Effectiveness and cost-effectiveness of interventions targeting harm reduction and chronic hepatitis C cascade of care in people who inject drugs: The case of France.

Direct-acting antivirals (DAAs) represent an opportunity to improve hepatitis C virus (HCV) care cascade. This combined with improved harm reduction interventions may lead to HCV elimination especially in people who inject drugs (PWID). We assessed the effectiveness/cost-effectiveness of improvements in harm reduction and chronic hepatitis C (CHC) care cascade in PWID in France. We used a dynamic model of HCV transmission and CHC natural history and evaluated the following: improved needle/syringe programmes-opioid substitution therapies, faster diagnosis/linkage to care, earlier treatment initiation, alone and in combination among active PWID (mean age = 36). Outcomes were as follows: life expectancy in discounted quality-adjusted life years (QALYs); direct lifetime discounted costs; incremental cost-effectiveness ratio (ICER); number of infections/reinfections. Under the current practice, life expectancy was 15.846 QALYs, for a mean lifetime cost of €20 762. Treatment initiation at F0 fibrosis stage alone was less effective and more costly than faster diagnosis/linkage to care combined with treatment initiation at F0, which increased life expectancy to 16.694 QALYs, decreased new infections by 37%, with a ICER = €5300/QALY. Combining these interventions with harm reduction improvements was the most effective scenario (life expectancy = 16.701 QALYs, 41% decrease in new infections) but was not cost-effective (ICER = €105 600/QALY); it became cost-effective with higher initial HCV incidence rates and lower harm reduction coverage than in our base-case scenario. This study illustrated the high effectiveness, and cost-effectiveness, of a faster diagnosis/linkage to care together with treatment from F0 with DAAs. This "Test and treat" strategy should play a central role both in improving the life expectancies of HCV-infected patients, and in reducing HCV transmission.

Dynamic modelling of hepatitis C virus transmission among people who inject drugs: a methodological review.

Equipment sharing among people who inject drugs (PWID) is a key risk factor in infection by hepatitis C virus (HCV). Both the effectiveness and cost-effectiveness of interventions aimed at reducing HCV transmission in this population (such as opioid substitution therapy, needle exchange programmes or improved treatment) are difficult to evaluate using field surveys. Ethical issues and complicated access to the PWID population make it difficult to gather epidemiological data. In this context, mathematical modelling of HCV transmission is a useful alternative for comparing the cost and effectiveness of various interventions. Several models have been developed in the past few years. They are often based on strong hypotheses concerning the population structure. This review presents compartmental and individual-based models to underline their strengths and limits in the context of HCV infection among PWID. The final section discusses the main results of the papers.

Prevalence of human immunodeficiency virus and hepatitis C virus among French prison inmates in 2010: a challenge for public health policy.

We evaluated prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among prison inmates in France in 2010, in a cross-sectional single-day study based on a two-stage design. Sampling favoured larger establishments and included all types of prisons. Establishments were stratified by geographical region. Estimates were adjusted by post-stratification of the total population of inmates in France. From 60,975 inmates in all 188 prisons on the sampling day, 2,154 were selected from 27 prisons, and 1,876 questionnaires completed. HIV prevalence was estimated at 2.0% (95% confidence interval (CI): 0.9­4.2), 2.6% (95% CI: 0.7­8.8) in women and 2.0% (95% CI: 0.9­4.3) in men; 75% of inmates were receiving treatment for HIV. HCV prevalence was estimated at 4.8% (95% CI: 3.5­6.5) and was higher for women (11.8%; 95% CI: 8.5­16.1) than men (4.5%; 95% CI: 3.3­6.3). Almost half of HCV-infected inmates had chronic hepatitis C and 44% were receiving or had received treatment. HIV and HCV prevalence was six times higher than in the general population, and 2.5% of inmates had viraemic hepatitis C. The moment of incarceration provides an ideal opportunity for testing and treating, limiting spread of HCV and improving patients' prognosis.

Mandatory immunization: the point of view of the French general population and practitioners.

This survey studies the opinion of the French general population, general practitioners and pediatricians regarding mandatory immunization. Data were collected through standardized telephone questionnaires administered to representative samples of the French population (n=4112) and of French general practitioners and pediatricians (1285 general practitioners (GPs) and 742 pediatricians). 56.5% of the general population is in favor of mandatory vaccination. Being in favor of hepatitis B vaccination, agreeing that "it would be important to continue immunizing against diphtheria in case immunization was made optional" or saying that "if immunization against diphtheria was discontinued, the disease would spread again", are some of the main determinants of a favorable opinion regarding mandatory immunization. The percentage of GPs and pediatricians in favor of mandatory immunization is 42%. Female pediatricians and those who would "insist on families in the importance of continuing immunizing all children against diphtheria in case this vaccination was only recommended" more often declare themselves in favor of mandatory immunization. The adoption of the principle of mandatory immunization seems to stem from the adoption of immunization as an individual and collective prevention tool.

Impact of a harm-reduction policy on HIV and hepatitis C virus transmission among drug users: recent French data--the ANRS-Coquelicot Study.

In France a harm-reduction policy was implemented in the late 1980s with the aim of reducing the prevalence of HIV and hepatitis C virus (HCV) infection among drug users. The ANRS-Coquelicot survey was designed to measure the prevalence of HIV and HCV infection among drug users and to examine determinants of at-risk behaviors. In 2002, information was collected from 166 drug users recruited in all types of services specializing in drug use intervention and harm reduction in Marseille, France. Self-reported HIV and HCV serostatus was compared with the results of serological tests done on capillary blood collected on filter paper. The self-reported and biologically documented prevalence rates of HIV infection were identical (22%). In contrast, the self-reported prevalence of HCV infection was 52%, whereas the biologically documented prevalence was 73%. Overall, 30% of HCV-infected drug users were unaware of their status. Forty-four percent of drug users under 30 years of age were HCV seropositive, suggesting that they had been infected early during drug use. The harm-reduction policy seems to have had a marked impact on HIV transmission among drug users but a much more limited impact on HCV transmission. The limitations and implications of the study are discussed.