Modeling what is required to prevent HIV and HCV among people who inject drugs in the U.S.

Transcription

1 Modeling what is required to prevent HIV and HCV among people who inject drugs in the U.S. Natasha K Martin, DPhil Associate Professor Division of Infectious Diseases and Global Health, University of California San Diego

2 HCV AND HIV PREVENTION INTERVENTIONS AMONG PWID 2

3 HARM REDUCTION EFFECTIVENESS ON HIV AND HCV Opiate agonist therapy (OAT) Needle and syringe programs (NSP) Combined harm reduction (OAT+ high coverage NSP) HIV incidence 54% 34% HCV incidence 50% 76%* 74% *In Europe, weaker effect in North America 1. MacArthur G, et al. BMJ Aspinall E et al. Int J Epidemiol Platt, L, et al. Cochrane Database Systematic Review 2017

4 OAT IMPACT ON HIV TREATMENT Systematic review and meta-analysis found OAT associated with: 69% increase in recruitment onto antiretroviral treatment (ART) 2-fold increase in ART adherence 23% decrease in odds of ART attrition 45% increase in odds of viral suppression Low A, et al. Clin Infec Dis 2016;63:1094 4

5 DAA HCV TREATMENT treatment outcomes HIGHLY EFFECTIVE in PWID AMONG PWID Sustained viral response (%) OST OAT no No OST OAT 94% 96% 94% 97% 96% 98% 96% 96% 92% 95% OBV/PTV/r + DSV + RBV 1 SOF/LDV + RBV 2 96% 98% SOF/VEL 3 SOF/VEL/VOX 4 GZR/ELB 5.6 GLE/PIB 7 OAT: Opiate agonist therapy current PWID 94% SOF/ VEL 8 1) Grebely 5 J, ILC ) Grebely J, CID ) Grebely J, CID ) Grebely J, ILC ) Zeuzem S, Ann Intern Med ) Dore GJ, Ann Intern Med ) Grebely J, INHSU ) Grebely J, ILC Slide courtesy of G Dore

6 DAA treatment outcomes in PWID MEDICAID RESTRICTIONS FOR HCV TREATMENT 2017 Medicaid FFS Sobriety Restrictions for HCV Treatment 2017 Medicaid FFS Liver Damage Restrictions for HCV Treatment Alaska Hawaii Alaska Puerto Rico No Restrictions Screening & Counseling Hawaii Abstain (1 mo.) Abstain (3 mos.) Abstain (6 mos.) Puerto Rico No Restrictions F1 F2 6 Stateofhepc.org Abstain (12 mos.) F3

7 TALK OUTLINE HCV elimination among PWID in the U.S. HIV prevention among PWID in the U.S. Incarceration challenges and opportunities to prevent HIV and HCV among PWID

8 WHAT IS NEEDED TO ELIMINATE HCV AMONG PWID IN THE U.S.? 8

9 WHO AND NASEM HCV ELIMINATION TARGETS Goal: Eliminate viral hepatitis as a public health threat by 2030 IMPACT TARGETS: 90% reduction in new HCV and HBV infections by % reduction HCV and HBV-related mortality by 2030

10 HCV TREATMENT... AS PREVENTION? Harm reduction important in averting infections but can t achieve HCV elimination in isolation 1,2 Substantial interest in HCV treatment as prevention Finite and curative But, risk of reinfection? Modeling evidence that modest HCV treatment scale-up could substantially reduce HCV prevalence/incidence among PWID Vickerman P et al. Addiction 2012; 2. Martin NK et al. Clin Infec Dis Martin NK et al. Hepatology Zelenev A et al. Lancet Infec Dis 2018

11 HCV PREVENTION AMONG PWID IN US: COMPARING URBAN AND RURAL SETTINGS San Francisco, CA -Very high prevalence -Lowest, stable incidence (~12/100py) Scott County, IN -High prevalence -Increasing, higher incidence (>40/100py) Perry County, KY -High prevalence -Moderate stable incidence (~20/100py)

12 HCV PREVENTION AMONG PWID IN SAN FRANCISCO, CA HCV chronic prevalence (%) Model predicts fairly stable epidemic Further scale-up of harm reduction has modest impact as syringe exchange already high coverage HCV incidence (/100py) Despite very high prevalence, elimination could be achieved with full HR + treating ~50/1000 PWID/yr 12 Fraser H, Martin NK, Vickerman P et al. in preparation

13 HCV PREVENTION AMONG PWID IN PERRY COUNTY, KY HCV chronic prevalence (%) Slowly expanding epidemic Substantial impact with full harm reduction (NSP+MAT scale-up) but cannot achieve elimination HCV incidence (/100py) Elimination could be achieved with full HR + treating <50/1000 PWID NSP 13 Fraser H, Martin NK, Vickerman P et al. in preparation

14 FORECASTING THE HCV EPIDEMIC AMONG PWID IN SCOTT COUNTY, IN HCV chronic prevalence (%) HCV chronic prevalence could rise to 83% in 2030 with no intervention Full harm reduction (50% MAT/ NSP) key to prevention but cannot reverse increase Combined harm reduction + treat 20/1000 PWID/yr stabilizes prevalence NSP Need more intervention in expanding epidemic setting NSP Fraser H, Martin NK, Vickerman P et al, Addiction 2018;113: March 11, 2018

15 RETREATMENT IS REQUIRED TO ACHIEVE ELIMINATION IN SCOTT COUNTY, IN HCV chronic prevalence (%) IF NO RETREATMENT OF REINFECTIONS: HCV epidemic can rebound due to reinfection Harm reduction can maintain impact BUT cannot reach WHO/ NASEM target + No HR (elimination target) Fraser H, Martin NK, Vickerman P et al, Addiction 2018;113:173-82

16 SETTINGS WITH INCREASING INCIDENCE REQUIRE MORE INTERVENTION Treatments per 1000 PWID required for elimination Without harm reduction scale-up <75/1000 PWID treated in SF & KY Double treatment rate in Scott County, IN as incidence higher and increasing With harm reduction scale-up Halves treatment rate in KY & IN Less impact in SF due to higher baseline coverage of syringe exchange Fraser H, et al, Addiction 2018;113: and Fraser H, Martin NK, Vickerman P et al. in preparation

17 EFFECT OF THE NETWORK: SHOULD WE TARGET SPECIFIC PWID FOR HCV TREATMENT? A study in Australia indicated a treat your friend strategy may have more prevention impact 1 But recent work incorporating the injecting network among PWID in Hartford, CT indicates a random treatment strategy has most impact 2 Zelenev A et al. Lancet ID Hellard M et al. Hepatology 2014; 60: Zelenev A et al. Lancet Infectious Diseases 2018;18:

18 PREVENTING HIV AMONG PWID U.S. INSIGHTS FROM MODELING 18

19 IDENTIFYING WHICH CARE CONTINUUM GAPS ARE CONTRIBUTING MOST TO HIV TRANSMISSION AMONG PWID United States, 2009 Skarbinski J, et al. JAMA Intern Med. 2015;175(4):

20 Escudero et al. BMC Public Health (2017) 17:614 IDENTIFYING WHICH CARE CONTINUUM GAPS ARE CONTRIBUTING MOST TO HIV TRANSMISSION AMONG PWID New York City Undiagnosed HIV+ PWID 33% population but contribute >50% new infections in NYC Need to target diagnosis and initiation/retention on ART

21 Marshall B, et al. Health Aff (2014) 33: COMBINATION PREVENTION TO MAXIMIZE HIV IMPACT Modeled HIV incidence among PWID (/100py) in New York City in 2040

22 Bernard CL, et al. PLoS Med May 24;14(5):e WHICH INTERVENTION TO PRIORITIZE? COST-EFFECTIVENESS IN THE U.S. First scale-up OAT Then NSP Then HIV test & treat PrEP not cost-effective

23 THE ROLE OF INCARCERATION IN TRANSMISSION AND PREVENTION OF HIV/HCV AMONG PWID 23

24 INCARCERATION INCREASES RISK OF HIV AND HCV INCIDENCE AMONG PWID Systematic review and meta-analysis found that recent incarceration significantly increases risk of acquiring HIV (by 81%) and HCV (by 62%) compared to non-recent incarceration This risk persists post release PRISON TREATMENT Stone J, Martin NK, Vickerman P et al. IAS 2017 poster TUPEC0767

25 PUBLIC HEALTH ORIENTED DRUG LAW REFORM COULD REDUCE HIV AMONG PWID: MEXICO CASE STUDY In 2009, Mexico decriminalized possession of select drugs for personal consumption and mandating drug treatment at third apprehension. To date, limited knowledge of the reform has hampered its implementation, resulting in little impact among PWID in Tijuana, Mexico 1,2 If implemented properly, could avert 21% of new HIV infections among PWID in Tijuana from PRISON TREATMENT 1. Arredondo J, et al. Harm Reduction Journal 2017; 14(1): Borquez A, Martin NK, et al. under review and presented at IAS 2016

26 COMBINATION HIV PREVENTION IN PRISON COULD AVERT HIV AMONG COMMUNITY PWID: MEXICO CASE STUDY Percentage of new infections averted among PWID % 30% 20% 10% 0% 12% (2 to 22%) ART in prison and on release 13% (6 to 24%) OAT in prison and on release 18% (8 to 31%) ART+ OAT in prison and on release *1 year retention OAT, 20%/yr ART drop-out Borquez A, Strathdee S, Vickerman P, Boily MC, Martin NK. IAS 2017 poster TUPEC0895

27 HCV SCREENING/TREATMENT IN PRISONS COULD SUBSTANTIALLY AVERT NEW INFECTIONS IN THE COMMUNITY United States Scotland Number Infections Averted y Risk 1-y All 5-y All 10-y All General population Prisons Prison treatment for 80% infected PWID prison entrants PRISON with sentences >12 weeks TREATMENT could halve chronic prevalence and incidence among PWID in 15 years He et al. Annals of Internal Medicine 2016:(164) Stone J, Martin NK, and Vickerman P et al. Addiction 2017

28 DISCUSSION

29 PREVENTION OF HCV AND HIV AMONG PWID Urgent need to tackle HCV and HIV epidemics among PWID, especially in outbreak settings Lack of harm reduction and restrictions on HCV therapy may result in very high HCV burden among PWID in some settings Need scale-up of combination harm reduction and HIV/HCV screening and treatment for prevention Achievable HCV treatment rates (<100/1000 PWID/yr) Retreatment of HCV reinfections without stigma Need public health oriented drug law reform and interventions to prevent harm among incarcerated PWID Setting specific approaches tailored to local epidemiology

30 FUTURE/FURTHER CONSIDERATIONS Need better epidemiological data to forecast epidemics and assess interventions required Need modeling examining differences in epidemic and intervention impact among subpopulations (race/ ethnicity and gender) Need future work examining the impact and economic consequences of drug policy changes on infectious disease risk and transmission among PWID

31 ACKNOWLEDGEMENTS UCSD: Annick Borquez, Leo Beletsky, Steffanie Strathdee, Daniela Abramovitz University of Bristol: Peter Vickerman, Matthew Hickman, Hannah Fraser, Jack Stone Health Protection Scotland: Sharon Hutchinson, David Goldberg, Queen Mary s London: Graham Foster Burnet Institute: Margaret Hellard University of New South Wales: Greg Dore, Jason Grebely, Andrew Lloyd CDC: Jon Zibbell, John Ward FUNDERS: National Institute for Drug Abuse R01 DA A1, UCSD Center for AIDS Research (P30 AI036214), US Center for Disease Control, Gilead Sciences, UK EPSRC, UK National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions at University of Bristol. The views expressed are those of the authors and not necessarily those of the UK NHS, UK NIHR, UK Department of Health.