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Direct-acting antiviral agents for HCV infection affecting people who inject drugs

Key Points

  • HCV prevalence and incidence among people who inject drugs (PWID) remains high

  • Direct-acting antiviral agents (DAA) for HCV with cure in >95% provide a tool for addressing HCV-related liver-disease burden among PWID

  • Adherence and response to DAA therapy among people receiving opioid substitution therapy (OST), including those with ongoing drug use, are comparable to other HCV-infected populations, although more data are required among current PWID who are not on OST

  • HCV reinfection can occur, so strategies to maximize prevention of reinfection (including OST and needle and syringe programmes) and access to DAA retreatment are crucial

  • Improved health services for PWID are needed to enhance HCV prevention, testing, access to care and treatment

  • Continued global leadership and advocacy is required to ensure that HCV prevention, care and treatment for PWID are accessible to all

Abstract

Globally, 12 million people are estimated to have injected drugs in the past year, 50% of whom have chronic HCV infection, with people who have previously injected drugs presenting an additional large reservoir of infection. The availability of simple and tolerable interferon-free direct-acting antiviral agents (DAAs) for HCV infection, which have a cure rate of >95% represents one of the most exciting advances in clinical medicine in the past few decades. Adherence and response to DAA therapy among people who inject drugs (PWID) receiving opioid substitution therapy (OST) in clinical trials are comparable to populations without a history of injecting drugs. Further data are required among current PWID not receiving OST. Given the potential prevention benefits of treatment, DAAs have enhanced cost-effectiveness among PWID. As HCV therapy is expanded to populations of PWID with high-risk behaviours for re-exposure, acknowledgement that HCV reinfection will occur is crucial, and appropriate strategies must be in place to maximize prevention of reinfection and offer retreatment for reinfection. This Review will also discuss essential components for broadening access to HCV care for PWID as we strive for the global elimination of HCV infection.

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Figure 1: Overlap of different populations of people who inject drugs.
Figure 2: Modelling the effect of HCV treatment on reinfection in people who inject drugs.
Figure 3: The HCV care cascade among PWID: estimates from Australia as an example.

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Acknowledgements

The authors would like to thank H. Razavi. Center for Disease Analysis, for providing the image for Fig. 2. J.G. acknowledges grant support from the NIH R01 DA 040506–01 and G.J.D. acknowledges grant support from RO1 DA 15999–01 and R01 DA 040506–01.

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J.G., B.H. and G.J.D. researched data for the article, contributed to discussion of content and reviewed and edited the manuscript before submission. J.G. wrote the first draft of the article.

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Correspondence to Jason Grebely.

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J.G. is a consultant and advisor, and has received research grants from AbbVie, Bristol-Myers Squibb, Cepheid, Gilead Sciences, Merck and Merck Sharp & Dohme. G.J.D. is a consultant and advisor, and has received research grants from Abbvie, Bristol–Myers Squibb, Cepheid, Gilead Sciences, Janssen Pharmaceuticals, Merck and Roche.

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Grebely, J., Hajarizadeh, B. & Dore, G. Direct-acting antiviral agents for HCV infection affecting people who inject drugs. Nat Rev Gastroenterol Hepatol 14, 641–651 (2017). https://doi.org/10.1038/nrgastro.2017.106

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