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Evaluation of hepatitis C treatment-as-prevention within Australian prisons (SToP-C): a prospective cohort study
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from Jules: this concept of treatment-as-prevention was discussed 10 yeas ago when DAAs first became available, so like everything else in HCV here we are 15 years later and everyone is still struggling to eliminate HCV 7 to implement programs with old ideas. Its like we keep rehashing old ideas because our federal, city & state leadership has been asleep at the wheel. We knew we could eliminate HCV 15 years ago. Treatment-as-prevention was widely discussed 10 year ago, and now we are still struggling to implement in full policies to get there. When will federal authorities & the White House put up the money to eliminate HCV?????
Our Nation has set a goal to eliminate viral hepatitis by 2030.", Pres. Biden - (05/19/21)
HCV Elimination: Universal Routine Screening Should be Mandated - (06/01/21)
New CDC Update - Acute HCV Increased 14% from 2018 to 2019 - (05/19/21)
July 1, 2021 - Lancet Gastroenterol Hepatol
- Behzad Hajarizadeh, Jason Grebely, Marianne Byrne, Pip Marks, Janaki Amin, Hamish McManus, Tony Butler, Evan B Cunningham, Peter Vickerman, Natasha K Martin, John G McHutchison, Diana M Brainard, Carla Treloar, Georgina M Chambers, Luke Grant, Colette Mcgrath, Andrew R Lloyd,* Gregory J Dore,* on behalf of the SToP-C study groupâ€
"DAA treatment scale-up was associated with reduced HCV incidence in prison, indicative of a beneficial effect of HCV treatment-as-prevention in this setting. These findings support broad DAA treatment scale-up within incarcerated populations.....People who inject drugs (PWID) are incarcerated at high rates for drug-related crimes.4 Thus, in many countries, PWID and people who are incarcerated are priority populations, given their high burden of HCV infection and their role in ongoing HCV transmission.5, 6 Delivery of effective HCV prevention and treatment interventions to these two populations is central to elimination efforts.......Treatment-as-prevention, initially used in the context of HIV therapy,7 incorporates treatment as a tool for limiting the spread of an infection in epidemics in a particular setting"
In conclusion, the findings of the SToP-C study indicate that HCV treatment-as-prevention, through DAA treatment scale-up, is an effective strategy in prison settings. The findings support enhanced delivery of DAA therapy for incarcerated populations, and suggest further consideration of HCV treatment-as-prevention strategies among the broader population at risk of HCV infection. The combination of rapid DAA treatment scale-up with efficient HCV diagnosis and enhanced primary HCV prevention strategies is likely to have even greater effect on HCV transmission, given the high HCV transmission risk associated with injecting drug use in the prison setting.
Summary
Background
Limited empirical evidence exists for the effectiveness of hepatitis C virus (HCV) treatment-as-prevention. The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study aimed to assess the effect of HCV treatment-as-prevention in the prison setting.
Methods
SToP-C was a prospective study, including a before-and-after analysis, within a cohort of people incarcerated in two maximum-security prisons (male) and two medium-security prisons (one male, one female) in New South Wales, Australia. All prison inmates aged at least 18 years were eligible for enrolment. After HCV testing, participants were monitored for risk behaviours and HCV infection, among three sub-populations: uninfected (HCV antibody-negative); previously infected (HCV antibody-positive, HCV RNA-negative); and infected (HCV antibody and HCV RNA-positive). Uninfected participants were followed up every 3-6 months to detect HCV primary infection and previously infected participants were followed up every 3-6 months to detect re-infection.
Participants with HCV infection were assessed for treatment, initially standard-of-care treatment (administered by prison health services) from 2014 to mid-2017, then direct-acting antiviral (DAA) treatment scale-up from mid-2017 onwards (12 weeks of sofosbuvir plus velpatasvir, administered through SToP-C). Participants were followed up until study closure in November, 2019. The primary study outcome was HCV incidence before and after DAA treatment scale-up among participants at risk of HCV primary infection or re-infection. This study is registered with ClinicalTrials.gov, NCT02064049.
Findings
Between Oct 30, 2014, and Sept 30, 2019, 3691 participants were enrolled in the SToP-C study. 719 (19%) participants had detectable HCV RNA, 2240 (61%) were at risk of primary HCV infection, and 725 (20%) were at risk of re-infection at baseline.
DAA treatment was initiated in 349 (70%) of 499 eligible participants during the treatment scale-up period. The HCV incidence analysis comprised 1643 participants at risk of HCV infection or re-infection during longitudinal follow-up (median age 33 years [IQR 27-42]; 1350 [82%] male).
487 (30%) of 1643 participants reported injecting drugs in prison.
HCV incidence decreased from 8⋅31 per 100 person-years in the pre-treatment scale-up period to 4⋅35 per 100 person-years in the post-treatment scale-up period (incidence rate ratio [IRR] 0⋅52 [95% CI 0⋅36-0⋅78]; p=0⋅0007).
The incidence of primary infection decreased from 6⋅64 per 100 person-years in the pre-treatment scale-up period to 2⋅85 per 100 person-years in the post-treatment scale-up period (IRR 0⋅43 [95% CI 0⋅25-0⋅74]; p=0⋅0019), whereas the incidence of re-infection decreased from 12⋅36 per 100 person-years to 7⋅27 per 100 person-years (0⋅59 [0⋅35-1⋅00]; p=0⋅050).
Among participants reporting injecting drugs during their current imprisonment, the incidence of primary infection decreased from 39⋅08 per 100 person-years in the pre-treatment scale-up period to 14⋅03 per 100 person-years in the post-treatment scale-up period (IRR 0⋅36 [95% CI 0⋅16-0⋅80]; p=0⋅0091), and the incidence of re-infection decreased from 15⋅26 per 100 person-years to 9⋅34 per 100 person-years (0⋅61 [0⋅34-1⋅09]; p=0⋅093).
The adjusted analysis (adjusted for age, Indigenous Australian ethnicity, duration of stay in prison, previous imprisonment, injecting drug use status, and prison site) indicated a significant reduction in the risk of HCV infection between the pre-DAA treatment scale-up and post-DAA treatment scale-up periods (adjusted hazard ratio 0⋅50 [95% CI 0⋅33-0⋅76]; p=0⋅0014).
Interpretation
DAA treatment scale-up was associated with reduced HCV incidence in prison, indicative of a beneficial effect of HCV treatment-as-prevention in this setting. These findings support broad DAA treatment scale-up within incarcerated populations.
Funding
Australian National Health and Medical Research Council Partnership Project Grant and Gilead Sciences.
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