School of Social and Community Medicine, University of Bristol, Bristol, UK; Social and Mathematical Epidemiology Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
Hepatology. 2013 Nov;58(5):1598-609. doi: 10.1002/hep.26431. Epub 2013 Aug 26.
Substantial reductions in hepatitis C virus (HCV) prevalence among people who inject drugs (PWID) cannot be achieved by harm reduction interventions such as needle exchange and opiate substitution therapy (OST) alone. Current HCV treatment is arduous and uptake is low, but new highly effective and tolerable interferon-free direct-acting antiviral (DAA) treatments could facilitate increased uptake. We projected the potential impact of DAA treatments on PWID HCV prevalence in three settings. A dynamic HCV transmission model was parameterized to three chronic HCV prevalence settings: Edinburgh, UK (25%); Melbourne, Australia (50%); and Vancouver, Canada (65%). Using realistic scenarios of future DAAs (90% sustained viral response, 12 weeks duration, available 2015), we projected the treatment rates required to reduce chronic HCV prevalence by half or three-quarters within 15 years. Current HCV treatment rates may have a minimal impact on prevalence in Melbourne and Vancouver (<2% relative reductions) but could reduce prevalence by 26% in 15 years in Edinburgh. Prevalence could halve within 15 years with treatment scale-up to 15, 40, or 76 per 1,000 PWID annually in Edinburgh, Melbourne, or Vancouver, respectively (2-, 13-, and 15-fold increases, respectively). Scale-up to 22, 54, or 98 per 1,000 PWID annually could reduce prevalence by three-quarters within 15 years. Less impact occurs with delayed scale-up, higher baseline prevalence, or shorter average injecting duration. Results are insensitive to risk heterogeneity or restricting treatment to PWID on OST. At existing HCV drug costs, halving chronic prevalence would require annual treatment budgets of US $3.2 million in Edinburgh and approximately $50 million in Melbourne and Vancouver.
Interferon-free DAAs could enable increased HCV treatment uptake among PWID, which could have a major preventative impact. However, treatment costs may limit scale-up, and should be addressed.
在注射吸毒者（PWID）中，仅通过减少伤害干预措施（如针具交换和阿片类药物替代疗法（OST））无法实现丙型肝炎病毒（HCV）流行率的大幅降低。目前的 HCV 治疗非常困难，且接受治疗的人数较少，但新的高效且耐受性好的无干扰素直接作用抗病毒（DAA）药物治疗可能会增加接受治疗的人数。我们预测了 DAA 治疗在三种情况下对 PWID HCV 流行率的潜在影响。一个 HCV 传播的动态模型，针对三个慢性 HCV 流行率设定值进行了参数化：英国爱丁堡（25%）；澳大利亚墨尔本（50%）；加拿大温哥华（65%）。使用未来 DAA 的现实场景（90%持续病毒学应答，12 周疗程，2015 年可用），我们预测了在 15 年内将慢性 HCV 流行率降低一半或四分之三所需的治疗率。目前的 HCV 治疗率对墨尔本和温哥华的流行率可能影响极小（相对减少<2%），但在 15 年内，爱丁堡的流行率可能降低 26%。在爱丁堡、墨尔本或温哥华，每年每 1000 名 PWID 治疗 15、40 或 76 人，流行率可在 15 年内减半（分别增加 2、13 和 15 倍）。每年每 1000 名 PWID 治疗 22、54 或 98 人，可在 15 年内将流行率降低四分之三。延迟治疗、较高的基线流行率或较短的平均注射时间会产生较小的影响。结果对风险异质性或将治疗限于接受 OST 的 PWID 不敏感。在现有的 HCV 药物成本下，将慢性流行率减半需要在爱丁堡每年治疗预算 320 万美元，在墨尔本和温哥华则需要大约 5000 万美元。
无干扰素的 DAA 可增加 PWID 对 HCV 的治疗接受率，从而产生重大预防影响。然而，治疗费用可能会限制治疗规模，这一点需要解决。
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