全球、区域和国家级不稳定住房对注射吸毒人群中 HIV 和丙型肝炎病毒传播的贡献：一项建模研究。

BACKGROUND: A considerable proportion of people who inject drugs are unstably housed. Although unstable housing is associated with HIV and HCV infection among people who inject drugs, its contribution to transmission is unknown. We estimated the global and national proportions of incident HIV and HCV infections among people who inject drugs attributed to housing instability from 2020 to 2029. METHODS: In this modelling study, we developed country-level models of unstable housing and HIV and HCV transmission among people who inject drugs in 58 countries globally, calibrated to country-specific data on the prevalences of HIV and HCV and unstable housing. Based on a recently published systematic review, unstably housed people who inject drugs were assumed to have a 39% (95% CI 6-84) increased risk of HIV transmission and a 64% (95% CI 43-89%) increased risk of HCV transmission. We used pooled country-level estimates from systematic reviews on HCV and HIV prevalence in people who inject drugs. Our models estimated the transmission population attributable fraction (tPAF) of unstable housing to HIV and HCV transmission among people who inject drugs, defined as the percentage of infections prevented from 2020 to 2029 if the additional risk due to unstable housing was removed. FINDINGS: Our models were produced for 58 countries with sufficient data (accounting for >66% of the global people who inject drugs population). Globally, we project unstable housing contributes 7·9% (95% credibility interval [CrI] 2·3-15·7) of new HIV infections and 11·2% (7·7-15·5) of new HCV infections among people who inject drugs from 2020 to 2029. Country-level tPAFs were strongly associated with the prevalence of unstable housing. tPAFs were greater in high-income countries (HIV 17·2% [95% CrI 5·1-30·0]; HCV 19·4% [95% CrI 13·8-26·0]) than in low-income or middle-income countries (HIV 6·6% [95% CrI 1·8-13·1]; HCV 8·3% [95% CrI 5·5-11·7]). tPAFs for HIV and HCV were highest in Afghanistan, Czech Republic, India, USA, England, and Wales where unstable housing contributed more than 20% of new HIV and HCV infections. INTERPRETATION: Unstable housing is an important modifiable risk factor for HIV and HCV transmission among people who inject drugs in many countries. The study emphasises the importance of implementing initiatives to mitigate these risks and reduce housing instability. FUNDING: National Institute for Health Research and National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse.

背景：相当一部分吸毒者居住不稳定。尽管不稳定的住房与吸毒者中的 HIV 和 HCV 感染有关，但它对传播的贡献尚不清楚。我们估计了 2020 年至 2029 年期间，全球 58 个国家/地区因住房不稳定而导致的吸毒者中新发 HIV 和 HCV 感染的全球和国家比例。

方法：在这项建模研究中，我们针对全球 58 个国家/地区的吸毒者中的不稳定住房和 HIV 和 HCV 传播建立了国家/地区模型，并针对特定国家/地区的 HIV 和 HCV 流行率和不稳定住房进行了校准。基于最近发表的系统评价，我们假设不稳定住房的吸毒者 HIV 传播风险增加 39%（95%CI 6-84），HCV 传播风险增加 64%（95%CI 43-89%）。我们使用了关于吸毒者中 HCV 和 HIV 流行率的系统评价的汇总国家层面估计值。我们的模型估计了不稳定住房对吸毒者中 HIV 和 HCV 传播的归因于传播的人群比例（tPAF），定义为如果消除由于不稳定住房而导致的额外风险，从 2020 年至 2029 年预防的感染百分比。

结果：我们的模型是针对具有足够数据的 58 个国家/地区（占全球吸毒者人口的>66%）制作的。全球范围内，我们预计不稳定住房将导致 2020 年至 2029 年期间吸毒者中新发 HIV 感染的 7.9%（95%置信区间[CrI] 2.3-15.7）和新 HCV 感染的 11.2%（7.7-15.5）。国家层面的 tPAF 与不稳定住房的流行率密切相关。高收入国家（HIV 17.2%[95%CrI 5.1-30.0]；HCV 19.4%[95%CrI 13.8-26.0]）的 tPAF 大于低收入或中等收入国家（HIV 6.6%[95%CrI 1.8-13.1]；HCV 8.3%[95%CrI 5.5-11.7]）。阿富汗、捷克共和国、印度、美国、英国和威尔士的 HIV 和 HCV 的 tPAF 最高，不稳定住房导致的 HIV 和 HCV 新感染超过 20%。

解释：不稳定的住房是许多国家/地区吸毒者中 HIV 和 HCV 传播的一个重要可改变的危险因素。该研究强调了实施减轻这些风险和减少住房不稳定的举措的重要性。

资金来源：美国国立卫生研究院、美国国立过敏和传染病研究所、美国国立药物滥用研究所。