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Epidemiology and prevention of HCV in IDUs. Viktor Mravcik MD PhD. HCV. enveloped RNA virus, genus Hepacivirus within the Flaviviridae family reservoir is human, but transmission to chimpanzees possible highly mutable – can escape host detection and elimination

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  • enveloped RNA virus, genus Hepacivirus within the Flaviviridae family
  • reservoir is human, but transmission to chimpanzees possible
  • highly mutable – can escape host detection and elimination
  • highly heterogeneous – 11 genotypes (1-4 the most prevalent) and more than 80 subtypes
    • In Europe historically genotypes 1-3, but recent transmission of genotype 4 among IDUs
natural history of hcv infection
Natural history of HCV infection
  • Incubation period: 2 weeks – 6 months
  • Acute infection: typically asymptomatic or unspecific symptoms
  • Spontaneous clearance: 20–60 % (Loomba et al. 2011)
    • IDUs 1/3 (van den Berg et al. 2011)
  • Cirrhosis in 8–45 % of chronic carriers in 20 years
    • 15 % in IDUs (John-Baptiste et al. 2010)
  • Liver decompensation and/or HCC peaks in 30 years afterinfection(Davis et al. 2010)
natural history of hcv infection1
Natural historyof HCV infection

Source: WHO (2014) Guidelines for the screening, care and treatment of persons with hepatitis C infection

factors contributing to progression of liver diseases in hcv infection
Factors contributing to progression of liver diseases in HCV infection

Podle Virová hepatitida C, Urbánek 2010 a Chronické virové hepatitidy, Galský a Plíšek, 2010

prevalence of hcv
Prevalence of HCV
  • Prevalence of anti-HCV globally 2.8 % (95% CI: 2,6–3,1%) = central estimate of 185 million people living with HCV infection (MohdHanafiah et al. 2012)
    • in Europe prevalence of HCV typically 1.5–3.5 %
    • in the Czech Republic: 0.2% (Němeček, 2003)
  • 350 000 deaths annually (1/4 cirrhosis and HCC attributable to HCV)(Perz et al. 2006)
hcv in idus
  • Global prevalence of anti-HCV in IDUs: 60–80% (Nelson et al. 2011)
    • the highest (over 90%) in Russia, China, Poland, Spain
  • Prevalence of anti-HCV in IDUs in EU: 12–85%, mostly over 40% (EMCDDA, 2012)
  • IDUs represent 75–100% all newly diagnosed cases of HCV in most Europeancountries(Wiessing et al. 2008)
  • Incidence rate in IDUs: up to 40, typically 10–20 per 100 person-years (Roy et al. 2002; Roy et al. 2007; Stein et al. 2009; Holtzman et al. 2009)
  • Re-infection in IDUs quite rare (3–5%) even in active drug users (Dalgard et al. 2002; Grebely et al. 2011)
ECDC AND EMCDDA GUIDLINES 2011:Prevention and control of infectious diseases among people who inject drugs


seven recommended key interventions
Seven recommended key interventions
  • Access to injection equipment (NSPs)
  • Vaccination
    • not in HCV
  • Drug dependence treatment
    • including OST
  • Testing (early detection)
    • including on-the-spot rapid testing
  • Infectious disease treatment
    • antiviral treatment in HCV
  • Health promotion
    • safer inj. behaviour, condom use, disease prevention, testing, treatment
  • Targeted delivery of services
    • organised, combined, referrals, multidisciplinary (one-stop-shop)

Combination of these key interventions enhances prevention synergy and effectiveness!

nsps and ost in hcv prevention
NSPs and OST in HCV prevention
  • NSPs less effective in prevention of HCV than in HIV (Mehta et al. 2011)
  • Simultaneous participation in NSP and OST enhances the effect (Hagan, 2011; van den Berg et al. 2007; Turner et al. 2011)
  • However NSP and OST have limited effect in substantial reduction of HCV prevalence – unless the intervention coverage is scaled-up to 60% for 40% baseline HCV prevalence (Vickerman et al., 2012a, Vickerman et al., 2012b)
  • Strong preventive potential of HCV treatment!
hcv treatment in idus
HCV treatment in IDUs
  • Standard: PEG-IFN and RBV for 48 (genotypes 1 and 4) or 24 (genotypes 2 and 3) weeks
    • SVR approx. 50% in genotype 1 and 65-82% in genotype 2 and 3
  • SVR in IDUs comparable to non-IDUs:
    • centralestimates 54-56% (Hellard et al. 2009, Dimova et al. 2012)
    • 56% (95%CI: 50-61%), 37% for GT 1/4, 67% for GT 2/3 (Aspinallet al. 2013)
  • DAAs:
    • higher SVR: median 90%, range 80–100% (Martin et al. 2013)
    • shorter regimens (12 weeks)
  • However HCV treatment uptake in IDUs is generally low
    • fear of low adherence leading to low SVR
    • range of specific factors related to uptake and adherence in IDUs
  • More in following presentations!
hcv treatment as a primary prevention
HCV treatment as a (primary) prevention
  • Risk of HCV transmission decreases with lower HCV prevalence
  • Even for low treatment rates, a large reduction of HCV at the population level can be achieved (Zeiler et al. 2010; Martin et al. 2011)
  • Effect is larger in populations with a lower baseline HCV prevalence (Vickerman et al. 2010)
  • HCV treatment of active injecting drug users is the most cost-effective policy option when the chronic HCV prevalence among PWID is below 60% and even for lower suggested SVR in IDUs (Martin et al. 2012)
  • In low-prevalent countries (anti-HCV below 30 %), treatment of active IDUs is more efficient (AnnekeS de Vos et al. 2013)
preventive effect of hcv treatment in idus
Preventive effect of HCV treatment in IDUs

Source: Martin NK, Vickerman P, Foster GR, Hutchinson SJ, Goldberg DJ, and Hickman M. J Hep 2011; 54:1137-44

preventive effect of hcv treatment in idus1
Preventive effect of HCV treatment in IDUs

Source: Can Hepatitis C virus treatmentbeused as a preventionstrategy? Additional model projectionsforAustralia and elsewhere, Vickerman et al., 2010