Hepatitis C elimination – Macro‐elimination

In 2016 the WHO set a goal to obtain an 80% reduction in new chronic HCV cases, requiring a level of diagnosis of 90%, treatment coverage of 80% and resulting in a 65% reduction in HCV‐related deaths by 2030. This goal is easier to reach in specific populations such as people who inject drugs (PWID), men who have sex with men (MSM) or blood‐transfusion recipients before screening for HCV became mandatory and in high‐income regions. It is much more difficult to achieve macro‐elimination throughout the population especially in low‐income areas with underdeveloped infrastructures, a high prevalence of HCV and limited economic resources. To achieve the WHO goals by 2030, awareness of HCV must increase and the cascade of care must be improved and implemented. Diagnostic procedures and treatment should be affordable and universally available. At the end of 2017 fewer than 15 countries were on track to reach these goals by 2030.     

Understanding and addressing hepatitis C reinfection in the oral direct‐acting antiviral era

The availability of effective, simple, well‐tolerated oral direct‐acting antiviral (DAA) hepatitis C regimens has raised optimism for hepatitis C virus (HCV) elimination at the population level. HCV reinfection in key populations such as people who inject drugs (PWID) and HIV‐infected men who have sex with men (MSM) however threatens the achievement of this goal from a patient, provider and population perspective. The goal of this review was to synthesize our current understanding of estimated rates and factors associated with HCV reinfection. This review also proposes interventions to aid understanding of and reduce hepatitis C reinfection among PWID and HIV‐infected MSM in the oral direct‐acting antiviral era.     

Mortality and morbidity related to hepatitis C virus infection in hospitalized adults—A propensity score matched analysis

The World Health Organization (WHO) aims to reduce HCV mortality, but estimates are difficult to obtain. We aimed to identify electronic health records of individuals with HCV infection, and assess mortality and morbidity. We applied electronic phenotyping strategies on routinely collected data from patients hospitalized at a tertiary referral hospital in Switzerland between 2009 and 2017. Individuals with HCV infection were identified using International Classification of Disease (ICD)-10 codes, prescribed medications and laboratory results (antibody, PCR, antigen or genotype test). Controls were selected using propensity score methods (matching by age, sex, intravenous drug use, alcohol abuse and HIV co-infection). Main outcomes were in-hospital mortality and attributable mortality (in HCV cases and study population). The non-matched dataset included records from 165,972 individuals (287,255 hospital stays). Electronic phenotyping identified 2285 stays with evidence of HCV infection (1677 individuals). Propensity score matching yielded 6855 stays (2285 with HCV, 4570 controls). In-hospital mortality was higher in HCV cases (RR 2.10, 95%CI 1.64 to 2.70). Among those infected, 52.5% of the deaths were attributable to HCV (95%CI 38.9 to 63.1). When cases were matched, the fraction of deaths attributable to HCV was 26.9% (HCV prevalence: 33%), whilst in the non-matched dataset, it was 0.92% (HCV prevalence: 0.8%). In this study, HCV infection was strongly associated with increased mortality. Our methodology may be used to monitor the efforts towards meeting the WHO elimination targets and underline the importance of electronic cohorts as a basis for national longitudinal surveillance.     

Treatment as Prevention for Hepatitis C (TraP Hep C) – a nationwide elimination programme in Iceland using direct‐acting antiviral agents

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct‐acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long‐term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016–2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale‐up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879.     

Systematic overview of hepatitis C infection in the Middle East and North Africa

AIM To assess the quality of and to critically synthesize the available data on hepatitis C infections in the Middle East and North Africa(MENA) region to map evidence gaps.METHODS We conducted an overview of systematic reviews(SRs) following an a priori developed protocol(CRD42017076736). Our overview followed the preferred reporting items for systematic reviews and metaanalyses guidelines for reporting SRs and abstracts and did not receive any funding. Two independent reviewers systematically searched MEDLINE and conducted a multistage screening of the identified articles. Out of 5758 identified articles, 37 SRs of hepatitis C virus(HCV) infection in populations living in 20 countries in the MENA region published between 2008 and 2016 were included in our overview. The nine primary outcomes of interest were HCV antibody(anti-) prevalences and incidences in different at-risk populations; the HCV viremic(RNA positive) rate in HCV-positive individuals; HCV viremic prevalence in the general population(GP); the prevalence of HCV co-infection with the hepatitis B virus, human immunodeficiency virus, or schistosomiasis; the HCV genotype/subtype distribution; and the risk factors for HCV transmission. The conflicts of interest declared by the authors of the SRs were also extracted. Good quality outcomes reported by the SRs were defined as having the population, outcome, study time and setting defined as recommended by the PICOTS framework and a sample size 100.RESULTS We included SRs reporting HCV outcomes with different levels of quality and precision. A substantial proportion of them synthesized data from mixed populations at differing levels of risk for acquiring HCV or at different HCV infection stages(recent and prior HCV transmissions). They also synthesized the data over long periods of time(e.g., two decades). Anti-HCV prevalence in the GP varied widely in the MENA region from 0.1%(study dates not reported) in the United Arab Emirates to 2.1%-13.5%(2003-2006) in Pakistan and 14.7%(2008) in Egypt. Data were not identified for Bahrain, Jordan, or Palestine. Good quality estimates of anti-HCV prevalence in the GP were reported for Algeria, Djibouti, Egypt, Iraq, Morocco, Pakistan, Syria, Sudan, Tunisia, and Yemen. Anti-HCV incidence estimates in the GP were reported only for Egypt(0.8-6.8 per 1000 person-year, 1997-2003). In Egypt, Morocco, and the United Arab Emirates, viremic rates in anti-HCV-positive individuals from the GP were approximately 70%. In the GP, the viremic prevalence varied from 0.7%(2011) in Saudi Arabia to 5.8%(2007-2008) in Pakistan and 10.0%(2008) in Egypt. Anti-HCV prevalence was lower in blood donors than in the GP, ranging from 0.2%(1992-1993) in Algeria to 1.7%(2005) in Yemen. The reporting quality of the outcomes in blood donors was good in the MENA countries, except in Qatar where no time framework was reported for the outcome. Some countries had anti-HCV prevalence estimates for children, transfused patients, contacts of HCV-infected patients, prisoners, sex workers, and men who have sex with men.CONCLUSION A substantial proportion of the reported outcomes may not help policymakers to develop micro-elimination strategies with precise HCV infection prevention and treatment programs in the region, as nowcasting HCV epidemiology using these data is potentially difficult. In addition to providing accurate information on HCV epidemiology, outcomes should also demonstrate practical and clinical significance and relevance. Based on the available data, most countries in the region have low to moderate anti-HCV prevalence. To achieve HCV elimination by 2030, up-to-date, good quality data on HCV epidemiology are required for the GP and key populations such as people who inject drugs and men who have sex with men.     

Correlation between hepatitis C virus prevalence and hepatocellular carcinoma mortality in Europe

In Europe, as worldwide, hepatocellular carcinoma (HCC) death rates are highly variable. Recent studies have reported that hepatitis C virus (HCV) infection may be responsible for the increased mortality from HCC in the UK and in France. We investigate here the potential relationship between HCC mortality and HCV prevalence in Europe. Population and mortality data of HCC were obtained for 22 European countries from the World Health Organization (WHO) databank. Age-standardized death rates were computed. The HCV prevalence among blood donors and the WHO estimate of HCV prevalence were used as two indicators of prevalence in the general population, when data were available. Spearman rank analysis was conducted between HCC mortality and HCV prevalence. For men, age-standardized death rates per 100 000 varied from 0.61 (Greece) to 12.19 (Hungary). HCC mortality among men was positively correlated with HCV prevalence among blood donors and with the WHO estimate: rank correlation coefficients were, respectively, 0.76 ( P = 0.02) and 0.72 ( P = 0.03). This study showed that the reported differences of HCC mortality in Europe correlate with HCV prevalence.     

Hepatitis C prevalence and elimination planning in Pakistan,a bottom-up approach accounting for provincial variation

In Pakistan, substantial changes to hepatitis C virus (HCV) programming and treatment have occurred since the 2008 nationwide serosurvey estimated a 4.8% anti-HCV prevalence. In the absence of an updated national study, this analysis uses provincial data to estimate a national prevalence and the interventions needed to achieve elimination. Using a Delphi process, epidemiologic HCV data for the four provinces of Pakistan (accounting for 97% of the population) were reviewed with 21 subject-matter experts in Pakistan. Province-level estimates were inputted into a mathematical model to estimate the national HCV disease burden in the absence of intervention (Base), and if the World Health Organization (WHO) elimination targets are achieved by 2030 (80% reduction in new infections, 90% diagnosis coverage, 80% treatment coverage, and 65% reduction in mortality: WHO Elimination). An estimated 9,746,000 (7,573,000–10,006,000) Pakistanis were living with viraemic HCV as of January 1, 2021; a viraemic prevalence of 4.3% (3.3–4.4). WHO Elimination would require an annual average of 18.8 million screens, 1.1 million treatments, and 46,700 new infections prevented anually between 2022 and 2030. Elimination would reduce total infections by 7,045,000, save 152,000 lives and prevent 104,000 incident cases of hepatocellular carcinoma from 2015 to 2030. Blood surveys, programmatic data, and expert panel input uncovered more HCV infections and lower treatment numbers in the provinces than estimated using national extrapolations, demonstrating the benefits of a bottom-up approach. Screening and treatment must increase 20 times and 5 times, respectively, to curb the HCV epidemic in Pakistan and achieve elimination by 2030.     

Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto,Canada: A cross-sectional analysis

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02–1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04–2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.     

The Importance of Prisons in Achieving Hepatitis C Elimination: Insights from the Australian Experience

Following the availability of highly effective direct-acting antivirals (DAAs) to treat hepatitis C infection, the uptake of treatment by people living with hepatitis C rose dramatically in high- and middle-income countries but has since declined. To achieve the World Health Organization’s (WHO) 2030 target to eliminate hepatitis C as a public health threat among people who inject drugs, an increase in testing and treatment is required, together with improved coverage of harm reduction interventions. The population that remains to be treated in high- and middle-income countries with high hepatitis C prevalence are among the most socially disadvantaged, including people who inject drugs and are involved in the criminal justice system, a group with disproportionate hepatitis C prevalence, compared with people in the wider community. Imprisonment provides an unrivalled opportunity for screening and treating large numbers of people for hepatitis C, who may not access mainstream health services in the community. Despite some implementation challenges, evidence of the efficacy, acceptability, and cost-effectiveness of in-prison hepatitis treatment programs is increasing worldwide, and evaluations of these programs have demonstrated the capacity for treating people in high numbers. In this Perspective we argue that the scale-up of hepatitis C prevention, testing, and treatment programs in prisons, along with the investigation of new and adapted approaches, is critical to achieving WHO elimination goals in many regions; the Australian experience is highlighted as a case example. We conclude by discussing opportunities to improve access to prevention, testing, and treatment for people in prison and other justice-involved populations, including harnessing the changed practices brought about by the COVID-19 pandemic.     

High response and re‐infection rates among people who inject drugs treated for hepatitis C in a community needle and syringe programme

To achieve WHO hepatitis C virus (HCV) elimination targets by 2030, mathematical models suggest there needs to be significant scale‐up of treatment among people who inject drugs (PWID). We tested whether people who actively inject drugs can be recruited and treated successfully through a community needle and syringe programme (NSP), and assessed rates of re‐infection. 105 HCV RNA positive participants were enrolled prospectively. Participants were recruited from the largest NSP in Dundee over 42 months. 94/105 individuals commenced treatment. Genotype 1 (G1) individuals (n = 37) were treated with peg‐interferon+ribavirin+Simepravir/Telaprevir. Genotype 2/3 (G2/3) (n = 57) received peg‐interferon+ribavirin. Weekly study visits took place within the NSP. Mean age of participants was 34.0 years (SD 6.9), 71.3% (61/94) were male. One in five (20/94) participants were homeless. 68.1% (64/94) were on OST (opiate substitution therapy) at enrolment; participants injected median 6.5 times/wk. In terms of clinical outcomes, >80% treatment adherence was 71.3% (67/94). There was no difference in SVR‐12 rates by genotype: 81.0% (30/37) for G1 and 82.5% (47/55) for G2/3. At 18 months post‐treatment, 15/77 participants were reinfected, followed up over 69.8 person‐years, yielding a re‐infection rate of 21.5/100 person‐years (95% CI 13.00‐35.65). This trial demonstrates that HCV treatment can be delivered successfully to the target population of treatment as prevention strategies. We report higher rates of re‐infection than existing estimates among PWID. Scale‐up of HCV treatment should be pursued alongside a comprehensive programme of harm reduction interventions to help minimize re‐infection and reduce HCV transmission.     

Chronic hepatitis C virus infections in Switzerland in 2020: Lower than expected and suggesting achievement of WHO elimination targets

In this multi-method study, we investigated the prevalence of chronic infections with the hepatitis C virus (HCV) in Switzerland in 2020, and assessed Switzerland's progress in eliminating HCV as a public health problem by 2030 with regard to the World Health Organization (WHO) criteria targeting infections acquired during the preceding year (‘new transmissions’) and HCV-associated mortality. Based on a systematic literature review, the reappraisal of a 2015 prevalence analysis assuming 0.5% prevalence among the Swiss population and data from many additional sources, we estimated the prevalence among subpopulations at increased risk and the general population. For new transmissions, we evaluated mandatory HCV notification data and estimated unreported new transmissions based on subpopulation characteristics. For the mortality estimate, we re-evaluated a previous mortality estimate 1995–2014 based on new data on comorbidities and age. We found a prevalence of ≤0.1% among the Swiss population. Discrepancies to the 2015 estimate were explained by previous (i) underestimation of sustained virologic response numbers, (ii) overestimation of HCV prevalence among PWID following bias towards subgroups at highest risk, (iii) overestimation of HCV prevalence among the general population from inclusion of high-risk persons and (iv) underestimation of spontaneous clearance and mortality. Our results suggest that the WHO elimination targets have been met 10 years earlier than previously foreseen. These advancements were made possible by Switzerland's outstanding role in harm-reduction programmes, the longstanding micro-elimination efforts concerning HIV-infected MSM and nosocomial transmissions, little immigration from high-prevalence countries except Italian-born persons born before 1953, and wealth of data and funding.     

Anti‐inflammatory therapy for atherosclerosis: interpreting divergent results from the CANTOS and CIRT clinical trials

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon‐based treatment was the standard of care. Often it was not practical to scale‐up these earlier models and interventions because the clinical care needs of patients taking interferon‐based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all‐oral direct‐acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV‐infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations’ needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV‐infected individuals from testing to cure and subsequent care and monitoring.     

Economic evaluation of HCV testing approaches in low and middle income countries

Background

Hepatitis C virus (HCV) infection represents a major public health burden with diverse epidemics worldwide, but at present, only a minority of infected persons have been tested and are aware of their diagnosis. The advent of highly effective direct acting antiviral (DAA) therapy, which is becoming available at increasingly lower costs in low and middle income countries (LMICs), represents a major opportunity to expand access to testing and treatment. However, there is uncertainty as to the optimal testing approaches and who to prioritize for testing. We undertook a narrative review of the cost-effectiveness literature on different testing approaches for chronic hepatitis C infection to inform decision-making and formulation of recommendations in the 2017 World Health Organization (WHO) viral hepatitis testing guidelines.

Methods

We undertook a focused search and narrative review of the literature for cost effectiveness studies of testing approaches in three main groups:- 1) focused testing of specific high-risk groups (defined as those who are part of a population with higher seroprevalence or who have a history of exposure or high-risk behaviours); 2) “birth cohort” testing among easily identified age groups (i.e. specific birth cohorts) known to have a high prevalence of HCV infection; and 3) routine testing in the general population. Articles included were those published in PubMed, written in English and published after 2000.

Results

We identified 26 eligible studies. Twenty-four of them were from Europe (n = 14) or the United States (n = 10). There was only one study from a LMIC (Egypt) and this evaluated general population testing. Thirteen studies evaluated focused testing among specific groups at high risk for HCV infection, including nine in persons who inject drugs (PWID); five among people in prison, and one among HIV-infected men who have sex with men (MSM). Eight studies evaluated birth cohort testing, and five evaluated testing in the general population. Most studies were based on a one-time testing intervention, but in one study testing was undertaken every 5 years and in another among HIV-infected MSM there was more frequent testing. Comparators were generally either: 1) no testing, 2) the status quo, or 3) multiple different strategies. Overall, we found broad agreement that focused testing of high risk groups such as persons who inject drugs and men who have sex with men was cost-effective, as was birth cohort testing. Key drivers of cost-effectiveness were the prevalence of HCV infection in these groups, efficacy and cost of treatment, stage of disease and linkage to care. The evidence for routine population testing was mixed, and the cost-effectiveness depends largely on the prevalence of HCV.

Conclusions

The evidence base for different HCV testing approaches in LMICs is limited, minimizing the contribution of cost-effectiveness data alone to decision-making and recommendations on testing approaches in the 2017 WHO viral hepatitis testing guidelines. Overall, the guidelines recommended focused testing in high risk-groups, particularly PWID, prisoners, and men who have sex with men; with consideration of two other approaches:- birth cohort testing in those countries with epidemiological evidence of a significant birth cohort effect; and routine access to testing across the general population in those countries with a high HCV seroprevalence above 2% - 5% in the general population. Further implementation research on different testing approaches is needed in order to help guide national policy planning.

     

A systematic review and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcerated persons

Communicable diseases are common in people who are incarcerated. We aimed to define the prevalence of chlamydia, gonorrhoea and syphilis in people who are incarcerated and to identify subgroups with the highest risk of infection. We searched for prevalence studies of chlamydia, gonorrhoea or syphilis in incarcerated populations. Pooled estimates were generated, and meta-regression was conducted. Random effects models yielded pooled prevalence estimates of 5.75% (95% confidence interval [CI] 5.01, 6.48) and 12.31% (95% CI 10.61, 14.01) for chlamydia in men and women, 1.4% (95% CI 1.09, 1.70) and 5.73% (4.76, 6.69) for gonorrhoea in men and women, and 2.45% (95% CI 2.08, 2.82) and 6.10% (95% CI 4.75, 7.46) for syphilis in men and women, respectively. Each infection was associated with female gender in meta-regression models. Chlamydia, gonorrhoea and syphilis are highly prevalent in these populations. Primary and secondary prevention efforts could improve individual and population health.     

HCV reinfection incidence among individuals treated for recent infection

One challenge to HCV elimination through therapeutic intervention is reinfection. The aim of this analysis was to calculate the incidence of HCV reinfection among both HIV‐positive and HIV‐negative individuals treated for recent HCV infection (estimated infection duration <18 months). Individuals with recent HCV infection who achieved an end‐of‐treatment response in four open‐label studies between 2004 and 2015 in Australia and New Zealand were assessed for HCV reinfection, confirmed by sequencing of the Core‐E2 and/or NS5B regions. Reinfection incidence was calculated using person‐time of observation. Exact Poisson regression analysis was used to assess factors associated with HCV reinfection. The cohort at risk for reinfection (n=120; 83% male; median age 36 years) was composed of HIV‐positive men‐who‐have‐sex‐with‐men (53%) and people who inject drugs (current 49%, ever 69%). Total follow‐up time at risk was 135 person‐years (median 1.08 years, range 0.17, 2.53). Ten cases of HCV reinfection were identified, for an incidence of 7.4 per 100 py (95% CI 4.0, 13.8). Reinfection incidence was significantly higher among participants who reported injection drug use at end of or post‐treatment, irrespective of HIV status (15.5 per 100 py, 95% CI 7.8, 31.1). In adjusted analysis, factors associated with reinfection were older age (aIRR 5.3, 95% CI 1.15, 51.5, P=.042) and injection drug use at end of or post‐treatment (aIRR 7.9, 95% CI 1.6, 77.2, P=.008). High reinfection incidence following treatment for recent HCV infection in individuals with ongoing risk behaviour emphasizes the need for post‐treatment surveillance, harm reduction strategies and education in at‐risk populations.     

HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact

Hepatitis C virus (HCV) antiviral treatment for people who inject drugs (PWID) could prevent onwards transmission and reduce chronic prevalence. We assessed current PWID treatment rates in seven UK settings and projected the potential impact of current and scaled‐up treatment on HCV chronic prevalence. Data on number of PWID treated and sustained viral response rates (SVR) were collected from seven UK settings: Bristol (37–48% HCV chronic prevalence among PWID), East London (37–48%), Manchester (48–56%), Nottingham (37–44%), Plymouth (30–37%), Dundee (20–27%) and North Wales (27–33%). A model of HCV transmission among PWID projected the 10‐year impact of (i) current treatment rates and SVR (ii) scale‐up with interferon‐free direct acting antivirals (IFN‐free DAAs) with 90% SVR. Treatment rates varied from <5 to over 25 per 1000 PWID. Pooled intention‐to‐treat SVR for PWID were 45% genotypes 1/4 [95%CI 33–57%] and 61% genotypes 2/3 [95%CI 47–76%]. Projections of chronic HCV prevalence among PWID after 10 years of current levels of treatment overlapped substantially with current HCV prevalence estimates. Scaling‐up treatment to 26/1000 PWID annually (achieved already in two sites) with IFN‐free DAAs could achieve an observable absolute reduction in HCV chronic prevalence of at least 15% among PWID in all sites and greater than a halving in chronic HCV in Plymouth, Dundee and North Wales within a decade. Current treatment rates among PWID are unlikely to achieve observable reductions in HCV chronic prevalence over the next 10 years. Achievable scale‐up, however, could lead to substantial reductions in HCV chronic prevalence.     

Global Trends of Monitoring and Data Collection on the HIV Response among Key Populations Since the 2001 UN Declaration of Commitment on HIV/AIDS

Monitoring and evaluation indicators for HIV programs’ response to the epidemic among key populations (sex workers, people who inject drugs, men who have sex with men, transgender people) are critical for reviewing the global response. From the beginning of global reporting, insufficiency of data has been a challenge for monitoring the epidemic response among key populations. However, key populations were only indirectly referenced in the 2001 Declaration of Commitment. By the 2006 Political Declaration on HIV/AIDS, data from key populations were still not required from every country, and were sparsely reported compared to other indicators. The 2011 Political Declaration on HIV/AIDS referenced key populations by name for the first time. In 2006, fewer than twenty countries (10%) reported HIV prevalence among key populations, whereas in 2012 the number of countries surpassed sixty (30%).     

Modelling the potential prevention benefits of a treat‐all hepatitis C treatment strategy at global,regional and country levels: A modelling study

The World Health Organization (WHO) recently produced guidelines advising a treat‐all policy for HCV to encourage widespread treatment scale‐up for achieving HCV elimination. We modelled the prevention impact achieved (HCV infections averted [IA]) from initiating this policy compared with treating different subgroups at country, regional and global levels. We assessed what country‐level factors affect impact. A dynamic, deterministic HCV transmission model was calibrated to data from global systematic reviews and UN data sets to simulate country‐level HCV epidemics with ongoing levels of treatment. For each country, the model projected the prevention impact (in HCV IA per treatment undertaken) of initiating four treatment strategies; either selected randomly (treat‐all) or targeted among people who inject drugs (PWID), people aged ≥35, or those with cirrhosis. The IA was assessed over 20 years. Linear regression was used to identify associations between IA per treatment and demographic factors. Eighty‐eight countries (85% of the global population) were modelled. Globally, the model estimated 0.35 (95% credibility interval [95%CrI]: 0.16‐0.61) IA over 20 years for every randomly allocated treatment, 0.30 (95%CrI: 0.12‐0.53) from treating those aged ≥35 and 0.28 (95%CrI: 0.12‐0.49) for those with cirrhosis. Globally, treating PWID achieved 1.27 (95%CrI: 0.68‐2.04) IA per treatment. The IA per randomly allocated treatment was positively associated with a country's population growth rate and negatively associated with higher HCV prevalence among PWID. In conclusion, appreciable prevention benefits could be achieved from WHO’s treat‐all strategy, although greater benefits per treatment can be achieved through targeting PWID. Higher impact will be achieved in countries with high population growth.     

Testing to sustain hepatitis C elimination targets in people who inject drugs: A network-based model

Little is known about the level of testing required to sustain elimination of hepatitis C (HCV), once achieved. In this study, we model the testing coverage required to maintain HCV elimination in an injecting network of people who inject drugs (PWID). We test the hypothesis that network-based strategies are a superior approach to deliver testing. We created a dynamic injecting network structure connecting 689 PWID based on empirical data. The primary outcome was the testing coverage required per month to maintain prevalence at the elimination threshold over 5 years. We compared four testing strategies. Without any testing or treatment provision, the prevalence of HCV increased from the elimination threshold (11.68%) to a mean of 25.4% (SD 2.96%) over the 5-year period. To maintain elimination with random testing, on average, 4.96% (SD 0.83%) of the injecting network needs to be tested per month. However, with a ‘bring your friends’ strategy, this was reduced to 3.79% (SD 0.64%) of the network (p < .001). The addition of contact tracing improved the efficiency of both strategies. In conclusion, we report that network-based approaches to testing such as ‘bring a friend’ initiatives and contact tracing lower the level of testing coverage required to maintain elimination.     

Hepatitis C elimination among people who inject drugs: Challenges and recommendations for action within a health systems framework

The burden of hepatitis C infection is considerable among people who inject drugs (PWID), with an estimated prevalence of 39%, representing an estimated 6.1 million people who have recently injected drugs living with hepatitis C infection. As such, PWID are a priority population for enhancing prevention, testing, linkage to care, treatment and follow‐up care in order to meet World Health Organization (WHO) hepatitis C elimination goals by 2030. There are many barriers to enhancing hepatitis C prevention and care among PWID including poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low hepatitis C testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. On 5 September 2017, the International Network of Hepatitis in Substance Users (INHSU) held a roundtable panel of international experts to discuss remaining challenges and future priorities for action from a health systems perspective. The WHO health systems framework comprises six core components: service delivery, health workforce, health information systems, medical procurement, health systems financing, and leadership and governance. Communication has been proposed as a seventh key element which promotes the central role of affected community engagement. This review paper presents recommended strategies for eliminating hepatitis C as a major public health threat among PWID and outlines future priorities for action within a health systems framework.