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      Modeling Hepatitis C Elimination Among People Who Inject Drugs in New Hampshire

      research-article
      , MD, MBA 1 , , , PhD 2
      JAMA Network Open
      American Medical Association

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          Key Points

          Question

          What improvements in the hepatitis C (HCV) care cascade are required to eliminate HCV among people who inject drugs (PWID)?

          Findings

          This decision analytic model of HCV transmission found that improved testing, treatment, and access to harm reduction were all associated with reductions in HCV prevalence and mortality among PWID. Improvements in both testing and treatment were associated with HCV prevalence of less than 2% by 2030.

          Meaning

          These findings suggest that HCV elimination may be possible among PWID by 2030 with improved testing and treatment; improved harm reduction may reduce the time and number of treatments required to achieve similar outcomes.

          Abstract

          This decision analytical model evaluates potential improvements in the hepatitis C virus (HCV) care cascade among people who inject drugs (PWID), focusing on improved testing, treatment uptake, and access to harm reduction.

          Abstract

          Importance

          The success of direct-acting antiviral therapies for chronic hepatitis C virus (HCV) infection led the World Health Organization to set elimination targets by 2030. For the United States to achieve these benchmarks, public health responses must target high-risk populations, such as people who inject drugs (PWID), a group with high rates of HCV incidence and low rates of treatment uptake.

          Objective

          To evaluate potential improvements in the HCV care cascade among PWID, focusing on improved testing, treatment uptake, and access to harm reduction.

          Design, Setting, and Participants

          This decision analytic model used a differential equation–based dynamic transmission model based on data from New Hampshire, an illustrative state with a large number of PWID and limited HCV treatment infrastructure. Surveillance data through 2020 was used for model parameterization, and the final analysis was conducted in May 2021.

          Main Outcomes and Measures

          Model forecasts of chronic HCV cases and advanced-stage HCV outcomes from 2022 to 2045.

          Results

          A total of 6 scenarios were tested: (1) the base case, (2) improved harm reduction, (3) improved testing, (4) improved treatment, (5) improved testing and treatment, and (6) improved testing, treatment, and harm reduction. All scenarios with improved testing, treatment uptake, and/or access to harm reduction were associated with decreases in forecasted HCV prevalence and HCV-associated mortality compared with the base case. Improving harm reduction, testing, and treatment individually were forecast to reduce prevalence of HCV in 2045 from 69.7% in the base case to 62.8%, 45.7%, and 35.5%, respectively. Combining treatment and testing improvements was associated with a 2045 prevalence of 0.3%; adding harm reduction improvements was associated with further reductions in prevalence forecasts (to 0.2%), with fewer total treatments (10 960 vs 13 219 from 2022-2045).

          Conclusions and Relevance

          In this modeling study, no single intervention was projected to achieve World Health Organization HCV elimination targets. Scenarios with improvements in both testing and treatment were associated with a prevalence of less than 3% by 2030 and achieved elimination targets. Adding improvements in harm reduction was associated with faster reductions in prevalence and fewer treatments.

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          Most cited references31

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          Estimating Prevalence of Hepatitis C Virus Infection in the United States, 2013-2016

          Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged ≥18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure.
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            • Article: not found

            Rising Mortality Associated With Hepatitis C Virus in the United States, 2003-2013.

            In the United States, hepatitis C virus (HCV)-associated mortality is increasing. From 2003-2013, the number of deaths associated with HCV has now surpassed 60 other nationally notifiable infectious conditions combined. The increasing HCV-associated mortality trend underscores the urgency in finding, evaluating, and treating HCV-infected persons.
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              • Record: found
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              • Article: not found

              Global Elimination of Chronic Hepatitis

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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                3 August 2021
                August 2021
                3 August 2021
                : 4
                : 8
                : e2119092
                Affiliations
                [1 ]Brigham and Women's Hospital, Boston, Massachusetts
                [2 ]Tuck School of Business at Dartmouth, Hanover, New Hampshire
                Author notes
                Article Information
                Accepted for Publication: May 27, 2021.
                Published: August 3, 2021. doi:10.1001/jamanetworkopen.2021.19092
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Blake A et al. JAMA Network Open.
                Corresponding Author: Andrew Blake, MD, MBA, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 ( ablake@ 123456bwh.harvard.edu ).
                Author Contributions: Drs Blake and Smith had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Both authors.
                Acquisition, analysis, or interpretation of data: Both authors.
                Drafting of the manuscript: Both authors.
                Critical revision of the manuscript for important intellectual content: Both authors.
                Statistical analysis: Both authors.
                Administrative, technical, or material support: Both authors.
                Conflict of Interest Disclosures: None reported.
                Additional Contributions: David de Gijsel, MD (Dartmouth Hitchcock Medical Center), helped in describing and parameterizing injection drug use and hepatitis C virus care in New Hampshire. This individual was not compensated for this work.
                Article
                zoi210567
                10.1001/jamanetworkopen.2021.19092
                8335578
                34342652
                6462a693-39d6-4b56-af80-fa010df54956
                Copyright 2021 Blake A et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 17 October 2020
                : 27 May 2021
                Categories
                Research
                Original Investigation
                Online Only
                Substance Use and Addiction

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