Academic Medical Center
Hiv en hepatitis C virus infecties bij druggebruikers: werkt harm reductie? Prof. Maria Prins GGD Amsterdam en AMC 2de Harm Reduction Congres, 14 april 2016 ,Utrecht
Hiv en hepatitis C virus (HCV) infecties bij druggebruikers: Werkt harm reductie?
Inhoud 1. 2. 3. 4.
Epidemiologie HCV (en hiv) infecties Effect harm reductie programma’s op verspreiding infecties Harm reductie en behandeling van infecties Conclusies en Public Health uitdagingen
1. Epidemiology Prevalence of anti-HCV in people who inject drugs
Globally 10 million anti-HCV positive Midpoint anti-HCV prevalence: 67.0%
Nelson et al, Lancet 2011
Incidence of HCV infection in people who inject drugs
Median 13 cases/100 py (IQR 8.7-28)
Wiessing et al, PLOS One 2014
HIV and HCV incidence by recruitment cohort ALIVE cohort, Baltimore, USA
Mehta et et al, JID 2011
Estimated number of adults (aged 15-79 years) living with HCV antibodies in the Netherlands, per main subgroup, 2009
28,100 HCV-infected individuals (min n=9600, max n=48000) Vriend, Epidemiol Infect 2012
Annual number of HIV-1 diagnoses per transmission group, Netherlands
SHM monitoring report 2014
HIV incidence among drug users Amsterdam Cohort Studies (ACS) 1984-2011
Number of acute HCV infections by transmission route, the Netherlands, 2004-2013 The Netherlands, 2004-2013
60
nr of infections
50
40
30
20
10
0 2004
2005
heteros ex ual
2006
2007
MSM
IDU
2008
2009
occupational accident
2010
vertical
2011
2012
other
2013
unknown
Source: RIVM-OSIRIS, notification data
HCV incidence among people who use drugs, Amsterdam Cohort Studies, the Netherlands, 1986-2012
20 15
Ever injected
10
All drug users
5 0 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08 20 10 20 12
Cases per 100 person years
25
Update: van den Berg, Eur J Epidemiol 2007, SHM report 2013
2. Effect harm reductie programma’s op verspreiding infecties Bus of the Public Health Service of Methadone Amsterdam Dam Square, Amsterdam, The Netherlands 1989
photo ANP
Trends in self-reported injecting and sexual risk behaviour among PWUD, ACS
STI screening 2010-2011 Prevalence : 2.5%
v.d. Knaap, Grady et al, Plos One 2013
Annual number of needles exchanged in Amsterdam 1984-2013 1.200.000 1.000.000 number
800.000 600.000 400.000 200.000 0 2012
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
year
Effect of harm reduction participation on HIV and HCV incidence: `Findings from the Amsterdam Cohort Studies among drug users HIV
HCV
IRR No harm reduction
95% CI 1
p value IRR <0.001
95% CI 1
<0.001
Incomplete harm reduction
0.87
(0.50-1.52)
1.17
(0.59-2.31)
Full harm reduction
0.43
(0.21-0.87)
0.36
(0.13-1.03)
-Limited dependence -No dependence
p value
0.046 (0.006-0.35)
0.044 (0.006-0.35)
0.20 (0.078-0.50)
0.13 (0.044-0.40)
Adjusted for injection duration, HIV status steady partner (for HIV only)
:
v.d. Berg et al, Addiction 2007
van den Berg Addiction 2007, Craine Epidemiol Infect 2009, Turner Addiction 2011, Hagen JID 2011, de Vos Addiction 2013, Iversen m J Public Heath 2013, McArthur Int J Drug Policy 2014
HIV and HCV spread model based on data from Amsterdam
rate, per 100 person years.
HCV incidence 30
Lowered risk?
25 20
A
A
15A
A A
10
A
5 0 1986
A
A
Baseline model ACSdata HarmReduction
A
A
A
A A A
1990
A
Main trends in HIV and HCV incidence among Amsterdam DU were reproduced assuming no harm reduction effects
A A
2000
A
A A
A A A A A
A
2010
calendar year
Assuming harm reduction measures had led to a strong decrease in risk behaviour over time improved the model
Universitair Medisch Centrum Utrecht
*de Vos et al, Addiction 2013
Phylogenetic analysis of 315 HIV-1 pol sequences ; Solid lines – branches of sequences of the MSM cohort participants; Dotted lines – those of the DU cohort participants * – sample from 2003
* 9 6
*
DU cluster
* 0.00 5
* (0 branch length)
HIV-1 strains specific (black) and non-specific (white) for drug users, seroconverters ACS p=0.0040 (**) 10 9 8 7 6 5 4 3 2 1 0
2005
2002
2000
1998
1996
1994
1992
1990
1988
1986
*
Lukashov at al. JAIDS 2013
3. Harm reductie en behandeling van infecties
van der Meer, JAMA 2012
11
Med. n of prevalent cases with HCV-related disease. No treatment Med. n of prevalent cases with HCV-related disease. Treating 25% of HIV negative PWID successfully: current situation Med. n of prevalent cases with HCV-related disease. Treating 95% of HIV negatives successfully and 65% of HIV positives. Potential future scenario Matser at al. Addiction 2012
EDINBURGH, SCOTLAND: ELIMINATION ACHIEVABLE WITH DAA SCALE-UP GIVEN LOW PREVALENCE
IFN-free DAAs
22 Martin et al. Hepatology 2013
HCV chronic prevalence among PWID (%)
7 UK CITIES: DAA SCALE-UP TO RATES CURRENTLY ACHIEVED RESULTS IN ELIMINATION IN LOWER PREVALENCE SETTINGS
100 90 80
Baseline in 2014 2024, no scale-up, ITT SVR with PEG-IFN + RBV 2024, scale-up to 26/1000 annually with IFN-free DAAs (all genotypes) in 2016
70 60 50 40 30 20 10 0
Bristol
East London
Manchester Nottingham Plymouth
Martin et al. Journal Viral Hepatitis 2014 23
Dundee
North Wales
FRANCE: HIGH LEVELS OF EXISTING TREATMENT MAY BE SUFFICIENT FOR ELIMINATION?
24
Cousien et al, Hepatology 2015
COMBINATION PREVENTION (HARM REDUCTION+DAAs) COULD ACHIEVE ELIMINATION AMONG PWID EVEN IN HIGH PREVALENCE SETTINGS 60% chronic HCV prevalence among PWID
• White: >80% reduction in prevalence within 10 years • Large (>40%) reductions require treatment
Martin et al, Clinical Infectious Diseases 2013 25
Who should we cure first? HCV treatment as prevention in people who inject drugs (PWID) Reinfections among key risk populations occur: pooled risk in PWID: 2.4/100py Aspinall Clin Inf Dis 2013
Modelling study: to which group treatment is best targeted When more than half of all exchanged syringes in a population of PWID are
contaminated by HCV, it is most efficient to treat low-risk PWID first.
Corresponding threshold of HCV-RNA-prevalence among PWID: 32%
Below this threshold, it is most efficient to treat high-risk PWID first
De Vos et al, Addiction, 2015
Proportion (%) of HCV-infected people who inject drugs undiagnosed
Median 49% (IQR 38-64)
Wiessing et al, PLOS One 2014
4. Conclusies en Public Health Uitdagingen Epidemiologie hiv en HCV onder klassieke druggebruikers in Nederland – weinig nieuwe hiv en HCV infecties, – groep speelt nauwelijks een rol in verspreiding van deze infecties – grote groep chronisch HCV geïnfecteerde personen Harm reductie lijkt een rol te hebben gespeeld in de afname maar is niet de enige verklaring Belangrijk is brede “harm reductie” benadering en hoge dekkingsgraad Hiv en HCV behandelingen verminderen ziektelast en kunnen bijdragen aan potentiele verdere verspreiding Hiv therapieën in Nederland droegen beperkt bij: 4% afname in HIV incidentie (Anneke de Vos, AIDS 2014)
Modellen suggereren dat HCV therapieën zeker kunnen bijdragen indien voldoende en de juiste personen worden bereikt en behandeld
4. Conclusies en Public Health Uitdagingen Toegespitst op Nederland 1.
2. 3. 4. 5. 6. 7. 8.
Hoe en waar sporen we effectief nog niet gediagnosticeerde en niet in zorg zijnde chronisch geïnfecteerde druggebruikers? Hoeveel zijn er bereikt en succesvol behandeld? Zien we groepen waar verspreiding plaatsvindt over het hoofd? Hoe motiveren we hen zich te laten testen en behandelen? Hoe verhogen we het bewustzijn bij professionals & doelgroepen? Hoe regelen we de toegang tot zorg het best? Hoe voorkomen we her-infecties? Is het kosteneffectief (ja, van Santen, submitted) en welke aanpak is het meest kosten effectief ? ≠ kostensparend ≠ goedkoop
Thanks Colleagues GGD Adam, deelnemers ACS Anneke de Vos (UMCU) , Lucas Wiessing (EMCDDA), Natasha Martin (University of California San Diego, USA),
