to heroin injection.  “The goal is to implement the Staying Safe approach with this new generation of young injectors, so they do not get infected with HIV or HCV,” said Dr. Guarino, a Co-investigator in the project.

The project described was supported by Award Numbers R21DA026328, R01DA019383, R01DA031597, and R01DA035146 from the National Institute on Drug Abuse. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health.

The research team members are: P. Mateu-Gelabert, M.V Gwadz, H. Guarino, M. Sandoval, C.M Cleland, A. Jordan, H. Hagan, H. Lune, S.R Friedman. Affiliations: National Development Research Institutes Inc. (PMG,HR,MS,SRF), New York, NY USA; College of Nursing (MVG,CMC,AJ,HH), New York University; Hunter College (SRF), City University of New York, NY USA.

About CDUHR

CDUHR, funded by the National Institute on Drug Abuse, is the first center for the socio-behavioral study of substance use and HIV in the United States. The Center is dedicated to increasing the understanding of the substance use-HIV/AIDS epidemic, particularly among individuals in high-risk contexts. The Center's theme is "Discovery to Implementation & Back: Research Translation for the HIV/Substance Use Epidemic." The Center facilitates the development of timely new research efforts, enhances implementation of funded projects and disseminates information to researchers, service providers and policy makers.

About New York University College of Nursing
NYU College of Nursing is a global leader in nursing education, research, and practice. It offers a Bachelor of Science in Nursing, a Master of Arts and Post-Master’s Certificate Programs, a Doctor of Philosophy in Research Theory and Development, and a Doctor of Nursing Practice degree.  For more information, visit www.nyu.edu/nursing.

This Press Release is in the following Topics:
College of Nursing, NYUToday-feature

Type: Press Release

Press Contact: Christopher James | (212) 998-6876

Source

Eradication of hepatitis C infection: The importance of targeting people who inject drugs

Hepatology

Volume 59, Issue 2, pages 366–369, February 2014

Editorial

You have full text access to this OnlineOpen article

Margaret Hellard^1,2,3,*, Joseph S. Doyle^1,2,3,4, Rachel Sacks-Davis^1,3, Alexander J. Thompson^5,6, Emma McBryde^1,4

Article first published online: 24 DEC 2013

DOI: 10.1002/hep.26623

Copyright © 2013 The Authors. HEPATOLOGYpublished by Wiley on behalf of the American Association for the Study of Liver Diseases.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Hepatitis C virus (HCV) affects ∼170 million people worldwide and causes significant morbidity and mortality.[1] In high-income countries, people who inject drugs (PWID) are at greatest risk of HCV infection.[2] Until recently HCV eradication seemed unlikely, but recent advances in HCV treatment and improved understanding of the effectiveness of harm-reduction intervention effectiveness give reason for optimism. Current HCV treatments can cure ∼75% of patients and new drugs will further improve effectiveness (over 90% cure) and improve tolerability.[3] If HCV treatment can be delivered effectively to those at highest risk of onward transmission, significant reductions in future HCV cases are possible. The feasibility of disease eradication must be assessed on both scientific criteria (e.g., epidemiological susceptibility, effective and practical intervention available, and demonstrated feasibility of elimination) and political criteria (e.g., burden of disease, cost of intervention).[4] With effective, curative treatment now available, HCV meets these criteria.

Importance of Targeting PWID

To achieve eradication, public health efforts must focus on PWID, the key drivers of HCV transmission. A sustained, multipronged approach could substantially reduce HCV infection in PWID over the next 10-20 years through a focus on HCV treatment as prevention, meaning improved access to more effective and well-tolerated HCV treatment. Other major elements include increasing coverage of opiate substitution therapy (OST), needle and syringe programs (NSPs), and regular HCV screening and counseling.

PWID are highly marginalized, so effective engagement and inclusion in strategy development are critical to HCV eradication. To date, health services have been unsuccessful in channeling PWID into HCV treatment, despite evidence of willingness to be treated[5] and treatment success.[6]

HCV Treatment as Prevention

For the past decade HCV treatment has mostly involved pegylated interferon and ribavirin (PEG/RBV); however, trials of direct-acting antivirals (DAAs) show increased rates of cure, improved tolerability, and reduced duration of treatment.[3, 7, 8] The first NS3 protease inhibitors, boceprevir and telaprevir, used in combination with PEG/RBV, have already improved outcomes, with up to 75% of patients chronically infected with HCV genotype-1 being cured.[3] Emerging therapies that include next-generation NS3 protease inhibitors, NS5A inhibitors, and NS5B polymerase inhibitors show great promise.[7, 8] An interferon-free 12-week DAA regimen with single daily dosing and over 90% cure is a real possibility.[3]

Highly effective and tolerable HCV therapies will make treatment as prevention feasible. This strategy will require targeting PWID, few of whom undergo HCV treatment despite increasing evidence of success.[6] The rarity of PWID undergoing treatment relates to concerns about interferon toxicity and RBV teratogenicity and unsubstantiated concerns about PWID compliance and high reinfection rates. Apart from managing adverse side effects, we know little about interventions that improve HCV treatment compliance.[9] However, increasing evidence shows that PWID are compliant when treated with PEG/RBV,[10] and compliance can only rise with improved treatment tolerability. Similarly, most evidence suggests HCV reinfection following treatment remains low.[11]

Models developed by Martin et al.[12] suggest that treating a relatively small proportion of PWID could significantly reduce HCV prevalence over 15 years, with the impact varying depending on the number treated, the background HCV prevalence, treatment efficacy, and the speed of treatment scale-up (Fig. 1). Estimated HCV prevalence halved when treatment was scaled up to 15, 40, or 76 per 1,000 PWID annually in Edinburgh (Scotland), Melbourne (Australia), and Vancouver (Canada), respectively, using DAAs. Current estimated HCV prevalence in PWID in those three jurisdictions is 25%, 50%, and 65%, respectively. Recent modeling of PWID in Vietnam also revealed treatment impact on HCV prevalence.[13]

Figure 1. Annual scaled-up treatment rate required to reduce prevalence by 1/4, 1/2, or 3/4 in Edinburgh, Melbourne, and Vancouver within 15 years (by 2027). Bars (and numbers) indicate the mean value, with whiskers representing the 95% credibility interval.

Harm Reduction to Reduce HCV Transmission

Prevention of HCV transmission is critically important for HCV eradication. Harm-reduction strategies for PWID, notably OST and NSPs, have been partially effective in reducing HCV transmission in PWID,[14] although poor coverage has limited their impact.[15] A recent study estimated that NSPs directly averted 97,000 (∼50%) new HCV infections in Australia during 2000-2009.[14] Modeling by Vickerman et al.[16] suggests that, in a setting where HCV prevalence is 40%, scaling OST/NSP coverage up from 0% to 20%, 40%, and 60% can reduce HCV prevalence over 10 years by 13%, 24%, and 33%, respectively. However, further increments in coverage produce only marginal improvements,[16] suggesting that complementary strategies are required to substantially reduce HCV prevalence.

Treatment Access and Cost

PWID are highly marginalized and few receive HCV treatment despite increasing evidence that treatment works.[6] Effective engagement with PWID is critical to HCV eradication. Integrated multidisciplinary approaches that include clinicians, nurses and other support services, located in community-based settings or OST clinics, can increase HCV assessment and treatment.[17] Infrastructure, workforce capacity and education programs focused on PWIDs' needs are needed for timely and effective strategy implementation; currently, many primary care clinicians and health service staff know little about HCV assessment and care.[18]

Current HCV treatment is expensive and the cost of scale-up with more expensive therapies will be considerable. Visconti et al.'s[19]modeling found that treating both current and former PWID for HCV using standard PEG/RBV was cost-effective. Martin et al.'s[20] model included the broader public health benefit of reducing HCV prevalence, and showed antiviral treatment for PWID saved £521 and £2,539 per quality-adjusted life year (QALY) when baseline HCV prevalence was 20% and 40%, respectively, compared with no treatment, well below generally accepted thresholds for cost-effective interventions. Despite the cost-effectiveness of treating PWID, the actual costs of HCV treatment, particularly DAAs, will challenge governments in both developed and resource-limited settings; nonetheless, the models suggest standard HCV therapy still has considerable benefits.

Injecting Networks

Most models assume homogeneous mixing of PWID with all other PWID in the population; few consider the impact of PWIDs' social and injecting networks on HCV transmission or clearance. A recent HCV PWID network model derived from empirical data indicated that injecting networks substantially impact transmission.[21] Further modeling suggested that treating PWIDs and their immediate contacts simultaneously (as opposed to ad hoc treatment) reduces the overall number of PWID needing treatment, reducing long-term HCV prevalence and treatment costs.

HCV Vaccination

Candidate vaccines designed to prevent initial infection, reduce viral persistence in acute infection, or lead to sustained virological response (SVR) in chronic infection are in phase 2 and 3 trials.[22] However, experience with the highly effective hepatitis B vaccine suggests uptake among PWID may be low.[23] Hence, an HCV vaccine will be just one component of an HCV eradication strategy.

In conclusion, eradicating HCV in PWID is ambitious but, based on the criteria for assessing disease eradicability,[4] achievable (Table 1). Treatment costs will be substantial and recruiting sufficient PWID to treatment programs challenging. However, scale-up of HCV diagnosis and treatment with new highly efficacious and tolerable drugs, plus effective and relatively inexpensive harm reduction and prevention approaches, will considerably reduce HCV prevalence. Eradicating HCV needs a sustained, focused and multipronged approach; the time to start is now.

Author Roles: M.H. wrote the first draft of the article. All authors reviewed and edited the primary and subsequent revised versions of the article.

Margaret Hellard1-3
Joseph S. Doyle1-4
Rachel Sacks-Davis1,3
Alexander J. Thompson4,5
Emma McBryde1,4

1Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
2Infectious Diseases Unit, The Alfred Hospital, Melbourne, Victoria, Australia
3Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
4Victorian Infectious Disease Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
5Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia

References

Source

What a Year for Harm Reduction!

Provided by The Huffington Post

Hilary McQuie
Western Regional Director, Harm Reduction Coalition

Posted: 12/22/2013 9:16 am

Harm reduction is a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. Harm reduction is also a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Although those working in harm reduction believe that drug criminalization maximizes harm, the focus of most harm reduction policy and practice is in the borderlands between legalization and prohibition. To quote an old social justice slogan, harm reduction is the art of "building a new society in the vacant lots of the old." And those lots are filling up, due to the hard work of people around the world. Here are 10 of the most important harm reduction developments in North America in 2013:

1. "Needle Exchange" in the US Turns 25

A quarter of a century ago, public health activists started doing needle exchange in Tacoma, WA, San Francisco, CA, and New York, NY. These efforts, now referred to as 'syringe access programs', spread and continued and have been widely recognized as the single most successful HIV prevention intervention. To date, however, they are legally excluded from receiving access to the federal funding enjoyed by all other HIV prevention efforts. Perhaps in 2014, we can report that the federal funding ban for syringe access programs was finally lifted for good.

2. States Decriminalize Syringes to Increase Safe Syringe Access

Syringe access policy varies by state, and this year, community organizing led the Nevada legislature to finally pave the way for syringe access programs and over the counter pharmacy sales by fully decriminalizing syringes, making it one of the strongest state enabling laws for syringe access programming. North Carolina partially decriminalized syringes to protect law enforcement from needlestick injury, but without legalizing their existing syringe access programs, yet.

3. Laws Passed in Six States to End Overdose Epidemic by Providing Antidote

Opioid overdose has surpassed auto accidents as the leading cause of accidental death in the US. New laws were passed this year in six states to encourage health care providers and community programs to widely distribute naloxone to treat opioid overdose incidents. Additionally, new programs started providing naloxone access in Colorado, Vermont, North Carolina, Kentucky, Ohio, New Jersey, Minnesota, and Missouri this year. Naloxone is used in opioid overdoses to counteract life-threatening depression of the central nervous system and respiratory system, allowing an overdosing person to breathe normally. Although traditionally administered by emergency response personnel, naloxone can be administered by minimally trained laypeople, which makes it ideal for treating overdose in people who have been prescribed opioid pain medication and in people who use heroin and other illicit opioids.

4. Opioid Overdose Antidote Provided by Rhode Island Walgreens Pharmacists Directly to Patients

2013 saw a statewide scale up of a collaborative pharmacy practice agreement for naloxone, bringing naloxone to all 26 Walgreens stores in Rhode Island and training 80 Walgreens pharmacists in how to counsel patients on, train in, and dispense naloxone (without a prescription) to anyone who asks for it.

5. Federal Agencies Declare Support for Peer-Delivered Naloxone Distribution

Under the Bush Administration, officials in the Office of National Drug Control Policy (ONDCP) opposed peer-delivered naloxone. Then Deputy Director Bertha Madras said drug users "aren't likely to be competent to deal with an overdose emergency", and stated that "rescue programs might take away the drug user's motivation to get into detoxification and drug treatment". Obama's White House Office of National Drug Control Policy takes a position 180 degrees from Madras, supports overdose prevention and naloxone programs, and included them in the 2013 Drug Control Strategy. Also this year, the drug treament agency of the federal government, the Substance Abuse and Mental Health Services Administration (SAMHSA) published their long-awaited "Opioid Overdose Prevention Toolkit" which has five components targeting first responders, community members, patients, prescribers, and overdose survivors and their family members. The toolkit provides information on naloxone distribution and prescription and overdose prevention. Peer-delivered naloxone distribution has definitely gone from an underground movement to a mainstream-supported strategy in 2013. Next year, perhaps we can report some funding for this critical yet unfunded lifesaver.

6. Jail-Based Overdose Prevention and Naloxone Distribution Begins

Opiate overdoses are all too common among people released from jail due to decreased tolerance. In March 2013, the Harm Reduction Coalition's Drug Overdose Prevention and Education (DOPE) Project began providing naloxone to inmates of the San Francisco County Jail as they were discharged. The DOPE Project, in collaboration with SFDPH's Jail Health Services, conducts overdose prevention trainings inside the jail, and is able to put naloxone kits in the property of inmates who choose to participate for pick up when they are released. This is the first non-research study in the country to begin providing naloxone directly to inmates as they re-enter the community.

7. Good Samaritan Laws for People Witnessing Overdoses Gain Traction, Law Enforcement Support

Community activists have been working to get Good Samaritan laws passed to protect people from arrest and prosecution for drug possession when they call 911 to report an overdose. Fourteen states have now enacted these laws, as have ninety college campuses. The Florida effort in 2012 was notably initiated by Palm Beach police, a harbinger of change in law enforcement support for harm reduction measures.

8. Newly-Approved Hepatitis C Treatments Move Closer to Making Interferon-Free Cure a Reality for People Who Inject Drugs.

Hepatitis C remains endemic among people who inject drugs, with chronic infection rates of 70% or more among long-term injectors. While new infections have declined dramatically since peaking in the 1980s, due in part to the expansion of syringe access programs, several states report a new wave of hepatitis C infections among younger injectors. While hepatitis C is curable, treatment has traditionally required use of interferon, a drug with significant psychological and physical side effects that does not work for everyone and is difficult to tolerate for many, particularly current and former substance users. In December, the US Food and Drug Administration (FDA) approved a new hepatitis C medication sofosbuvir (Sovaldi, Gilead Sciences, Inc), which can be used without interferon for some people. Other therapies in development offer hope that all people with hepatitis C will have interferon-free treatment options available by the end of 2014.

9. Community Organizes to Mandate Hepatitis C Testing in New York

An estimated 3-4 million people are infected with the hepatitis C virus, and three quarters of them are unaware of it. Baby boomers - those born between 1945 and 1965 - make up over 70% of people with chronic infection, and are at highest risk of liver complications. Following CDC's 2012 recommendation of a one-time hepatitis C test for all baby boomers, a coalition of harm reduction workers, people who use drugs, and other allies passed a bill in New York mandating that doctors inform their patients and offer a hepatitis C test. As better-tolerated treatments with high cure rates become available, this legislation ensures that thousands of lives that may have been lost to liver cancer and other hepatitis C complications are diagnosed and treated.

10. Montreal Approved to Open Four Supervised Injection Sites

There are approximately 90 supervised injection sites worldwide in Europe and Australia, and only one in North America: InSite in Vancouver, British Columbia. After InSite's long legal fight with their conservative government, Canada's Supreme Court ruled in 2009 that the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on InSite's premises, allowing the facility to stay open indefinitely. In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. This month, Montreal was given permission to open four injection sites of their own, ensuring that Vancouver's InSite is the first but not the last legal supervised injection site in North America. Perhaps we finally succeed in opening one in the US in 2014.

Hilary McQuie is Regional Director of the Harm Reduction Coalition, and is based in Oakland, CA http://harmreduction.org/

Source

VIH/VHC En Prison, L’urgence (HIV/HCV In Prisons, Emergency)

Original Translation

VIH/VHC EN PRISON, L’URGENCE

Depuis les années 90, les associations de lutte contre le sida  dénoncent la situation sanitaire catastrophique des prisons françaises. L'étude PREVACAR (estimation de la prévalence virale et de l'offre de soins en milieu carcéral) publiée par l’InVS (Institut national de Veille Sanitaire) vient, une nouvelle fois, confirmer les constats et les cris d'alarme des acteurs de terrains. Le TRT-5 monte au front dans un communiqué (6 novembre). Le voici.

"Dans les prisons françaises, la prévalence du VIH est de 2 % : c’est 10 fois celle de la population générale. La  prévalence du VHC de 4,8 % c’est 6 fois celle la population générale. L'étude demande un dépistage et une prise en charge de ces pathologies infectieuses pour en limiter la transmission et améliorer le pronostic des patients. L'an dernier, l'étude PRI2DE (accès aux mesures de prévention et réduction des risques infectieux en milieu pénitentiaire) confirmait l'existence de pratiques à risques liées à l'injection de drogues par voie intraveineuse.

Trente ans après le début de l'épidémie du VIH, nous sommes toujours dans l’attente de mesures urgentes de réduction des risques et de l’application de la loi du 18 janvier 1994 sur l'égalité de la prise en charge sanitaire entre le milieu libre et le milieu carcéral.

Les ministres de la Justice et de la Santé ont initié en début d’année des groupes de travail paritaires, l’un sur la suspension de peine, le second sur la prévention et la réduction des risques en milieu carcéral. Le groupe prévention et réduction des risques infectieux a récemment transmis ses recommandations aux ministères concernés, proposant de débuter une expérimentation de programmes d’échanges de seringues.

Notre collectif participe à ces études et travaux et considère qu'il n'existe aucune justification fondée pour continuer à priver les personnes détenues d'un égal accès aux soins et aux mesures de prévention. La mise en place de programmes d'échanges de seringues expérimentaux constituerait une formidable avancée. Des programmes d'échanges de seringues en milieu carcéral ont été expérimentés depuis plus de 20 ans dans de nombreux pays et ont montré l'efficacité d'une approche combinée de traitements de substitution aux opiacés, de programme d’échange de seringues et d’éducation par les pairs. Ces dispositifs n'ont pas entraîné de recrudescence de la toxicomanie, ni provoqué d’incidents de sécurité liés à la détention de seringues. Au vu de cette nouvelle enquête et des conclusions des derniers travaux d’experts, nous demandons un engagement ferme et immédiat du gouvernement pour la mise en place de programmes d'échanges de seringues expérimentaux en prison."

---

Translation

HIV / HCV IN PRISONS, EMERGENCY

Since the 90s, associations fighting against AIDS denounce catastrophic health situation of French prisons. The PREVACAR study (estimation of viral prevalence and health care provision in prisons) published by InVS (Institut National de Veille Sanitaire) has, once again, confirm the findings and alarm cries of actors land. The TRT-5 goes to the front in a statement (November 6). Here it is.

"In French prisons, HIV prevalence is 2%, it is 10 times that of the general population prevalence of HCV is 4.8% 6 times that in the general population The study requires.. detection and treatment of these infectious diseases to reduce transmission and improve the prognosis of patients. Last year, the PRI2DE (access to prevention and reduction of risk of infection in prison) study confirmed the existence of risk practices related to injection drug intravenously.

Thirty years after the beginning of the HIV epidemic, we are still waiting for urgent measures to reduce risks and the application of the law of 18 January 1994 on the equality of health care between free environment and prisons.

Ministers of Justice and of Health have initiated earlier this year of joint working groups, one on the suspended sentence, the second on the prevention and reduction of risks in prisons. The prevention and reduction of risk of infection group has recently submitted its recommendations to the ministries concerned, proposing to start an experiment of needle exchange programs.

Our group is involved in these studies and work and considers that there is no justification for continuing basis to deprive detainees of equal access to care and prevention. The establishment of experimental needle exchange programs would be a huge step forward. Of needle exchange programs in prisons have been tested for over 20 years in many countries and have shown the effectiveness of a combined approach to treatment of opiate substitution of needle exchange program and peer education. These devices have not resulted in increase of drug or caused by security incidents related to the detention of syringes. In light of this new investigation and the findings of recent work of experts, we require a firm and immediate government commitment to the development of experimental needle exchange programs in prison. "

Source

Get Tested: Hadiyah Charles from the Harm Reduction Coalition talks about the need for HepC testing

GET TESTED

Hadiyah Charles from the Harm Reduction Coalition talks about the need for HepC testing

Source

Prison needle exchange programs rare despite evidence

October 29, 2013

Although the UN and WHO advocate for needle and syringe exchanges for inmates, only 60 prisons of more than 10 000 worldwide have programs.

Photo Credit: © 2013 Thinkstock

Clean needle distribution in prisons is "poor and patchy" around the world, despite evidence that it reduces the spread of infectious diseases and does not increase drug use, an international expert told a panel discussion in Toronto, Ontario.

"There's a big gap between what is being recognized at the UN [United Nations] level and what is going on, on the ground," Heino Stöver, a professor at the University of Applied Sciences in Frankfurt, Germany, recently told an audience at the Dalla Lana School of Public Health.

Although the United Nations Office on Drugs and Crime and the World Health Organization (WHO) both advocate for needle and syringe exchanges for inmates, only 60 prisons out of more than 10 000 worldwide have launched programs since Switzerland set up the first one in 1994, said Stöver. Switzerland, Spain, Kyrgyzstan, Moldova, Romania, Portugal and Luxembourg all have needle exchange programs in at least one prison.

Germany ended six of its seven programs in the past decade. "They were politically controversial but not professionally controversial. We have very fine evidence that they were working," said Stöver, who has advocated for prison needle exchanges since he was "a young man … throwing syringes over the prison walls."

A WHO review of 55 European prison needle exchange programs found no reported increase in drug use and no negative unintended consequences. No needles were used as weapons, for example.

Among Canadian inmates, 30% of males and 34.9% of females have contracted Hepatitis C, compared to .95% of men and .61% of women in the general population. The figures for inmates are based on Correctional Service Canada's 2008 statistics, the most recent available, compared with 2007 figures for the general population. For HIV, the rates are 1.7% (males) and 4.7% (females), compared to 0.2% in the Canadian population.

Canada does not offer needle exchange programs in any prison. The absence of such programs is the subject of a current lawsuit that prisoner, HIV/AIDS and Aboriginal advocacy groups have launched. They hope a successful suit will force federal prisons to implement needle exchanges.

Correctional Service Canada "has a comprehensive anti-drug strategy ... providing needles for illicit drug use run counter to that strategy," spokesperson Melissa Hart writes in an email.

The lawsuit argues that prisoners are entitled to the same standards of essential health care as in the wider community, and that the 200 needle exchange programs available across Canada are part of this essential health package, says Lisa Kerr, a lawyer and academic who studies approaches to incarceration and justice.

In addition, lawyers have pointed to the Canadian Charter of Rights and Freedoms, arguing dirty needles in prisons makes life worse for indigenous people, for women, and for people with disabilities, Kerr told the panel in Toronto. Indigenous people, who make up 4% of the Canadian population, account for 23% of the prison population.

Current methods of reducing infections have shortcomings. Machines that dispense bleach and condoms, for example, are sometimes located near cameras and prisoners worry about increased surveillance if they use them. The dispensing machines are also frequently empty, said Seth Clarke, the community development coordinator for the Prisoners' HIV/AIDS Support Action Network.

Furthermore, bleach is not 100% effective in eliminating Hepatitis C, and the "best practice" method of cleaning, rinsing and cleaning again is not pragmatic for the "quite hastily" way prisoners  use needles, Clarke said. After all, drug use and tattooing are both illegal in prisons.

In addition to providing needle exchange programs, prison authorities should help rather than punish addicts, argued Clarke. For example, when a prisoner recently turned in his needle because he wanted to stop using, he was slapped with an institutional charge. "This kind of thing happens all the time," he said.

In a taped interview aired during the presentation, one former prisoner said that inmates construct needles out of "markers, light bulb filaments [and] the inside of a pen tube," and often share them. Injectable drugs are popular, he said, because "it's the biggest bang for your buck."

As to how the drugs are getting into prisoners, Clarke answered indirectly, noting that family members and friends often face drug dogs and careful searches but "they're not doing that for staff a lot of the time."

DOI:10.1503/cmaj.109-4644

— Wendy Glauser, Toronto, Ont

Source

Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness

International Journal of Drug Policy

Article in Press

Georgina J. MacArthur, Eva van Velzen, Norah Palmateer, Jo Kimber, Anastasia Pharris, Vivian Hope, Avril Taylor, Kirsty Roy, Esther Aspinall,  David Goldberg, Tim Rhodes, Dagmar Hedrich, Mika Salminen, Matthew Hickman, Sharon J. Hutchinson

Received 27 June 2012; received in revised form 25 June 2013; accepted 3 July 2013. published online 23 August 2013.
Corrected Proof

Abstract

Background

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Methods

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000–2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into ‘core’ or ‘supplementary’ using critical appraisal criteria, and the strength of review-level evidence was assessed.

Results

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.

Conclusion

Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Keywords: Hepatitis C, HIV, Harm reduction, People who inject drugs, Review

PII: S0955-3959(13)00116-3

doi:10.1016/j.drugpo.2013.07.001

© 2013 Elsevier B.V. All rights reserved.

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Multiple Tactics Needed to Combat Hepatitis C in Young Drug Users

Provided by Pharmacy Times

Aimee Simone, Assistant Editor

Published Online: Wednesday, August 7, 2013

With hepatitis C infections on the rise among young injection drug users, researchers have recommended a range of promising prevention tactics.

The number of young adults infected with the hepatitis C virus (HCV) is on the rise, and researchers estimate that more than 31,000 young injection drug users could become infected each year in the United States. To help reduce the rate of HCV infection in young drug users, the authors of a new review suggest 6 strategies to prevent the spread of the virus.

The recommendations, published in an August 15, 2013, supplement to Clinical Infectious Diseases, are based primarily on evidence from the large, ongoing “U Find Out” (UFO) study. The study, which began in 2000, enrolls HCV-negative injection drug users younger than 30 in San Francisco, California, and keeps track of the rate of new infections. This data, coupled with results of additional studies, has helped researchers identify a range of promising HCV prevention tactics.

The first suggestion focuses on the reduction of shared drug equipment. A meta-analysis of 21 studies found that the risk of contracting HCV from shared use of drug preparation containers, filters, and rinse water was similar to the risk of infection associated with sharing syringes. If drug preparation equipment sharing were eliminated, the results indicated, a large portion of HCV infections could be prevented. The authors of the current review note that education, training, and increasing the availability of single-use supplies are necessary to prevent new HCV infections.

Although little research has been done to evaluate the efficacy of safety education in injectors, the review authors next suggest that testing and counseling populations at risk for HCV may reduce risky behavior as well as the spread of the virus. In the UFO study, researchers found that drug injectors reduced their alcohol intake and used less non-injection drugs within 6 months of receiving HCV-positive test results, indicating that testing may reduce risky behaviors. The authors are optimistic that the availability of rapid HCV point-of-care tests, recently approved by the FDA, may increase rates of HCV testing, diagnosing, and treatment.

The third tactic recommended by the authors is to develop intervention strategies at a relationship level, as drug use is often a social activity. The UFO study indicates that injectors in sexual relationships with other injectors are more likely to share needles with their partners and, therefore, are at heightened risk of HCV infection. Given the results of a recent study that showed that couple-based testing and counseling effectively reduced risky behaviors in injectors, the authors note that researchers should assess the impact of these interventions on HCV outcomes.

The reviewers next recommend an increase in injection cessation interventions. Evidence from the UFO study suggests that even temporary injection cessation helps prevent HCV infections. The authors note that encouraging injectors to quit, even after multiple failed attempts, may prevent the spread of HCV infections and increase the number of users who quit permanently.

The fifth strategy, based on mathematical models, is to increase needle distribution, expand HCV treatment, and continue to research and develop vaccines against HCV. Researchers modeled the effects of syringe availability on HIV and HCV prevalence among drug injectors in Australia and estimated that increasing the number of needles distributed each year in the United States from 30 million to 60 million could potentially cut the number of new HCV infections in half.

Finally, the authors suggest the adoption of programs combining multiple prevention strategies. The results of a study conducted in the United Kingdom suggested that high coverage of opioid substitution treatment combined with syringe distribution programs could reduce the risk of new HCV infections by up to 80%. Combined prevention methods were also shown to be significantly more effective in reducing HCV rates than a single method in 2 separate studies.

Although the authors have identified strategies they believe will help reduce the spread of HCV, they note that political backing and additional resources will be needed to implement these tactics and to overcome the many obstacles to reducing the infection rate in young injectors.

Source

Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs: Moving the Agenda Forward

Provided by NATAP

All PDFs attached

Clinical Infectious Diseases
Volume 57 suppl 2 August 15, 2013

- Moving the Agenda Forward: The Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs
Jason Grebely, Philip Bruggmann, Markus Backmund, and Gregory J. Dore
Moving the Agenda Forward: The Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs

- Injection Drug Use and Hepatitis C Virus Infection in Young Adult Injectors: Using Evidence to Inform Comprehensive Prevention
Kimberly Page, Meghan D. Morris, Judith A. Hahn, Lisa Maher, and Maria Prins
Injection Drug Use and Hepatitis C Virus Infection in Young Adult Injectors: Using Evidence to Inform Comprehensive Prevention

- Combination Interventions to Prevent HCV Transmission Among People Who Inject Drugs: Modeling the Impact of Antiviral Treatment, Needle and Syringe Programs, and Opiate Substitution Therapy
Natasha K. Martin, Matthew Hickman, Sharon J. Hutchinson, David J. Goldberg, and Peter Vickerman
Combination Interventions to Prevent HCV Transmission Among People Who Inject Drugs: Modeling the Impact of Antiviral Treatment, Needle and Syringe Programs, and Opiate Substitution Therapy

- Hepatitis C Virus Vaccines Among People Who Inject Drugs
Andrea L. Cox and David L. Thomas
Hepatitis C Virus Vaccines Among People Who Inject Drugs

- Understanding Barriers to Hepatitis C Virus Care and Stigmatization From a Social Perspective
Carla Treloar, Jake Rance, and Markus Backmund
Understanding Barriers to Hepatitis C Virus Care and Stigmatization From a Social Perspective

- Models of Care for the Management of Hepatitis C Virus Among People Who Inject Drugs: One Size Does Not Fit All
Philip Bruggmann and Alain H. Litwin
Models of Care for the Management of Hepatitis C Virus Among People Who Inject Drugs: One Size Does Not Fit All

- Assessment and Treatment of Hepatitis C Virus Infection Among People Who Inject Drugs in the Opioid Substitution Setting: ETHOS Study
Maryam Alavi, Jason Grebely, Michelle Micallef,, Adrian J. Dunlop,, Annie C. Balcomb, Carolyn A. Day, Carla Treloar, Nicky Bath, Paul S. Haber, Gregory J. Dore, and on behalf of the Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) Study Group
Assessment and Treatment of Hepatitis C Virus Infection Among People Who Inject Drugs in the Opioid Substitution Setting: ETHOS Study

- Enhancing Assessment and Treatment of Hepatitis C in the Custodial Setting Jeffrey J. Post, Amber Arain, and Andrew R. Lloyd
Enhancing Assessment and Treatment of Hepatitis C in the Custodial Setting

- Peer Support Models for People With a History of Injecting Drug Use Undertaking Assessment and Treatment for Hepatitis C Virus Infection
Sione Crawford and Nicky Bath
Peer Support Models for People With a History of Injecting Drug Use Undertaking Assessment and Treatment for Hepatitis C Virus Infection

- Treatment of Hepatitis C Virus Infection Among People Who Are Actively Injecting Drugs: A Systematic Review and Meta-analysis
Esther J. Aspinall, Stephen Corson, Joseph S. Doyle, Jason Grebely, Sharon J. Hutchinson, Gregory J. Dore, David J. Goldberg, and Margaret E. Hellard
Treatment of Hepatitis C Virus Infection Among People Who Are Actively Injecting Drugs: A Systematic Review and Meta-analysis

- Directly Observed Pegylated Interferon Plus Self-Administered Ribavirin for the Treatment of Hepatitis C Virus Infection in People Actively Using Drugs: A Randomized Controlled Trial
Robert J. Hilsden, Gisela Macphail, Jason Grebely, Brian Conway, and Samuel S. Lee
Directly Observed Pegylated Interferon Plus Self- Administered Ribavirin for the Treatment of Hepatitis C Virus Infection in People Actively Using Drugs: A Randomized Controlled Trial

- Psychoeducation Improves Hepatitis C Virus Treatment During Opioid Substitution Therapy: A Controlled, Prospective Multicenter Trial
Jens Reimer, Christiane Sybille Schmidt, Bernd Schulte, Dirk Gansefort, Jorg Golz, Guido Gerken, Norbert Scherbaum, Uwe Verthein, and Markus Backmund
Psychoeducation Improves Hepatitis C Virus Treatment During Opioid Substitution Therapy: A Controlled, Prospective Multicenter Trial

- Hepatitis C Virus Reinfection Following Treatment Among People Who Use Drugs
Bart P. Grady, Janke Schinkel, Xiomara V. Thomas, and Olav Dalgard
Hepatitis C Virus Reinfection Following Treatment Among People Who Use Drugs

- Management of Mental Health Problems Prior to and During Treatment of Hepatitis C Virus Infection in Patients With Drug Addiction
Martin Schaefer, Rahul Sarkar, and Crisanto Diez-Quevedo
Management of Mental Health Problems Prior to and During Treatment of Hepatitis C Virus Infection in Patients With Drug Addiction

- Drug-Drug Interactions in the Treatment of HCV Among People Who Inject Drugs Stefan Mauss and Hartwig Klinker
Drug-Drug Interactions in the Treatment of HCVAmong People Who Inject Drugs

- Recommendations for the Management of Hepatitis C Virus Infection Among People Who Inject Drugs
Recommendations for the Management of Hepatitis C Virus Infection Among People Who Inject Drugs

Geert Robaeys, Jason Grebely, Stefan Mauss, Philip Bruggmann, Joseph Moussalli, Andrea De Gottardi, Tracy Swan, Amber Arain, Achim Kautz, Heino Stover, Heiner Wedemeyer, Martin Schaefer, Lynn Taylor, Markus Backmund, Olav Dalgard, Maria Prins, Gregory J. Dore, and on behalf of the International Network on Hepatitis in Substance Users

Source

Hepatitis C: 6 Prevention Strategies That Work

Medscape Medical News

Ricki Lewis, PhD

Jul 26, 2013

Hepatitis C virus (HCV) infection is on the rise, particularly among young white adults living in rural and suburban areas who abuse intravenous opiate drugs. A review article published in a special supplement to Clinical Infectious Diseases, coinciding with World Hepatitis Week, discusses 6 ways to combat the spread of HCV in this group.

HCV incidence is increasing among those aged 15 to 30 years who inject drugs, according to the US Department of Health and Human Services. HCV is 10 times as infectious as HIV and surpassed HIV in number of deaths in the United States in 2007. Nearly 4 million people in the United States have chronic HCV infection.

For 16 years, Kimberly Page, PhD, MPH, from the University of California, San Francisco, and colleagues have conducted the "U Find Out," or UFO, Study with injection-drug users. The program is modeled on clean syringe programs, but with greater emphasis on social issues that fuel drug abuse and on integrating multiple approaches to combat HCV infection. Data from the ongoing prospective study show that the interventions used can reduce the risk of seroconversion.

In addition, the investigators note that more than 31,000 young adults who inject drugs of abuse will become infected with HCV in the United States each year. "Although there is evidence that HCV incidence has declined in recent decades, if the number of young injectors increases, as the [Centers for Disease Control and Prevention] suggests is occurring in the United States, these gains could be lost. Ongoing and targeted surveillance efforts to enumerate the population at risk and assess the burden of infection are essential steps in targeting and implementing effective HCV prevention in this group," the authors write.

Therefore, they recommend 6 comprehensive measures to prevent the spread of hepatitis C:

1. Reducing risk from shared ancillary drug preparation equipment, such as containers, rinse water, and filters. The researchers estimate that paying attention to the ancillaries as well as shared syringes could prevent at least 25% of seroconversions. The availability of single-use supplies could lower risk.

2. Using a new rapid test at point of care that offers results in 20 minutes can detect infection before seroconversion and, combined with counseling, can help to stem transmission.

3. Addressing social and relational contexts of injecting can encourage uninfected individuals to take precautions when injecting drugs with infected sex partners.

4. Encouraging "taking a break" from injecting drugs because HCV cannot be transmitted without this behavior. In past studies, the investigators discovered that the more often drug abusers attempted to quit, the more likely they were to eventually succeed.

5. Developing models to guide delivery of new prevention strategies, including already-available approaches such as increasing syringe availability and future strategies such as direct-acting antivirals that can be used prophylactically, as well as vaccines.

6. Combining interventions in synergistic ways, such as needle exchange and methadone maintenance programs.

"With ongoing and expanding transmission of HCV, there is little doubt that there is a need to implement what is in the prevention 'toolbox,' as well as add to it," they write. "Expanding HCV prevention and reaching the new generation of young injectors will require dedicated advocacy, pragmatism, and persistence to enable access to all of these technologies."

The work was supported by the National Institute on Drug Abuse. The Kirby Institute is funded by the Australian Government Department of Health and Ageing. One coauthor is also supported by a National Health and Medical Research Council Senior Research Fellowship. The other authors have disclosed no relevant financial relationships.

Clin Infect Dis. 2013;57:S32-S38. Abstract

Source

Also See:

1. Miriam researcher helps develop global hepatitis C recommendations for injection-drug users
2. Six Recommended Measures to Prevent Hepatitis C for Young Injection-Drug Users
3. Moving the Agenda Forward: The Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs

Miriam researcher helps develop global hepatitis C recommendations for injection-drug users

Public release date: 25-Jul-2013
Contact: Jessica Collins Grimes
jgrimes2@lifespan.org
Lifespan

July 28 is World Hepatitis Day

(PROVIDENCE, R.I.) – A Miriam Hospital researcher has joined forces with international colleagues to call for new strategies to better manage and improve assessment and treatment for hepatitis C (HCV) infection in individuals who inject drugs.

Lynn E. Taylor, M.D., an HIV specialist focusing on HIV and viral hepatitis coinfection at The Miriam Hospital, was the only American physician invited to join the expert international panel that issued these first-of-its-kind recommendations. They were published online yesterday by the journal Clinical Infectious Diseases, just ahead of World Hepatitis Day on July 28.

The recommendations are part of a supplement entitled "Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs: Moving the Agenda Forward," developed in collaboration with the International Network on Hepatitis Care in Substance Users.

"In well-resourced parts of the world, most hepatitis C exists among people who currently inject drugs and those who have injected drugs in the past. However, treatment access and uptake among this population remains low – even though we increasingly have effective treatments for hepatitis C, which is a curable disease," said Taylor.

"Research supporting our recommendations – the first international set ever released for treating hepatitis C in people who inject drugs – demonstrates that treatment can be successful when barriers to care are addressed within a supportive environment," she added. "In fact, the burden of liver disease worldwide could be dramatically reduced by increasing treatment for hepatitis C infection among people who inject drugs, by preventing forward transmission."

An estimated five million people in the U.S. have chronic HCV infection, a liver disease that may result in long-term health problems, including liver scarring, liver failure and liver cancer. According to the Centers for Disease Control and Prevention, approximately 12,000 people die every year from HCV-related liver disease.

Until recently, HCV treatment guidelines excluded people who inject drugs, due to concerns about poor adherence, adverse events and re-infection. However, successful HCV treatment studies among this population have challenged this paradigm. The new international guidelines present evidence-based recommendations for treating HCV among individuals who inject drugs with appropriate evaluation and support.

Taylor is also lead author on a separate paper, appearing in the same supplement of Clinical Infectious Diseases, which focuses on the need for improved HCV care of another subset of the HCV-infected population: those who inject drugs and are also infected with HIV.

Chronic HCV infection has become a leading cause of non-AIDS related illness and death among individuals infected with HIV. Due to overlapping routes of transmission, dual infection is common: in the United States, 30 percent of HIV-infected people have chronic HCV, which is spread via contaminated blood, often through injection drug use. However, newer research suggests it may also be transmitted sexually among HIV-infected men who have sex with other men.

"HIV-infected individuals contending with injection drug use are the most likely to be affected by HCV, but the least likely to have access to treatment for HCV," said Taylor. "They should have equal and universal access to HIV/AIDS, HCV and addiction prevention, care and treatment."

She says essential but basic steps include improving prevention and screening for both infections and engaging co-infected individuals who inject drugs in HIV and HCV care early after diagnoses.

"The benefits of therapeutic advances in HCV will be limited for this group until barriers such as cost and access are overcome," she added. "Even with HCV cure rates approaching 100 percent with newer medications, effectiveness at population level will require expanding HCV therapy on large scale. These recommendations are an important step towards the goal of elimination of hepatitis C."

Taylor is also director of the HIV/Viral Hepatitis Program at The Miriam Hospital and an assistant professor of medicine at The Warren Alpert Medical School of Brown University.

###

About The Miriam Hospital

The Miriam Hospital is a 247-bed, not-for-profit teaching hospital affiliated with The Warren Alpert Medical School of Brown University. It offers expertise in cardiology, oncology, orthopedics, men's health, and minimally invasive surgery and is home to the state's first Joint Commission-certified Stroke Center and robotic surgery program. The hospital, which received more than $23 million in external research funding last year, is nationally known for its HIV/AIDS and behavioral and preventive medicine research, including weight control, physical activity and smoking cessation. The Miriam Hospital has been awarded Magnet Recognition for Excellence in Nursing Services four times and is a founding member of the Lifespan health system. Follow us on Facebook and on Twitter (@MiriamHospital).

Source

Also See:

1. Six Recommended Measures to Prevent Hepatitis C for Young Injection-Drug Users
2. Moving the Agenda Forward: The Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs

Moving the Agenda Forward: The Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs

Clin Infect Dis. (2013) 57 (suppl 2): S29-S31. doi: 10.1093/cid/cit264

This article appears in:Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs: Moving the Agenda Forward

Jason Grebely1, Philip Bruggmann2, Markus Backmund3,4, and Gregory J. Dore1

+ Author Affiliations

The majority of hepatitis C virus (HCV) occurs among people who inject drugs (PWID) [1], and the burden of HCV-related liver disease is still increasing [2]. HCV treatment is safe and effective among PWID [3], and international guidelines encourage HCV treatment in this group [4, 5], but HCV treatment uptake remains low among PWID [6, 7], mainly due to patient-, practitioner- and systems-related barriers to care. However, strategies have emerged to improve the prevention and management of HCV infection among PWID.

To foster the dissemination of knowledge in the field of viral hepatitis among PWID, the International Network on Hepatitis in Substance Users (INHSU) was established. INHSU established the International Symposium on Hepatitis in Substance Users (held every 2 years), focused on the management of viral hepatitis among PWID, specifically HCV infection. The first symposium was held in Zurich, Switzerland, in 2009 and the second was held in Brussels, Belgium, in 2011. The symposium is attended by researchers, practitioners, and community members and includes sessions on the epidemiology and natural history of viral hepatitis, clinical applications of basic science research, management of medical comorbidities and social science– and community-based perspectives. At the meeting in 2011, a panel of international experts was assembled in collaboration with the European Liver Patients Association to develop the first international recommendations for the management of HCV among PWID. This supplement presents original research from the most recent meeting, highlights recent advances in the field, and presents recommendations for the clinical management of HCV infection among PWID.

HCV PREVENTION AMONG PWID

It is estimated that 10 million PWID were HCV antibody positive in 2010, with a global HCV prevalence of 67% among PWID [8]. HCV incidence also remains high among PWID [9].

In the first article of this supplement, Page et al review and highlight the challenges of behavioral interventions for HCV prevention [9]. The authors demonstrate that harm-reduction programs successful in preventing human immunodeficiency virus (HIV) infection among PWID have been less effective for preventing HCV infection and that combined strategies are likely required [9]. Martin et al use mathematical modeling to project the impact of combining opiate substitution treatment (OST), high-coverage needle and syringe programs (NSPs), and HCV treatment on HCV prevalence and incidence among PWID [10]. Data from their study suggest that large reductions (>45%) in HCV chronic prevalence over 10 years requires HCV antiviral treatment, with the scale-up of combined interventions, including OST and NSPs, substantially reducing the treatment rate required to achieve specific HCV prevalence reductions. An alternative way of preventing HCV infection would be through the availability of an HCV vaccine. Cox and Thomas highlight the need for an HCV vaccine for PWID, demonstrate that protective immunity against persistent HCV infection is possible, and summarize recent advancements in HCV vaccine research, including recent phase 1/2 trials of an HCV candidate vaccine among PWID [11].

ENHANCING HCV ASSESSMENT AMONG PWID

Although HCV treatment is successful among PWID [3], assessment and uptake remain low [6, 7]. Understanding the barriers and facilitators of HCV care is critical in the design of strategies and programs for effectively increasing the proportion of PWID assessed and treated for HCV.

In this supplement, Treloar et al discuss barriers to HCV care and stigmatization, considering components required for the design programs to effectively engage PWID in HCV care [12]. Bruggmann et al review the spectrum of HCV care models among PWID, highlighting that “one size does not fit all” and that when barriers are systematically addressed within a supportive environment, HCV assessment and treatment among PWID can be very successful [13]. This is consistent with data from Alavi et al from the Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) Study, demonstrating that when HCV nursing and specialist support are integrated into existing OST or community health clinics, a high proportion of PWID with chronic HCV assessed by a nurse can be engaged in HCV care [14]. Another setting with opportunity for expanding HCV assessment and treatment is prisons. Post et al review the considerable burden of HCV in prisons, highlight potential challenges, and illustrate programs that have successfully integrated HCV screening, assessment, and treatment for prisoners with HCV [15]. One important consideration as we move forward with the development of new models of care is the involvement of the affected community. In this supplement, Crawford et al review different peer support models [16] and highlight the importance of involving community-based groups early into the design and implementation of these programs to achieve the greatest opportunity for engagement by PWID.

ENHANCING HCV TREATMENT AMONG PWID

It has been clearly demonstrated that PWID can be successfully treated [3]. However, the populations studied are often heterogeneous (combination of current and former PWID) and there are few data on HCV treatment outcomes among active PWID. Further, few prospective trials have evaluated strategies to enhance adherence and response to treatment among PWID.

In a systematic review and meta-analysis of treatment for HCV infection among active PWID, Aspinall et al demonstrate an overall sustained virologic response (SVR) of 56% [17]. This is the first systematic review of HCV treatment among those with ongoing drug use at the time of treatment and illustrates that active PWID can respond favorably to therapy. In the first randomized controlled trial performed to date among active drug users, Hilsden et al randomized participants to immediate vs delayed HCV treatment [18]. They demonstrate that directly observed pegylated interferon and self-administrated ribavirin can lead to a high proportion of patients with SVR among active drug users, but suggest that delaying treatment may compromise subsequent engagement in HCV treatment [18]. Last, in the largest trial reported to date among people with chronic HCV infection receiving OST, Reimer et al demonstrate that an intervention based on psychoeducation may enhance adherence to HCV treatment and reduce dropouts, particularly among people with longer treatment durations (those with genotypes 1/4) or those with mental health comorbidities [19].

MANAGING HCV TREATMENT AMONG PWID

Until recently, HCV treatment guidelines (and many practitioners) excluded PWID from consideration, citing concerns about adherence, increased susceptibility to side effects and reinfection. Issues of HIV infection and management of multiple drug interactions (both prescribed and nonprescribed drug use) complicate HCV management in this population. However, until recently there have been no recommendations for the management of HCV among PWID.

Grady et al demonstrate that the rate of reinfection reported to date has been low (1%–5% per year), which does not support decisions to withhold HCV treatment in this group based on concerns of reinfection [20]. Schaefer et al focus on another common barrier to HCV treatment assessment, namely, mental health issues [21]. They review the available evidence in this area, providing practical information for practitioners interested in managing HCV among PWID. Taylor et al summarize the data to date on management of HCV/HIV coinfection, including recent data investigating new direct-acting antivirals and studies of PWID with HCV/HIV coinfection [22]. Mauss et al focus on the problem of drug–drug interactions, which are an issue among PWID, given the potential for HCV direct-acting antivirals to interact with drugs used to treat HIV coinfection, OST (eg, methadone and buprenorphine), and nonprescription drugs [23].

The supplement is concluded with recommendations for the management of HCV infection among PWID [24]. This is meant to supplement existing international guidelines for HCV treatment, focusing on specific issues encountered among PWID. These guidelines should serve as an evidence-based tool for practitioners managing HCV among PWID.

FUTURE PERSPECTIVES

High rates of HCV infection still occur among PWID. Research is needed to evaluate the efficacy of combined HCV prevention approaches (such as HCV treatment as prevention, OST, NSPs, and vaccines). In addition to primary prevention, efforts must be expanded to prevent advanced liver disease due to chronic HCV. HCV treatment can reduce morbidity and mortality, but HCV assessment and treatment remains low among PWID. The availability of simple, well-tolerated, and highly effective interferon-free direct-acting antivirals will facilitate engagement among PWID, but research on strategies to enhance HCV screening and assessment is still needed. The evaluation of strategies to enhance adherence and therapy outcomes (eg, directly observed therapy, medication reminders, adherence education, peer support) should also be a research priority.

Research in this area needs to move beyond small, single-center, retrospective studies demonstrating that HCV treatment among PWID is feasible. Larger, prospective clinical trials run through international clinical networks are required to more rapidly evaluate potential treatment strategies. One such trial, ACTIVATE (A Collaborative Trial in Injectors of Individualized Treatment for Genotype 2/3), is a phase 4, open-label, multicenter, international trial of response-guided treatment with directly observed pegylated interferon alfa 2b and self-administered ribavirin for patients with chronic HCV genotype 2 or 3 infection and ongoing injection drug use. It is the first attempt to establish a clinical network and may be a step in the right direction. Further evidence-based research focused on strategies for enhanced HCV prevention, screening, assessment, and treatment among PWID will be required to reduce the HCV-related burden that still exists globally.

Notes

Financial support. INHSU receives support from Merck, Janssen, Abbvie, Gilead, Roche, and Orasure. J. G. is supported through a National Health and Medical Research Council Career Development Fellowship. G. D. is supported through a National Health and Medical Research Council Practitioner Fellowship.

Supplement sponsorship. This article was published as part of a supplement entitled “Prevention and Management of Hepatitis C Virus Among People Who Inject Drugs: Moving the Agenda Forward,” sponsored by an unrestricted grant from the International Network on Hepatitis in Substance Users (INHSU), The Kirby Institute (University of New South Wales), Abbvie, Gilead Sciences, Janssen-Cilag, and Merck.

Potential conflicts of interest. All authors: No reported conflicts.

All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

© The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:

journals.permissions@oup.com.

References

Source

Combining treatments for people who inject drugs is the first step towards eliminating hepatitis C

Public release date: 24-Jul-2013
Contact: Caroline Clancy
caroline.clancy@bristol.ac.uk
44-011-792-88086
University of Bristol

The burden of liver disease could be dramatically reduced by scaling up the combination of interventions for hepatitis C infection among people who inject drugs according to University of Bristol researchers. The findings, published today [24 July], form part of new global recommendations on treating the virus.

Around 150 million people globally are chronically infected with the hepatitis C virus (HCV)1 – a major cause of liver disease that can lead to serious complications such as liver failure or cancer, which are associated with considerable costs to the health care system. In developed countries the majority of transmissions and cases are among people who inject drugs2 – in the UK, this equates to around 90 per cent of hepatitis C infections.3

The study, published today in the journal Clinical Infectious Diseases by Dr Natasha Martin and colleagues at University of Bristol, the London School of Hygiene and Tropical Medicine and Health Protection Scotland, suggests that combining HCV antiviral treatment with opiate substitution therapy (OST) such as methadone and buprenorphine, and high-coverage needle and syringe programmes (HCNSP) is critical for achieving substantial reductions by up to 50 per cent over ten years.

Matthew Hickman, Professor in Public Health and Epidemiology at Bristol's School of Social and Community Medicine and co-author of the research, said: "High-coverage needle and syringe programmes (NSP) and opiate substitution therapy (OST) are the key primary interventions to treat hepatitis C among people who inject drugs; but HCV treatment is required if we want to achieve greater than 45 per cent reduction in HCV prevalence over a ten year period.

"Our model projections show that scaling up OST and high coverage NSP can reduce the number of HCV treatments required to achieve reductions in HCV – and emphasises the importance of a combination of interventions. Further research is needed to examine the cost effectiveness and affordability of scaling up HCV treatment."

The research supports the first set of global recommendations, published by the International Network on Hepatitis Care in Substance Users (INHSU), ever released for treating hepatitis C in people who inject drugs which has shown that treatment can be very successful when barriers are addressed within a supportive environment.

Philip Bruggmann, President of the INHSU, who have published the recommendations on treating the disease in substance users, said: "Reducing the significant burden of liver disease related to hepatitis C internationally will require improved HCV care in the population most affected: those people who currently inject or formerly injected drugs. By providing appropriate care to this group, we can reduce the burden of hepatitis C-related liver disease in this vulnerable population and slow the spread of this global epidemic. These new recommendations serve as a first step in eliminating hepatitis C."

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Paper

The study 'Combination Interventions to Prevent HCV Transmission Among People Who Inject Drugs: Modeling the Impact of Antiviral Treatment,Needle and Syringe Programs, and Opiate Substitution Therapy' is published today [24 July] in the journal Clinical Infectious Diseases.

Global recommendations

The global recommendations are published online today [24 July] in the journal Clinical Infectious Diseases in a supplement entitled 'Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs: Moving the Agenda Forward'.

Further information:

1. World Health Organisation: http://www.who.int/mediacentre/factsheets/fs164/en/

2. Global epidemiology of hepatitis C virus infection. Lancet Infect Dis 2005; 5:558-67

3. An evidence synthesis approach to estimating hepatitis C prevalence in England and Wales. Stat Methods Med Res 2009; 18:361-79.

4. About hepatitis C

Hepatitis C is a blood-borne virus that predominantly infects the cells of the liver. This can result in inflammation and significant damage to the liver. It can also affect the liver's ability to perform its essential functions. Although it has always been regarded as a liver disease - 'hepatitis' means 'inflammation of the liver' - recent research has shown that the hepatitis C virus (HCV) affects a number of other areas of the body. These can include the digestive system, the lymphatic system, the immune system and the brain.

Source: The Hepatitis Trust - http://www.hepctrust.org.uk/Hepatitis_C_Info/About+Hepatitis+C/About+Hepatitis+C

Source