Modelling the impact of HIV and hepatitis C virus prevention and treatment interventions among people who inject drugs in Kenya.

OBJECTIVES: People who inject drugs (PWID) in Kenya have high HIV (range across settings: 14-26%) and hepatitis C virus (HCV; 11-36%) prevalence. We evaluated the impact of existing and scaled-up interventions on HIV and HCV incidence among PWID in Kenya. DESIGN: HIV and HCV transmission model among PWID, calibrated to Nairobi and Kenya's Coastal region. METHODS: For each setting, we projected the impact (percent of HIV/HCV infections averted in 2020) of existing coverages of antiretroviral therapy (ART; 63-79%), opioid agonist therapy (OAT; 8-13%) and needle and syringe programmes (NSP; 45-61%). We then projected the impact (reduction in HIV/HCV incidence over 2021-2030), of scaling-up harm reduction [Full harm reduction ('Full HR'): 50% OAT, 75% NSP] and/or HIV (UNAIDS 90-90-90) and HCV treatment (1000 PWID over 2021-2025) and reducing sexual risk (by 25/50/75%). We estimated HCV treatment levels needed to reduce HCV incidence by 90% by 2030. RESULTS: In 2020, OAT and NSP averted 46.0-50.8% (range of medians) of HIV infections and 50.0-66.1% of HCV infections, mostly because of NSP. ART only averted 12.9-39.8% of HIV infections because of suboptimal viral suppression (28-48%). Full HR and ART could reduce HIV incidence by 51.5-64% and HCV incidence by 84.6-86.6% by 2030. Also halving sexual risk could reduce HIV incidence by 68.0-74.1%. Alongside full HR, treating 2244 PWID over 2021-2025 could reduce HCV incidence by 90% by 2030. CONCLUSION: Existing interventions are having substantial impact on HIV and HCV transmission in Kenya. However, to eliminate HIV and HCV, further scale-up is needed with reductions in sexual risk and HCV treatment.

An intensive model of care for hepatitis C virus screening and treatment with direct-acting antivirals in people who inject drugs in Nairobi, Kenya: a model-based cost-effectiveness analysis.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) treatment is essential for eliminating HCV in people who inject drugs (PWID), but has limited coverage in resource-limited settings. We measured the cost-effectiveness of a pilot HCV screening and treatment intervention using directly observed therapy among PWID attending harm reduction services in Nairobi, Kenya. DESIGN: We utilized an existing model of HIV and HCV transmission among current and former PWID in Nairobi to estimate the cost-effectiveness of screening and treatment for HCV, including prevention benefits versus no screening and treatment. The cure rate of treatment and costs for screening and treatment were estimated from intervention data, while other model parameters were derived from literature. Cost-effectiveness was evaluated over a life-time horizon from the health-care provider's perspective. One-way and probabilistic sensitivity analyses were performed. SETTING: Nairobi, Kenya. POPULATION: PWID. MEASUREMENTS: Treatment costs, incremental cost-effectiveness ratio (cost per disability-adjusted life year averted). FINDINGS: The cost per disability-adjusted life-year averted for the intervention was $975, with 92.1% of the probabilistic sensitivity analyses simulations falling below the per capita gross domestic product for Kenya ($1509; commonly used as a suitable threshold for determining whether an intervention is cost-effective). However, the intervention was not cost-effective at the opportunity cost-based cost-effectiveness threshold of $647 per disability-adjusted life-year averted. Sensitivity analyses showed that the intervention could provide more value for money by including modelled estimates for HCV disease care costs, assuming lower drug prices ($75 instead of $728 per course) and excluding directly-observed therapy costs. CONCLUSIONS: The current strategy of screening and treatment for hepatitis C virus (HCV) among people who inject drugs in Nairobi is likely to be highly cost-effective with currently available cheaper drug prices, if directly-observed therapy is not used and HCV disease care costs are accounted for.

Modelling the impact of HIV and HCV prevention and treatment interventions for people who inject drugs in Dar es Salaam, Tanzania.

INTRODUCTION: People who inject drugs (PWID) in Dar es Salaam, Tanzania, have a high prevalence of HIV and hepatitis C virus (HCV). While needle and syringe programmes (NSP), opioid agonist therapy (OAT) and anti-retroviral therapy (ART) are available in Tanzania, their coverage is sub-optimal. We assess the impact of existing and scaled up harm reduction (HR) interventions on HIV and HCV transmission among PWID in Dar es Salaam. METHODS: An HIV and HCV transmission model among PWID in Tanzania was calibrated to data over 2006-2018 on HIV (∼30% and ∼67% prevalence in males and females in 2011) and HCV prevalence (∼16% in 2017), numbers on HR interventions (5254 ever on OAT in 2018, 766-1479 accessing NSP in 2017) and ART coverage (63.1% in 2015). We evaluated the impact of existing interventions in 2019 and impact by 2030 of scaling-up the coverage of OAT (to 50% of PWID), NSP (75%, both combined termed "full HR") and ART (81% with 90% virally suppressed) from 2019, reducing sexual HIV transmission by 50%, and/or HCV-treating 10% of PWID infected with HCV annually. RESULTS: The model projects HIV and HCV prevalence of 19.0% (95% credibility interval: 16.4-21.2%) and 41.0% (24.4-49.0%) in 2019, respectively. For HIV, 24.6% (13.6-32.6%) and 70.3% (59.3-77.1%) of incident infections among male and female PWID are sexually transmitted, respectively. Due to their low coverage (22.8% for OAT, 16.3% for NSP in 2019), OAT and NSP averted 20.4% (12.9-24.7%) of HIV infections and 21.7% (17.0-25.2%) of HCV infections in 2019. Existing ART (68.5% coverage by 2019) averted 48.1% (29.7-64.3%) of HIV infections in 2019. Scaling up to full HR will reduce HIV and HCV incidence by 62.6% (52.5-74.0%) and 81.4% (56.7-81.4%), respectively, over 2019-2030; scaled up ART alongside full HR will decrease HIV incidence by 66.8% (55.6-77.5%), increasing to 81.5% (73.7-87.5%) when sexual risk is also reduced. HCV-treatment alongside full HR will decrease HCV incidence by 92.4% (80.7-95.8%) by 2030. CONCLUSIONS: Combination interventions, including sexual risk reduction and HCV treatment, are needed to eliminate HCV and HIV among PWID in Tanzania.

Population estimation and harm reduction among people who inject drugs in Addis Ababa, Ethiopia.

BACKGROUND: Injecting drug use is known to contribute significantly to the spread of the HIV epidemic in many parts of the developing world. Due to the hidden nature and stigma of the problem, it is difficult to study using routine surveys. Therefore, this study aims to estimate the number of people who inject drugs in Addis Ababa, Ethiopia, and to describe the epidemiological and social situation related to HIV among people who inject drugs. METHODS: The study used rapid assessment methods, followed by combined methods of estimating populations, using nomination and multiplier methods. The combined methods used two datasets: the first includes the proportion of people who use services within a year as a multiplier, and the second, a count of the list of people with a problem who used the specific service within a year as a benchmark. The rapid assessment incorporated different qualitative tools to elicit information related to injectable drugs, using existing data sources, in-depth interviews, and focus group discussions. RESULTS: The study estimated a total of 4068; with 95% CI (3196, 5207) people who inject drugs (PWIDs) in Addis Ababa. The study found people who inject drugs were young in age, male, with a lower educational status, unmarried, and living in small clerical business. People who inject drugs and participated in the study were more likely to use additional substances like alcohol, khat, and cannabis. The most common form of injectable drug used was heroin, and most of the people who inject drugs reported sharing syringes and needles. A high proportion of study subjects also disclosed having positive test results for HIV, hepatitis B, and C. CONCLUSION: The population size of people who inject drugs in Addis Ababa is high. Lack of service in harm reduction in the city has made PWIDs vulnerable and at higher risk for HIV/AIDs and hepatitis B and C. Therefore, responsible bodies must start implementing the essential harm reduction strategies given by the World Health Organization.

Exploring the Perceived Risks and Benefits of Heroin Use among Young People (18-24 Years) in Mauritius: Economic Insights from an Exploratory Qualitative Study.

The decreasing age of young people injecting illicit drugs is an under-reported challenge for the prevention of HIV transmission worldwide. Young people aged 15-24 years represent 1 in 5 persons living with HIV in Mauritius where the epidemic is driven by injecting drug use and risky sexual behaviours. We recruited 22 heroin users aged 18-24 and 5 service providers working in harm reduction (HR) for the present study. Qualitative data were collected through unstructured interviews. We adopted an economic framework and an inductive approach to the analysis, which implied revising codes and themes. The risks heroin users described as consumers of illicit drugs and as clients of HR services could not be analyzed in isolation. Polydrug use emerged as a recurrent coping mechanism resulting from the changing dynamics within the heroin market. The risks faced by women went beyond addiction and infection with HIV. How participants viewed the risks and benefits linked to using heroin was greatly influenced by gaps in knowledge that left room for uncertainty and reinforcing mechanisms such as peer influence. The study shows that qualitative research can produce in-depth socio-behavioural insights required to produce more effective services for young people.