在墨西哥提华纳，能否实现针对注射吸毒人群的丙型肝炎病毒 (HCV) 消除？一项建模分析。
Is hepatitis C virus (HCV) elimination achievable among people who inject drugs in Tijuana, Mexico? A modeling analysis.
机构信息
Department of Family Medicine & Public Health, University of California San Diego, La Jolla, California, United States; School of Public Health, San Diego State University, San Diego, California, United States.
Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States.
出版信息
Int J Drug Policy. 2021 Feb;88:102710. doi: 10.1016/j.drugpo.2020.102710. Epub 2020 Mar 9.
BACKGROUND
In 2019, Mexico became the first Latin American country committed to hepatitis C virus (HCV) elimination, but the amount of intervention scale-up required is unclear. In Tijuana, HCV among people who inject drugs (PWID) is high; yet there is minimal and intermittent harm reduction, and involuntary exposure to compulsory abstinence programs (CAP) occurs which is associated with increased HCV risk. We determined what combination intervention scale-up can achieve HCV elimination among current and former PWID in Tijuana.
METHODS
We constructed a dynamic, deterministic model of HCV transmission, disease progression, and harm reduction among current and former PWID parameterized to Tijuana (~10,000 current PWID, 90% HCV seropositive, minimal opiate agonist therapy [OAT] or high coverage needle/syringe programs [HCNSP]). We evaluated the number of direct-acting antiviral (DAA) treatments needed from 2019 to achieve elimination targets (80% incidence reduction, 65% mortality reduction by 2030) with: (a) DAAs alone, (b) DAAs plus scale-up of OAT+HCNSP (up to 50% coverage of OAT and HCNSP separately, producing 25% of PWID receiving both), (c) DAAs plus CAP scale-up to 50%. Scenarios examined the number of DAAs required if prioritized to current PWID or provided regardless of current injection status, and impact of harm reduction interruptions.
RESULTS
Modeling suggests among ~30,000 current and former PWID in Tijuana, 16,160 (95%CI: 12,770-21,610) have chronic HCV. DAA scale-up can achieve the incidence target, requiring 770 treatments/year (95%CI: 640-970) if prioritized to current PWID. 40% fewer DAAs are required with OAT+HCNSP scale-up to 50% among PWID, whereas more are required with involuntary CAP scale-up. Both targets can only be achieved through treating both current and former PWID (1,710 treatments/year), and impact is reduced with harm reduction interruptions.
CONCLUSIONS
Elimination targets are achievable in Tijuana through scale-up of harm reduction and DAA therapy, whereas involuntary CAP and harm reduction interruptions hamper elimination.
背景
2019 年，墨西哥成为首个致力于消除丙型肝炎病毒（HCV）的拉丁美洲国家，但需要扩大干预规模的程度尚不清楚。在提华纳，注射毒品者（PWID）中的 HCV 感染率很高；然而，减害服务的提供很少且断断续续，而且会强制 PWID 参加强制性戒毒计划（CAP），这会增加 HCV 感染的风险。我们确定了在提华纳，当前和既往 PWID 中扩大联合干预措施可以达到消除 HCV 的效果。
方法
我们构建了一个 HCV 传播、疾病进展和当前及既往 PWID 中减害服务的动态、确定性模型，参数化到提华纳（约 10,000 名当前 PWID，90% HCV 血清阳性，最小阿片类激动剂治疗[OAT]或高覆盖率针/注射器方案[HCNSP]）。我们评估了从 2019 年开始需要多少直接作用抗病毒（DAA）治疗才能达到消除目标（2030 年发病率降低 80%，死亡率降低 65%）：（a）仅 DAA，（b）DAA 加 OAT+HCNSP 扩大规模（OAT 和 HCNSP 分别覆盖 50%，使 25%的 PWID 同时接受两种治疗），（c）扩大 CAP 规模至 50%。检查了如果优先考虑当前 PWID 或无论当前注射状况如何提供 DAA，以及减害服务中断的情况下，所需 DAA 的数量。
结果
建模表明，在提华纳约 30,000 名当前和既往 PWID 中，有 16,160 人（95%CI：12,770-21,610）患有慢性 HCV。如果优先考虑当前 PWID，DAA 扩大规模可以达到发病率目标，每年需要 770 次治疗（95%CI：640-970）。如果将 OAT+HCNSP 扩大规模至 50%，PWID 所需的 DAA 数量减少 40%，而 CAP 扩大规模至 50%所需的 DAA 数量则更多。只有通过治疗当前和既往 PWID（每年 1,710 次治疗）才能实现这两个目标，而且减害服务中断会影响效果。
结论
通过扩大减害服务和 DAA 治疗，可以在提华纳实现消除目标，而强制性 CAP 和减害服务中断会阻碍消除。
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