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      Previous incarceration impacts access to hepatitis C virus (HCV) treatment among HIV‐HCV co‐infected patients in Canada

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          The prevalence of hepatitis C virus ( HCV) is far higher in prison settings than in the general population; thus, micro‐elimination strategies must target people in prison to eliminate HCV. We aimed to examine incarceration patterns and determine whether incarceration impacts HCV treatment uptake among Canadian HIVHCV co‐infected individuals in the direct‐acting antiviral ( DAA) era.


          The Canadian Co‐Infection Cohort prospectively follows HIVHCV co‐infected people from 18 centres. HCV RNA‐positive participants with available baseline information on incarceration history were included and followed from 21 November 2013 (when second‐generation DAAs were approved by Health Canada) until 30 June 2017. A Cox proportional hazards model was used to assess the effect of time‐updated incarceration status on time to treatment uptake, adjusting for patient‐level characteristics known to be associated with treatment uptake in the DAA era.


          Overall, 1433 participants (1032/72% men) were included; 67% had a history of incarceration and 39% were re‐incarcerated at least once. Compared to those never incarcerated, previously incarcerated participants were more likely to be Indigenous, earn <$1500 CAD/month, report current or past injection drug use and have poorly controlled HIV. There were 339 second‐generation DAA treatment initiations during follow‐up (18/100 person‐years). Overall, 48% of participants never incarcerated were treated (27/100 person‐years) compared to only 31% of previously incarcerated participants (15/100 person‐years). Sustained virologic response ( SVR) rates at 12 weeks were 95% and 92% respectively. After adjusting for other factors, participants with a history of incarceration (adjusted hazard ratio ( aHR): 0.7, 95% CI: 0.5 to 0.9) were less likely to initiate treatment, as were those with a monthly income <$1500 ( aHR: 0.7, 95% CI: 0.5 to 0.9) or who reported current injection drug use ( aHR: 0.7, 95% CI: 0.4 to 1.0). Participants with undetectable HIV RNA ( aHR: 2.1, 95% CI: 1.6 to 2.9) or significant fibrosis ( aHR: 1.5, 95% CI: 1.2 to 1.9) were more likely to initiate treatment.


          The majority of HIVHCV co‐infected persons had a history of incarceration. Those previously incarcerated were 30% less likely to access treatment in the DAA era even after accounting for several patient‐level characteristics. With SVR rates above 90%, HCV elimination may be possible if treatment is expanded for this vulnerable and neglected group.

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          Can antiviral therapy for hepatitis C reduce the prevalence of HCV among injecting drug user populations? A modeling analysis of its prevention utility.

          Hepatitis C virus antiviral treatment is effective for individual patients but few active injecting drug users are treated. We considered the utility of antiviral treatment for primary prevention of hepatitis C. A hepatitis C transmission model among injecting drug users was developed, incorporating treatment (62.5% average sustained viral response) with no retreatment after initial treatment failure, potential re-infection for those cured, equal genotype setting (genotype 1:genotype 2/3), and no immunity. In addition, we examined scenarios with varied treatment response rates, immunity, or retreatment of treatment failures. In the baseline scenario, annually treating 10 infections per 1000 injecting drug users results in a relative decrease in hepatitis C prevalence over 10 years of 31%, 13%, or 7% for baseline (untreated endemic chronic infection) prevalences of 20%, 40%, or 60%, respectively. Sensitivity analyses show that including the potential for immunity has minimal effect on the predictions; prevalence reductions remain even if SVR is assumed to be 25% lower among active IDU than current evidence suggests; retreatment of treatment failures does not alter the short-term (<5 years) projections, but does increase treatment gains within 20 years; hepatitis C free life years gained from treating active injecting drug users are projected to be higher than from treating non-injecting drug users for prevalences below 60%. Despite the possibility of re-infection, modest rates of hepatitis C treatment among active injecting drug users could effectively reduce transmission. Evaluating and extending strategies to treat hepatitis C among active injectors are warranted. Copyright © 2010 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
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            The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia.

            Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.
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              Cohort profile: the Canadian HIV-hepatitis C co-infection cohort study.


                Author and article information

                J Int AIDS Soc
                J Int AIDS Soc
                Journal of the International AIDS Society
                John Wiley and Sons Inc. (Hoboken )
                21 November 2018
                November 2018
                : 21
                : 11 ( doiID: 10.1002/jia2.2018.21.issue-11 )
                [ 1 ] Division of Infectious Diseases/Chronic Viral Illness Service Department of Medicine Glen site McGill University Health Centre Montreal QC Canada
                [ 2 ] Research Institute of the McGill University Health Centre Montreal QC Canada
                [ 3 ] Department of Epidemiology, Biostatistics, and Occupational Health McGill University Montreal QC Canada
                [ 4 ] Department of Medicine University of Saskatchewan Regina SK Canada
                [ 5 ] Department of Medicine University of Ottawa Ottawa ON Canada
                [ 6 ] Department of Medicine University of Calgary Calgary AB Canada
                [ 7 ] University Health Network Toronto ON Canada
                [ 8 ] CIHR Canadian HIV Trials Network Vancouver BC Canada
                [ 9 ] Centre de Recherche du Centre Hospitalier de l’ Université de Montréal Montreal QC Canada
                [ 10 ] Department of Medicine University of British Columbia Vancouver BC Canada
                [ 11 ] British Columbia Centre for Excellence in HIV/AIDS Vancouver BC Canada
                Author notes
                [* ] Corresponding author: Nadine Kronfli, Division of Infectious Diseases and Chronic Viral Illness Service, Glen site, McGill University Health Centre, 1001 Decarie Boulevard D02.4110, Montreal, Quebec H4A 3J1, Canada. Tel: (514) 934‐1934. ( nadine.kronfli@ )
                © 2018 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.

                This is an open access article under the terms of the License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 2, Tables: 2, Pages: 8, Words: 6899
                Funded by: Fonds de recherche du Québec – Santé (FRQ‐S); Réseau SIDA/maladies infectieuses
                Funded by: Canadian Institutes of Health Research
                Award ID: CIHR FDN‐143270
                Funded by: CIHR Canadian HIV Trials Network
                Award ID: CTN222
                Research Article
                Research Articles
                Custom metadata
                November 2018
                Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.5.3 mode:remove_FC converted:21.11.2018


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