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Treatment as Prevention: A Comprehensive Approach to Hepatitis C Virus in Persons Who Inject Drugs

Globally, approximately 184 million individuals are currently infected with the hepatitis C virus (HCV). Of this patient population, 75% to 85% will develop chronic HCV infection, which can lead to liver disease, including cirrhosis and hepatocellular carcinoma.

According to the World Health Organization, the incidence of HCV infection is declining around the world—except for in the United States. Between 2002 and 2005, the United States saw a decline in new HCV infections, that was followed by a period of stability from 2005 to 2010. However, a 2.6-fold increase of acute infections was noted from 2010 to 2014. The primary route of transmission, accounting for nearly 60% of these new infec­tions, was intravenous drug use.1,2

There are an estimated 10 million persons who inject drugs (PWIDs) globally who are infected with HCV. Depending on the location, the incidence of HCV can be 40% to 90% of PWIDs, even as high 98%.3 Risk factors that are associated with HCV in PWIDs include residing in nonurban areas, white ethnicity, individuals younger than 35 years, and a history of prescription drug use and abuse.4 With the advent of direct-acting antiviral agents (DAAs), including well-tolerated medications with minimal side effects resulting in cure rates of 95% to 99%, treatment of HCV in PWIDs is necessary to cure HCV and prevent transmission of new infections.5

Unfortunately, PWIDs who are actively using are much less likely to receive approval for HCV treatment because of the high cost of these medications. Computer models have demonstrated that even a modest decrease in the number of individuals with HCV who inject drugs can re­sult in a decrease in prevalence among this population.3 Multiple strategies have been employed to target PWIDs to reduce the number of infected individuals and pre­vent transmission among their peers.2 These strategies include behavioral interventions; substance abuse treat­ment, including opiate-replacement therapy; needle exchange programs; and treatment of HCV to achieve cure in patients with active HCV infection.
Two studies have examined the impact of behavior­al interventions on the incidence of HCV seroconver­sion among PWIDs. In the first, Garfein et al randomized patients to receive peer education with 6 training sessions versus attention matched controls. The odds ratio for HCV seroconversion was 1.15, with a 95% confidence interval (CI, 0.72-1.82) demonstrating no difference between the peer education group and the attention-matched controls.6

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