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1.
Addiction ; 2020 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-33140543

RESUMO

BACKGROUND AND AIM: Globally, nearly one in five people who inject drugs (PWID) are living with HIV, and the rate of new HIV infections in PWID is increasing in some settings. Early diagnosis is crucial for effective HIV control. We reviewed the evidence on the association between opioid agonist therapy (OAT) and HIV testing uptake among PWID. METHODS: We conducted a systematic review searching MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and PsycINFO for studies published January 2000 to March 2019. Reference lists and conference proceedings were hand-searched. Observational and intervention studies were eligible for inclusion. Risk of bias was assessed using the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tool. Meta-analyses were conducted using random-effects models. RESULTS: Of 13,373 records identified, 11 studies from Australia, Europe, Malaysia, and USA were included. All studies had at least a serious risk of bias, largely due to confounding and selection bias, making it difficult to draw causal conclusions from the evidence. Ten studies provided data on the association between current OAT use and recent HIV testing. Six showed a positive association while four provided little evidence of an association - pooled odds ratio (OR): 1.71 (95% CI: 1.28-2.27). Looking at having ever been on OAT and having ever been HIV tested, seven studies showed a positive association and three showed either weak or no evidence of an association - pooled OR: 3.82 (95% CI: 2.96-4.95). CONCLUSIONS: Opioid agonist therapy may increase uptake of HIV testing among people who inject drugs, providing further evidence that opioid agonist therapy improves the HIV treatment care cascade.

2.
BMJ Open ; 10(11): e039234, 2020 Nov 18.
Artigo em Inglês | MEDLINE | ID: mdl-33208326

RESUMO

INTRODUCTION: In Vietnam, people who inject drugs (PWID), who are the major population infected by hepatitis C virus (HCV), remain largely undiagnosed and unlinked to HCV prevention and care despite recommended universal hepatitis C treatment. The data on the outcomes of HCV treatment among PWID also remain limited in resource-limited settings. The DRug use & Infections in ViEtnam-hepatitis C (DRIVE-C) study examines the effectiveness of a model of hepatitis C screening and integrated care targeting PWID that largely uses community-based organisations (CBO) in Hai Phong, Vietnam. In a wider perspective, this model may have the potential to eliminate HCV among PWID in this city. METHODS AND ANALYSIS: The model of care comprises large community-based mass screening, simplified treatment with direct-acting antivirals (DAAs) and major involvement of CBO for PWID reaching out, linkage to care, treatment adherence and prevention of reinfection. The effectiveness of DAA care strategy among PWID, the potential obstacles to widespread implementation and its impact at population level will be assessed. A cost-effectiveness analysis is planned to further inform policy-makers. The enrolment target is 1050 PWID, recruited from the DRIVE study in Hai Phong. After initiation of pan-genotypic treatment consisting of sofosbuvir and daclatasvir administrated for 12 weeks, with ribavirin added in cases of cirrhosis, participants are followed-up for 48 weeks. The primary outcome is the proportion of patients with sustained virological response at week 48, that will be compared with a theoretical expected rate of 70%. ETHICS AND DISSEMINATION: The study was approved by Haiphong University of Medicine and Pharmacy's Ethics Review Board and the Vietnamese Ministry of Health. The sponsor and the investigators are committed to conducting this study in accordance with ethics principles contained in the World Medical Association's Declaration of Helsinki (Ethical Principles for Medical Research Involving Human Subjects). Informed consent is obtained before study enrolment. The data are anonymised and stored in a secure database. The study is ongoing. Results will be presented at international conferences and submitted to international peer-review journals. TRIAL REGISTRATION NUMBER: NCT03537196.

3.
J Viral Hepat ; 2020 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-33051950

RESUMO

Despite the availability of effective direct-acting antiviral (DAA) treatments for Hepatitis C virus (HCV) infection, many people remain undiagnosed and untreated. We assessed the cost-effectiveness of a Médecins Sans Frontières (MSF) HCV screening and treatment programme within a primary health clinic in Karachi, Pakistan. A health state transition Markov model was developed to estimate the cost-effectiveness of the MSF programme. Programme cost and outcome data were analysed retrospectively. The incremental cost-effectiveness ratio (ICER) was calculated in terms of incremental cost (2016 US$) per disability-adjusted life year (DALY) averted from the provider's perspective over a lifetime horizon. The robustness of the model was evaluated using deterministic and probabilistic sensitivity analyses (PSA). The ICER for implementing testing and treatment compared to no programme was US$450/DALY averted, with 100% of PSA runs falling below the per capita Gross Domestic Product threshold for cost-effective interventions for Pakistan (US$1,422). The ICER increased to US$532/DALY averted assuming national HCV seroprevalence (5.5% versus 33% observed in the intervention). If the cost of liver disease care was included (adapted from resource use data from Cambodia which has similar GDP to Pakistan), the ICER dropped to US$148/DALY, while it became cost-saving if a recently negotiated reduced drug cost of $75/treatment course was assumed (versus $282 in base-case) in addition to cost of liver disease care. In conclusion, screening and DAA treatment for HCV infection are expected to be highly cost-effective in Pakistan, supporting the expansion of similar screening and treatment programmes across Pakistan.

4.
medRxiv ; 2020 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-33083811

RESUMO

Introduction The COVID-19 pandemic is impacting HIV care globally, with gaps in HIV treatment expected to increase HIV transmission and HIV-related mortality. We estimated how COVID-19-related disruptions could impact HIV transmission and mortality among men who have sex with men (MSM) in four cities in China. Methods Regional data from China indicated that the number of MSM undergoing facility-based HIV testing reduced by 59% during the COVID-19 pandemic, alongside reductions in ART initiation (34%), numbers of sexual partners (62%) and consistency of condom use (25%). A deterministic mathematical model of HIV transmission and treatment among MSM in China was used to estimate the impact of these disruptions on the number of new HIV infections and HIV-related deaths. Disruption scenarios were assessed for their individual and combined impact over 1 and 5 years for a 3-, 4- or 6-month disruption period. Results Our China model predicted that new HIV infections and HIV-related deaths would be increased most by disruptions to viral suppression, with 25% reductions for a 3-month period increasing HIV infections by 5-14% over 1 year and deaths by 7-12%. Observed reductions in condom use increased HIV infections by 5-14% but had minimal impact (<1%) on deaths. Smaller impacts on infections and deaths (<3%) were seen for disruptions to facility testing and ART initiation, but reduced partner numbers resulted in 11-23% fewer infections and 0.4-1.0% fewer deaths. Longer disruption periods of 4 and 6 months amplified the impact of combined disruption scenarios. When all realistic disruptions were modelled simultaneously, an overall decrease in new HIV infections was always predicted over one year (3-17%), but not over 5 years (1% increase - 4% decrease), while deaths mostly increased over one year (1-2%) and 5 years (1.2 increase - 0.3 decrease). Conclusions The overall impact of COVID-19 on new HIV infections and HIV-related deaths is dependent on the nature, scale and length of the various disruptions. Resources should be directed to ensuring levels of viral suppression and condom use are maintained to mitigate any adverse effects of COVID-19 related disruption on HIV transmission and control among MSM in China.

5.
PLoS One ; 15(10): e0240224, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33035238

RESUMO

OBJECTIVE: We aim to show the feasibility of using an integrated prevention and care continuum (PCC) model as a complete and improved tool for HIV control measurement and programming. Alignment of prevention and care continua is essential to further improve health outcomes and minimize HIV transmission risk. DESIGN: Cross-sectional study. METHODS: Data from 977 persons who inject drugs (PWID) collected in 2011-2016 in Tallinn, Estonia, were used to construct an HIV PCC for PWID, stratified by risk for acquiring or transmitting HIV infection and by coverage of combined interventions. We also estimated the average protective effect of current levels of intervention provision. RESULTS: 74.4%, 20.3% and 35.2% of PWID were currently using needle and syringe programmes (NSP), drug treatment and HIV testing, respectively. 51.1% of current PWID were HIV seropositive and of those 62.5% were currently on ART and 19.0% were virally suppressed. Across the PCC, individuals moved between categories of being aware and ever using drug treatment (resulting in -50% "leakage"); from ever having used to currently using drug treatment (-59%); between "ever testing" and "current (continuous) testing" (-62%); and from self-reported antiretroviral therapy (ART) adherence to viral suppression (-70%). Use of prevention services was higher among those at risk of transmission (HIV positive). The overall reduction in acquisition risk among HIV-negative PWID was 77.7% (95% CrI 67.8-84.5%), estimated by the modelled protective effects of current levels of NSP, drug treatment and ART compared to none of these services. CONCLUSIONS: Our findings suggest that developing a cohesive model for HIV prevention and treatment is feasible and reflects the bi-directional relationships between prevention and care. The integrated continuum model indicates the major factors which may predict the epidemic course and control response.

6.
Artigo em Inglês | MEDLINE | ID: mdl-33105397

RESUMO

BACKGROUND: Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015-2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin. SETTING: Cotonou, Benin METHODS:: We developed a compartmental HIV transmission model, featuring PrEP, and ART among the high-risk (FSW, clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared to TasP. We estimated the population-level impact of the two-year study and several twenty-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage (median, 2.5th-97.5th percentile uncertainty interval (95%UI)) of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP, 49% ART) scenarios. RESULTS: The two-year study (2017 coverages: 9% PrEP, 83% ART) prevented an estimated 8% (95%UI 6-12) and 6% (3-10) infections among FSW over two and twenty years, respectively, compared to 7% (3-11) and 5% (2-9) overall. The PrEP and TasP arms prevented 0.4% (0.2-0.8) and 4.6% (2.2-8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP, 88% ART) prevented 21% (17-26) and 17% (10-27) infections among FSW respectively, and 5% (3-10) and 17% (10-27) overall. Compared to TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9x and 1.2x more infections among FSW and overall, respectively. CONCLUSIONS: The modest demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.

7.
Int J Infect Dis ; 101: 374-379, 2020 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-32992012

RESUMO

OBJECTIVES: Hepatitis C Virus (HCV) is a significant cause of chronic liver disease. Among at-risk populations, access to diagnosis and treatment is challenging. We describe an integrated model of care, Hepcare Europe, developed to address this challenge. METHODS: Using a case-study approach, we describe the cascade of care outcomes at all sites. Cost analyses estimated the cost per person screened and linked to care. RESULTS: A total of 2608 participants were recruited across 218 clinical sites. HCV antibody test results were obtained for 2568(98•5%); 1074(41•8%) were antibody-positive, 687(60•5%) tested positive for HCV-RNA, 650(60•5%) were linked to care, and 319(43•5%) started treatment. 196(61•4%) of treatment initiates achieved a Sustained Viral Response (SVR) at dataset closure, 108(33•9%) were still on treatment, eight (2•7%) defaulted from treatment, and seven (2•6%) had virologic failure or died. The cost per person screened varied from €194 to €635, while the cost per person linked to care varied from €364 to €2035. CONCLUSIONS: Hepcare enhanced access to HCV treatment and cure, and costs were affordable in all settings, offering a framework for scale-up and reproducibility.

8.
BMC Infect Dis ; 20(1): 704, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32977745

RESUMO

INTRODUCTION: In sub-Saharan Africa, considerable HIV-burden exists among women. Anti-retroviral (ARV) based prevention products could decrease this burden, and their uptake could be increased if they also protect against pregnancy and sexually transmitted infections (STI). METHODS: A discrete choice experiment (DCE) was undertaken in South Africa (2015) through a household survey of adult females (n = 158) and adolescent girls (n = 204) who self-reported HIV-negative status. The DCE was used to project the uptake (percentage using product) of oral pre-exposure prophylaxis (PrEP), vaginal rings, and injectable long-lasting ARV agents among these women, and how uptake could depend on whether these products protect against pregnancy or STI acquisition. Uptake estimates were used to model how each product could decrease a women's HIV acquisition risk. RESULTS: In adolescent women, there will be limited uptake (< 6% for any product) and impact (< 4% decrease in HIV acquisition risk) of new products unless they provide pregnancy protection, which could quadruple use and impact. Adult women have weaker preference for pregnancy protection, with moderate use (< 17% for each) and impact (< 14 percentage point decrease) if they only provide HIV protection. All women had highest preference for injectable ARVs, with oral PrEP having high preference if injectable ARVs are not available. Adult women will use the ring, but adolescent women will not. Importantly, even with three additional prevention products, all providing pregnancy and STI protection, > 14% of women will remain unprotected and > 31% of the baseline acquisition risk will remain. CONCLUSIONS: Incorporating multiple prevention components into new ARV-based prevention products may increase their uptake and impact among women.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Dispositivos Anticoncepcionais Femininos , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , HIV , Profilaxia Pré-Exposição/métodos , Adolescente , Adulto , Feminino , Infecções por HIV/virologia , Humanos , Gravidez , Autorrelato , África do Sul/epidemiologia , Adulto Jovem
9.
J Int AIDS Soc ; 23(8): e25608, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32851812

RESUMO

INTRODUCTION: People who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C (HCV). Since the turn of the century, various organizations have funded non-governmental organizations (NGOs) in Ukraine to provide PWID with needles and syringes, condoms, HIV and HCV testing, and improve linkage to opioid agonist therapy (OAT) and HIV treatment. We investigated whether contact with these NGOs was associated with improved HIV prevention and treatment outcomes among PWID. METHODS: Five rounds of respondent-driven sampled integrated bio-behavioural survey data (2009 [N = 3962], 2011 [N = 9069], 2013 [N = 9502], 2015 [N = 9405], and 2017 [N = 10076]) among PWID in Ukraine (including HIV/HCV testing and questionnaires) were analysed using mixed-effect logistic regression models (mixed-effects: city, year). These regression models assessed associations between being an NGO client and various behavioural, OAT, HIV testing and HIV treatment outcomes, adjusting for demographic characteristics (age, gender, lifetime imprisonment, registration in a drug abuse clinic, education level). We also assessed associations between being an NGO client and being HIV positive or HCV positive, likewise adjusting for demographic characteristics (as above). RESULTS: NGO clients were more likely to have received HIV testing ever (adjusted odds ratio [aOR] 5.37, 95% confidence interval [95% CI]: 4.97 to 5.80) or in the last year (aOR 3.37, 95% CI: 3.20 to 3.54), to have used condoms at last sexual intercourse (aOR 1.37, 95% CI: 1.30 to 1.44) and sterile needles at last injection (aOR 1.37, 95% CI: 1.20 to 1.56), to be currently (aOR 4.19, 95% CI: 3.48 to 5.05) or ever (aOR 2.52, 95% CI: 2.32 to 2.74) on OAT, and to have received syringes (aOR 109.89, 95% CI: 99.26 to 121.66) or condoms (aOR 54.39, 95% CI: 50.17 to 58.96) in the last year. PWID who were HIV positive (aOR 1.40, 95% CI: 1.33 to 1.48) or HCV positive (aOR 1.57, 95% CI: 1.49 to 1.65) were more likely to have contact with NGOs, with HIV positive PWID in contact with NGOs being more likely to be registered at AIDS centres (aOR 2.34, 95% CI: 1.88 to 2.92) and to be on antiretroviral therapy (aOR 1.60, 95% CI: 1.40 to 1.83). CONCLUSIONS: Contact with PWID targeted NGOs in Ukraine is associated with consistently better preventive, HIV testing and HIV treatment outcomes, suggesting a beneficial impact of harm reduction NGO programming.

10.
Value Health ; 23(8): 1003-1011, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828211

RESUMO

OBJECTIVES: The prevalence of hepatitis is high in emergency department (ED) attendees in the United Kingdom, with a prevalence of up to 2% for hepatitis B (HBV) HBsAg, and 2.9% for hepatitis C (HCV) RNA. The aim of this paper is to perform an economic evaluation of opt-out ED-based HCV and HBV testing. METHODS: A Markov model was developed to analyze the cost-effectiveness of opt-out HCV and HBV testing in EDs in the UK. The model used data from UK studies of ED testing to parameterize the HCV and HBV prevalence (1.4% HCV RNA, 0.84% HBsAg), test costs, and intervention effects (contact rates and linkage to care). For HCV, we used an antibody test cost of £3.64 and RNA test cost of £68.38, and assumed direct-acting antiviral treatment costs of £10 000. For HBV, we used a combined HBsAg and confirmatory test cost of £5.79. We also modeled the minimum prevalence of HCV (RNA-positive) and HBV (HBsAg) required to make ED testing cost-effective at a £20 000 willingness to pay per quality-adjusted life-year threshold. RESULTS: In the base case, ED testing was highly cost-effective, with HCV and HBV testing costing £8019 and £9858 per quality-adjusted life-year gained, respectively. HCV and HBV ED testing remained cost-effective at 0.25% HCV RNA or HBsAg prevalence or higher. CONCLUSIONS: Emergency department testing for HCV and HBV is highly likely to be cost-effective in many areas across the UK depending on their prevalence. Ongoing studies will help evaluate ED testing across different regions to inform testing guidelines.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Hepatite B/diagnóstico , Hepatite C/diagnóstico , Programas de Rastreamento/organização & administração , Análise Custo-Benefício , Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Humanos , Cadeias de Markov , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Modelos Econométricos , Reino Unido
11.
BMJ Open ; 10(8): e036355, 2020 08 26.
Artigo em Inglês | MEDLINE | ID: mdl-32847908

RESUMO

OBJECTIVES: We aimed to calculate cumulative hepatitis C virus (HCV) treatment coverage among individuals enrolled in opioid agonist therapy (OAT) in Norway between 2013 and 2017 and to document the treatment transition to direct-acting antiviral (DAA) agents. Moreover, we aimed to describe adherence to DAAs in the same cohort. DESIGN: Prospective cohort, registry data. SETTING: Specialist healthcare service (secondary) PARTICIPANTS AND OUTCOMES: This observational study was based on data from The Norwegian Prescription Database. We studied dispensed OAT and HCV treatment annually to calculate the cumulative frequency, and employed secondary sources to calculate prevalence, incidence and HCV treatment coverage from 2013 to 2017, among the OAT population. Factors associated with adherence to DAAs were identified a priori and subject to logistic regression. RESULTS: 10 371 individuals were identified with dispensed OAT, 1475 individuals of these were identified with dispensed HCV treatment. Annual HCV treatment coverage increased from 3.5% (95% CI: 3.2 to 4.4) in 2013 to 17% (95% CI: 17 to 20) in 2017, giving a cumulative HCV coverage among OAT patients in Norway of 38.5%. A complete shift to interferon-free treatment regimens occurred, where DAAs accounting for 32% of HCV treatments in 2013 and 99% in 2017. About two-thirds of OAT patients were considered adherent to their DAA regimens across all genotypes. High level of OAT continuity was associated with improved adherence to DAAs (adjusted OR 1.4, 95% CI: 1 to 2, p=0.035). CONCLUSIONS: A large increase in HCV treatment coverage attributed by a complete shift to interferon-free regimens among the Norwegian OAT population has been demonstrated. However, treatment coverage is inadmissibly too low and a further substantial scale-up in HCV treatment is required to reach the universal targets of controlling and eliminating the HCV endemic.

12.
Drug Alcohol Depend ; 213: 108135, 2020 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-32603976

RESUMO

BACKGROUND: Stimulants, such as amphetamines and cocaine, are widely injected among people who inject drugs (PWID). Systematic reviews indicate stimulant injection is associated with HIV and HCV among PWID. Using these associations, we estimated the contribution of stimulant injection to HIV and HCV transmission among PWID. METHODS: We modeled HIV and HCV transmission among PWID, incorporating excess injecting and sexual risk among PWID who inject stimulants. We simulated three illustrative settings with different stimulants injected, prevalence of stimulant injecting, and HIV/HCV epidemiology. We estimated one-year population attributable fractions of stimulant injection on new HIV and HCV infections, and impact of scaling up needle-syringe programs (NSP). RESULTS: In low prevalence settings of stimulant injection (St. Petersburg-like, where 13 % inject amphetamine), 9% (2.5-97.5 % interval [95 %I]: 6-15 %) and 7% (95 %I 4-11 %) of incident HIV and HCV cases, respectively, could be associated with stimulant injection in the next year. With moderate stimulant injection (Montreal-like, where 34 % inject cocaine), 29 % (95 %I: 19-37 %) and 19 % (95 %I: 16-21 %) of incident HIV and HCV cases, respectively, could be associated with stimulant injection. In high-burden settings like Bangkok where 65 % inject methamphetamine, 23 % (95%I:10-34%) and 20 % (95%I: 9-27%) of incident HIV and HCV cases could be due to stimulant injection. High-coverage NSP (60 %) among PWID who inject stimulants could reduce HIV (by 22-65 %) and HCV incidence (by 7-11 %) in a decade. DISCUSSION: Stimulant injection contributes substantially to HIV and HCV among PWID. NSP scale-up and development of novel interventions among PWID who inject stimulants are warranted.

13.
Int J Drug Policy ; 84: 102866, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32712484

RESUMO

BACKGROUND: Injecting risk behaviour, such as receptive sharing of injecting equipment and/or re-using one's equipment, is associated with bloodborne virus transmission and infections in people who inject drugs (PWID). We aimed to estimate prevalence and correlates of injecting risk behaviours amongst PWID. METHODS: We conducted a systematic review and meta-analyses to estimate country, regional, and global prevalences of injecting risk behaviours (including sharing or re-using needle/syringe and sharing other injecting equipment). Using meta-regression analyses, we determined associations between study- and country-level characteristics and receptive needle/syringe sharing. RESULTS: From 61,077 identified papers and reports and 61 studies from expert consutation, evidence on injecting risk behaviours was available for 464 studies from 88 countries. Globally, it is estimated that 17.9% (95%CI: 16.2-19.6%) of PWID engaged in receptive needle/syringe sharing at last injection, 23.9% (95%CI: 21.2-26.5%) in the past month, and 32.8% (95%CI: 28.6-37.0%) in the past 6-12 months. Receptive sharing of other injecting equipment was common. Higher prevalence of receptive needle/syringe sharing in the previous month was associated with samples of PWID with a lower proportion of females, shorter average injecting duration, a higher proportion with ≥daily injecting, and older studies. Countries with lower development index, higher gender inequality and lower NSP coverage had higher proportions reporting receptive needle/syringe sharing. CONCLUSIONS: High levels of injecting risk behaviours were observed amongst PWID globally, although estimates were only available for half of the countries with evidence of injecting drug use. There is a need for better capturing of injecting risk behaviours in these countries to inform implementation of harm reduction services and evaluate potential impacts of interventions to reduce risk.

14.
Lancet Infect Dis ; 20(8): 976-982, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32530426

RESUMO

BACKGROUND: WHO recommends that men who have sex with men (MSM) receive gonorrhoea and chlamydia testing, but many evidence-based preventive services are unaffordable. The pay-it-forward strategy offers an individual a gift (eg, a test for sexually transmitted diseases) and then asks whether they would like to give a gift (eg, a future test) to another person. This study examined the effectiveness of a pay-it-forward programme to increase gonorrhoea and chlamydia testing among MSM in China. METHODS: We did a randomised controlled superiority trial at three HIV testing sites run by MSM community-based organisations in Guangzhou and Beijing, China. We included MSM aged 16 years or older who were seeking HIV testing and met indications for gonorrhoea and chlamydia testing. Restricted randomisation was done using computer-generated permuted blocks. 30 groups were randomised into three arms (1:1:1): a pay-it-forward arm in which men were offered free gonorrhoea and chlamydia testing and then asked whether they would like to donate for testing of prospective participants, a pay-what-you-want arm in which men were offered free testing and given the option to pay any desired amount for the test, and a standard-of-care arm in which testing was offered at ¥150 (US$22). There was no masking to arm assignment. The primary outcome was gonorrhoea and chlamydia test uptake ascertained by administrative records. We used generalised estimating equations to estimate intervention effects with one-sided 95% CIs and a prespecified superiority margin of 20%. The trial is registered with ClinicalTrials.gov, NCT03741725. FINDINGS: Between Dec 8, 2018, and Jan 19, 2019, 301 men were recruited and included in the analysis. 101 were randomly assigned to the pay-it-forward group, 100 to the pay-what-you-want group, and 100 to the standard-of-care group. Test uptake for gonorrhoea and chlamydia was 56% (57 of 101 participants) in the pay-it-forward arm, 46% (46 of 100 participants) in the pay-what-you-want arm, and 18% (18 of 100 participants) in the standard-of-care arm. The estimated difference in test uptake between the pay-it-forward and standard-of-care group was 38·4% (95% CI lower bound 28·4%). Among men in the pay-it-forward arm, 54 of 57 (95%) chose to donate to support testing for others. INTERPRETATION: The pay-it-forward strategy can increase gonorrhoea and chlamydia testing uptake among Chinese MSM and could be a useful tool for scaling up preventive services that carry a mandatory fee. FUNDING: US National Institute of Health; Special Programme for Research and Training in Tropical Diseases, sponsored by UNICEF, UNDP, World Bank, and WHO; the National Key Research and Development Program of China; Doris Duke Charitable Foundation; and Social Entrepreneurship to Spur Health.


Assuntos
Infecções por Chlamydia/epidemiologia , Gonorreia/epidemiologia , Homossexualidade Masculina , Reembolso de Seguro de Saúde , Doenças Sexualmente Transmissíveis/epidemiologia , Adulto , China/epidemiologia , Infecções por Chlamydia/diagnóstico , Infecções por Chlamydia/microbiologia , Testes Diagnósticos de Rotina , Gonorreia/diagnóstico , Gonorreia/microbiologia , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Doenças Sexualmente Transmissíveis/diagnóstico , Doenças Sexualmente Transmissíveis/microbiologia , Fatores Socioeconômicos , Adulto Jovem
16.
Liver Int ; 40(10): 2356-2366, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32475010

RESUMO

BACKGROUND & AIMS: In 2016, Médecins Sans Frontières established the first general population Hepatitis C virus (HCV) screening and treatment site in Cambodia, offering free direct-acting antiviral (DAA) treatment. This study analysed the cost-effectiveness of this intervention. METHODS: Costs, quality adjusted life years (QALYs) and cost-effectiveness of the intervention were projected with a Markov model over a lifetime horizon, discounted at 3%/year. Patient-level resource-use and outcome data, treatment costs, costs of HCV-related healthcare and EQ-5D-5L health states were collected from an observational cohort study evaluating the effectiveness of DAA treatment under full and simplified models of care compared to no treatment; other model parameters were derived from literature. Incremental cost-effectiveness ratios (cost/QALY gained) were compared to an opportunity cost-based willingness-to-pay threshold for Cambodia ($248/QALY). RESULTS: The total cost of testing and treatment per patient for the full model of care was $925(IQR $668-1631), reducing to $376(IQR $344-422) for the simplified model of care. EQ-5D-5L values varied by fibrosis stage: decompensated cirrhosis had the lowest value, values increased during and following treatment. The simplified model of care was cost saving compared to no treatment, while the full model of care, although cost-effective compared to no treatment ($187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingness-to-pay threshold for Cambodia. This result is robust to variation in parameters. CONCLUSIONS: The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in low-resource settings.

17.
Clin Infect Dis ; 2020 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-32447375

RESUMO

BACKGROUND: People who inject drugs (PWID) experience barriers to accessing testing and treatment for hepatitis C virus (HCV) infection. Opioid agonist therapy (OAT) may provide an opportunity to improve access to HCV care. This systematic review assessed the association of OAT and HCV testing, treatment, and treatment outcomes among PWID. METHODS: Bibliographic databases and conference presentations were searched for studies assessing the association between OAT and HCV testing, treatment, and treatment outcomes [direct-acting antiviral (DAA) therapy only] among people who inject drugs (in the past year). Meta-analysis was used to pool estimates. RESULTS: Among 9,877 articles identified, 22 studies conducted in Australia, Europe, North America, and Thailand were eligible and included. Risk of bias was serious in 21 studies and moderate in one study. Current/recent OAT was associated with an increased odds of recent HCV antibody testing [4 studies; odds ratio (OR), 1.80; 95% CI:1.36, 2.39), HCV RNA testing among those who were HCV antibody positive (2 studies; OR, 1.83; 95% CI:1.27, 2.62), and DAA treatment uptake among those who were HCV RNA positive (7 studies; OR 1.53; 95% CI: 1.07, 2.20). There was insufficient evidence of an association between OAT and treatment completion (9 studies) or sustained virologic response following DAA therapy (9 studies). CONCLUSIONS: Opioid agonist therapy can increase linkage to HCV care, including uptake of HCV testing and treatment among PWID. This supports the scale-up of OAT as part of strategies to enhance HCV treatment to further HCV elimination efforts.

18.
19.
Value Health ; 23(2): 180-190, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32113623

RESUMO

OBJECTIVES: Direct-acting antivirals containing nonstructural protein 5A (NS5A) inhibitors administered over 8 to 12 weeks are effective in ∼95% of patients with hepatitis C virus. Nevertheless, patients resistant to NS5A inhibitors have lower cure rates over 8 weeks (<85%); for these patients, 12 weeks of treatment produces cure rates greater than 95%. We evaluated the lifetime cost-effectiveness of testing for NS5A resistance at baseline and optimizing treatment duration accordingly in genotype 1 noncirrhotic treatment-naïve patients from the perspective of the UK National Health Service. METHODS: A decision-analytic model compared (1) standard 12-week treatment (no testing), (2) shortened 8-week treatment (no testing), and (3) baseline testing with 12-/8-week treatment for those with/without NS5A polymorphisms. Patients who failed first-line therapy were retreated for 12 weeks. Model inputs were derived from published studies. Costs, quality-adjusted life-years, and the probability of cost-effectiveness were calculated. RESULTS: Baseline testing had an incremental net monetary benefit (INMB) of £11 838 versus standard 12 weeks of therapy (no testing) and low probability (31%) of being the most cost-effective, assuming £30 000 willingness to pay. Shortened 8 weeks of treatment (no testing) had an INMB of £12 294 and the highest probability (69%) of being most cost-effective. Scenario analyses showed baseline testing generally had the highest INMB and probability of being most cost-effective if first- and second-line drug prices were low (<£20k). CONCLUSIONS: Optimizing treatment duration based on NS5A polymorphisms for genotype 1 noncirrhotic treatment-naive patients in the United Kingdom is not cost-effective if the drug costs are high; the strategy is generally most cost-effective when drug prices are low (<£20k).


Assuntos
Antivirais/economia , Antivirais/uso terapêutico , Custos de Medicamentos , Farmacorresistência Viral , Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/tratamento farmacológico , Hepatite C Crônica/economia , Técnicas de Diagnóstico Molecular/economia , Polimorfismo Genético , Proteínas não Estruturais Virais/antagonistas & inibidores , Adulto , Antivirais/efeitos adversos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Árvores de Decisões , Farmacorresistência Viral/genética , Feminino , Genótipo , Hepacivirus/genética , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/virologia , Humanos , Masculino , Cadeias de Markov , Modelos Econômicos , Terapia de Alvo Molecular/economia , Valor Preditivo dos Testes , Anos de Vida Ajustados por Qualidade de Vida , Medicina Estatal/economia , Fatores de Tempo , Resultado do Tratamento , Reino Unido , Proteínas não Estruturais Virais/genética , Proteínas não Estruturais Virais/metabolismo
20.
Int J Drug Policy ; : 102707, 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32151496

RESUMO

BACKGROUND: People who inject drugs (PWID) experience high incarceration rates, with current/recent incarceration being associated with increased hepatitis C virus (HCV) transmission. We assess the contribution of incarceration to HCV transmission amongst PWID in Perry County (PC), Kentucky, USA, and the impact of scaling-up community and in-prison opioid substitution therapy (OST), including the potential for reducing incarceration. METHODS: A dynamic model of incarceration and HCV transmission amongst PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from PC, incorporating an empirically estimated 2.8-fold (95%CI: 1.36-5.77) elevated HCV acquisition risk amongst currently incarcerated or recently released (<6 months) PWID compared to other PWID. We projected the percentage of new HCV infections that would be prevented among PWID over 2020-2030 if incarceration no longer elevated HCV transmission risk, if needle and syringe programmes (NSP) and OST are scaled-up, and/or if drug use was decriminalized (incarceration/reincarceration rates are halved) with 50% of PWID that would have been imprisoned being diverted onto OST. We assume OST reduces reincarceration by 10-42%. RESULTS: Over 2020-2030, removing the effect of incarceration on HCV transmission could prevent 42.7% (95% credibility interval: 15.0-67.4%) of new HCV infections amongst PWID. Conversely, scaling-up community OST and NSP to 50% coverage could prevent 28.5% (20.0-37.4%) of new infections, with this increasing to 32.7% (24.5-41.2%) if PWID are retained on OST upon incarceration, 36.4% (27.7-44.9%) if PWID initiate OST in prison, and 45.3% (35.9-54.1%) if PWID are retained on OST upon release. decriminalization (with diversion to OST) could further increase this impact, preventing 56.8% (45.3-64.5%) of new infections. The impact of these OST interventions decreases by 2.1-28.6% if OST does not reduce incarceration. CONCLUSION: Incarceration is likely to be an important contributor to HCV transmission amongst PWID in PC. Prison-based OST could be an important intervention for reducing this risk.

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