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

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

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          Key Points


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


          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.


          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.


          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.



          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.


          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.


          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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          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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            Scaling up prevention and treatment towards the elimination of hepatitis C: a global mathematical model

            Summary Background The revolution in hepatitis C virus (HCV) treatment through the development of direct-acting antivirals (DAAs) has generated international interest in the global elimination of the disease as a public health threat. In 2017, this led WHO to establish elimination targets for 2030. We evaluated the impact of public health interventions on the global HCV epidemic and investigated whether WHO's elimination targets could be met. Methods We developed a dynamic transmission model of the global HCV epidemic, calibrated to 190 countries, which incorporates data on demography, people who inject drugs (PWID), current coverage of treatment and prevention programmes, natural history of the disease, HCV prevalence, and HCV-attributable mortality. We estimated the worldwide impact of scaling up interventions that reduce risk of transmission, improve access to treatment, and increase screening for HCV infection by considering six scenarios: no change made to existing levels of diagnosis or treatment; sequentially adding the following interventions: blood safety and infection control, PWID harm reduction, offering of DAAs at diagnosis, and outreach screening to increase the number diagnosed; and a scenario in which DAAs are not introduced (ie, treatment is only with pegylated interferon and oral ribavirin) to investigate the effect of DAA use. We explored the effect of varying the coverage or impact of these interventions in sensitivity analyses and also assessed the impact on the global epidemic of removing certain key countries from the package of interventions. Findings By 2030, interventions that reduce risk of transmission in the non-PWID population by 80% and increase coverage of harm reduction services to 40% of PWID could avert 14·1 million (95% credible interval 13·0–15·2) new infections. Offering DAAs at time of diagnosis in all countries could prevent 640 000 deaths (620 000–670 000) from cirrhosis and liver cancer. A comprehensive package of prevention, screening, and treatment interventions could avert 15·1 million (13·8–16·1) new infections and 1·5 million (1·4–1·6) cirrhosis and liver cancer deaths, corresponding to an 81% (78–82) reduction in incidence and a 61% (60–62) reduction in mortality compared with 2015 baseline. This reaches the WHO HCV incidence reduction target of 80% but is just short of the mortality reduction target of 65%, which could be reached by 2032. Reducing global burden depends upon success of prevention interventions, implemention of outreach screening, and progress made in key high-burden countries including China, India, and Pakistan. Interpretation Further improvements in blood safety and infection control, expansion or creation of PWID harm reduction services, and extensive screening for HCV with concomitant treatment for all are necessary to reduce the burden of HCV. These findings should inform the ongoing global action to eliminate the HCV epidemic. Funding Wellcome Trust.
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              National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment.

              We estimated national and state trends in opioid agonist medication-assisted treatment (OA-MAT) need and capacity to identify gaps and inform policy decisions.

                Author and article information

                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                3 August 2021
                August 2021
                3 August 2021
                : 4
                : 8
                [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.
                Copyright 2021 Blake A et al. JAMA Network Open.

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

                Original Investigation
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                Substance Use and Addiction


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