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October 3 -7, 2019
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Iceland Making Progress Toward
Eliminating HCV--But Challenges Remain

  IDWeek, October 2-6, 2019, Washington, DC
Mark Mascolini
Iceland may be on its way to eliminating HCV infection through aggressive outreach and use of direct-acting antivirals (DAAs), according to analysis of recent data [1]. But challenges remain, including rising injection drug use and increasing homelessness.
Several factors suggest that Iceland has a good shot at eliminating HCV infection by 2020 through robust case-searching and widespread use of DAAs. Researchers at Landspitali University Hospital and collaborators at other centers noted that Iceland has had mandatory HCV reporting since 1991, an estimated viremic HCV prevalence of only 0.3%, and about 800 to 1000 total cases, more than 80% of them already diagnosed. HCV-infected people have unrestricted access to DAAs through national health insurance.
In 2016 Iceland launched the Treatment as Prevention for Hepatitis C (TraP HepC) program, which aims to find and treat people with HCV and to track incidence of domestic HCV transmission, cirrhosis, and hepatocellular carcinoma, and to monitor HCV prevalence in people who inject drugs. TraP HepC intends to treat all HCV PCR-positive people in Iceland, including active drug injectors, incarcerated people, and people with advanced liver fibrosis or cirrhosis.
TraP HepC had a swift impact on HCV testing. From 2009 through 2015, fewer than 6000 HCV tests were recorded yearly. In 2016, the first year of TraP HepC, that number shot to 6717, then to 8481 in 2017, and to 9811 in 2018, a highly significant increase over previous years (P < 0.001). From January 2016 through July 2019, Iceland recorded 845 baseline HCV evaluations in 757 people and 818 treatment initiations in 733 people. Those numbers accounted for more than 90% of the estimated total number of HCV patients in the country.
A recent HCV cure analysis involved 407 people who did not inject drugs in the past 6 months and 202 who did. The overall cure rate was significantly higher in the noninjecting group than in current injectors, but still excellent in current injectors (92.4% versus 82.9%, P = 0.0006). An analysis limited to people who completed treatment determined cure rates of 95.3% in noninjectors and 89.9% in current injectors (P = 0.0254).
Analysis of 210 recent injectors found higher cure rates among those living in halfway houses (93%), in their own property or with relatives (86%), and in penitentiaries (81%), than in homeless people (67%). People who injected stimulants had a higher cure rate than those who injected opiates (85% versus 69%). Modeling incorporating these and other variables determined that only homelessness independently predicted treatment failure (RR 2.417, 95% confidence interval 1.34 to 4.37, P = 0.0077).
Researchers tracked prevalence of HCV viremia in drug injectors at Vogur Addiction Hospital, a sentinel site, from 2010 through 2018. Among current injectors viremia prevalence hovered around 50% through 2015 then dropped steeply when TraP HepC arrived in 2016, falling to 10% in 2018.
But recent data also indicate challenges to eliminating HCV by 2020. Since 2014 the number of newly identified drug injectors seen at Vogur Addiction Hospital climbed by 48%. According to wastewater analysis, since 2016 Reykjavik, Iceland's capital, saw a 3-fold jump in amphetamine levels and an 8-fold jump in cocaine levels. From 2009 through 2017, homelessness tripled in Reykjavik, attributed to increasing drug use, rising alcohol use, and spiking psychological problems.
The researchers concluded that HCV elimination efforts via TraP HepC are going well, even among people actively injecting drugs. They predicted that "Iceland is on track to eliminate HCV," but challenges including increasing drug use and homelessness must be addressed because they "may jeopardize the success of elimination efforts."
1. Gottfredsson M, Runarsdottir V, Love TJ, et al. Threats to successful elimination of viral hepatitis: results from the nationwide treatment as prevention for hepatitis C (TraP HepC) program in Iceland. IDWeek, October 2-6, 2019, Washington, DC. Abstract 2895.