Jenny Iversen

Aims: The 2016 Global Health Sector Strategy (GHSS) on viral hepatitis aims to reduce new hepatitis C virus (HCV) infections by 80% by 2030, including a 30% reduction by 2020. This study aimed to estimate primary HCV incident infection among a national sample of people who inject drugs (PWID) before and after the introduction of unrestricted access to HCV direct‐acting antiviral (DAA) therapy via Australia's Pharmaceutical Benefits Scheme in 2016.Design: A simple deterministic linkage method identified repeat respondents in serial cross‐sectional surveys conducted among PWID. Two separate retrospective cohorts of HCV antibody‐negative respondents were created, corresponding to the pre‐ (2010–15) and post‐ (2016–21) DAA time‐periods.Setting and Participants: This study took place in Australia. Among 757 PWID retained (376 pre‐DAA, 381 post‐DAA), more than half were male (60%), the majority were heterosexual (80%), the median age was 40 years (interquartile range = 33–46 years) and the predominant drugs last injected were heroin (24%), pharmaceutical opioids (27%) and methamphetamine (41%).Measurements: The primary outcome was HCV seroconversion, defined as a negative HCV antibody test result followed by a positive HCV antibody result. Time to primary incident HCV infection was estimated using the person‐years (PY) method.Findings: A total 97 of 376 (2010–15) and 41 of 381 (2016–21) HCV seroconversions were identified. Primary HCV incidence more than halved, from 13.6 per 100 PY [95% confidence intervals (CI) = 11.2, 16.6] in 2010–15 to 5.4 per 100 PY (95% CI = 3.9, 7.3) in 2016–21. The decline was independent of observed differences in demographic and drug use characteristics over the two time‐periods (adjusted hazard ratio = 0.47, 95% CI = 0.31–0.69, P < 0.001).Conclusions: Australia has had a 53% reduction in primary hepatitis C virus (HCV) incidence among people who inject drugs following unrestricted availability of HCV direct acting antiviral therapy in March 2016. Given that PWID are the predominant population at risk of HCV infection in Australia, findings add to the evidence that Australia has probably met its 2020 Global Health Sector Strategy subtarget of a 30% decline in new infections.

Background: This review aimed to identify hepatitis C virus (HCV) prevalence estimates among the general population and six key populations (people who inject drugs, men who have sex with men, sex workers, prisoners/detainees, Indigenous people, and migrants) in the World Health Organization Western Pacific Region (WHO WPR). Methods: Original research articles published between 2016 and 2020 were identified from bibliographic databases. Publications were retrieved, replicas removed, and abstracts screened. Retained full texts were assessed and excluded if inclusion criteria were not met. Methodological quality was assessed using the Johanna Briggs Institute critical appraisal checklist for prevalence data. Data on HCV exposure and active infection were extracted and aggregated and forest plots generated for each population by country. Results: There were no HCV prevalence estimates in any population for more than half of WPR countries and territories. Among the 76 estimates, 97% presented prevalence of exposure and 33% prevalence of active infection. General population viraemic prevalence was 1% or less, except in Mongolia. Results confirm the endemic nature of HCV among people who inject drugs, with estimates of exposure ranging from 30% in Cambodia to 76% in Hong Kong. Conclusions: Countries require detailed knowledge of HCV prevalence in diverse populations to evaluate the impact of efforts to support WHO HCV elimination goals. Results provide baseline estimates from which to monitor and evaluate progress and by which to benchmark future elimination efforts.

Background: People who inject drugs (PWID) may be at elevated risk of adverse outcomes from SARS-CoV-2 infection; however, data on COVID-19 vaccine uptake among PWID are scarce. This study aimed to determine COVID-19 vaccine uptake among PWID, identify factors associated with sub-optimal uptake, and compare uptake to the general population. Methods: The Australian Needle Syringe Program Survey is an annual sentinel surveillance project, comprising a self-completed questionnaire and provision of a dried blood sample for HIV and HCV testing. In 2021, respondents provided information on their COVID-19 vaccination status. Multivariate logistic regression models identified correlates of vaccine uptake. Results: Among 1166 respondents, 49% had been vaccinated and in most states and territories, vaccine uptake was significantly lower than among the general population. Independent predictors of vaccine uptake were longer duration of vaccine eligibility (AOR 3.42, 95% CI 2.65, 4.41); prior SARS-CoV-2 diagnostic testing (AOR 2.90, 95% CI 2.22, 3.79); injection of opioids (AOR 1.91, 95% CI 1.20, 3.05); and current opioid agonist therapy (AOR 1.70, 95% CI 1.23, 2.33). Women (AOR 0.70, 95% CI 0.54, 0.92) and those who reported daily or more frequent injection (AOR 0.75, 95% CI 0.57, 1.00) were significantly less likely to be vaccinated. Conclusions: In most Australian states and territories, uptake of COVID-19 vaccine among PWID lagged uptake among the general population. Increased efforts are required to ensure PWID have equitable access to vaccination. Vaccination programmes within harm reduction services and via outreach, coupled with increased support for peers to act as vaccine champions, are likely to reduce barriers and improve COVID-19 vaccine uptake in this population.

Introduction: Female sexual partners of men who inject drugs (MWID) living with HIV are at risk of HIV transmission. HIV prevalence estimates among non-drug using female sex partners of MWID are scarce, with no studies documenting HIV incidence. We investigated HIV prevalence and incidence among female spouses of MWID registered at Nai Zindagi Trust (NZT), Pakistan, between 2012 and 2019.Methods: NZT registration and service provision data for female spouses who participated in HIV testing and counselling calculated HIV prevalence and incidence using the person years (PY) method. Cox proportional hazards models identified factors associated with incident infection.Results: Overall HIV prevalence among female spouses of MWID was 8.5%. Among 3478 HIV-negative female spouses, 109 incident infections were observed, yielding an incidence rate of 1.5/100PY (95% CI 1.2–1.8). Independent predictors of incident infection were registration in Punjab province (AHR 1.73 95% CI 1.13–2.68,p = 0.012) and 1–5 years of education (AHR 1.89 95% CI 1.22–2.93,p = 0.004). Knowledge of HIV at registration was protective against infection (AHR 0.51, 95% CI 0.26–0.99,p = 0.047), along with a MWID spouse who had initiated antiretroviral therapy (ART) (AHR 0.25, 95% CI 0.16–0.38,p < 0.001), while incident infection was inversely associated with number of children (≥ 5 children AHR 0.44 95% CI 0.22–0.88,p = 0.022).Conclusions: Additional efforts are needed to reduce HIV transmission among female spouses of MWID, including targeted provision of HIV education and access to HIV screening. Interventions that target MWID are also required, including evidence-based drug treatment and access to ART, including support to maximize adherence. Finally, consideration should be given to making HIV pre-exposure prophylaxis available to female spouses at high risk of HIV transmission, particularly young women and those whose husbands are not receiving, or have difficulty adhering to, ART.

Introduction: Sex workers who use drugs represent two distinct populations, yet programmatic and policy responses are siloed and failed to acknowledge the ways in which populations overlap and needs intersect. Although prevalence of drug use among sex workers is believed to be higher than the general population, no published estimates of global prevalence exist. We aimed to estimate the prevalence of lifetime illicit drug use among sex workers overall, by gender (cis, transgender, and non-binary), and sub-region.Methods: We searched electronic databases for studies measuring the prevalence of illicit drug use among sex workers from the past decade [2009–2018]. Data were combined to generate pooled prevalence and associated 95% confidence intervals of lifetime use using a random effects model. Countries were categorised into geographic sub-regions, and sub-regional pooled estimates of lifetime use among female sex workers generated and mapped.Results: Among 86 studies in 46 countries, pooled prevalence of lifetime illicit drug use among sex workers was 35% (95% CI 30–41%). There was significant diversity (I² > 90.0%, P < 0.01), and prevalence ranged from 1.2% to 84%. Most studies reported lifetime drug use among female sex workers (32 studies from 20 countries), and pooled prevalence in this sub-group was 29% (95% CI 24–34%). Insufficient data precluded generation of estimates for male and transgender sex workers.Conclusions: Our review identified significant gaps in data quality and availability. Future research in partnership with sex workers is necessary to explore the diversity of populations and contexts in which drug use and sex work intersect, inform more accurate estimates of prevalence, identify differences in risks and exposures, and guide the creation, implementation, and evaluation of programmes and services.

Introduction: Key populations at elevated risk to contract or transmit HIV may also be at higher risk of COVID‐19 complications and adverse outcomes associated with public health prevention measures. However, the conditions faced by specific populations vary according to social, structural and environmental factors, including stigma and discrimination, criminalization, social and economic safety nets and the local epidemiology of HIV and COVID‐19, which determine risk of exposure and vulnerability to adverse health outcomes, as well as the ability to comply with measures such as physical distancing. This commentary identifies common vulnerabilities and cross‐cutting themes in terms of the impacts of COVID‐19 on key populations before addressing issues and concerns specific to particular populations.Discussion: Cross‐cutting themes include direct impacts such as disrupted access to essential medicines, commodities and services such as anti‐retroviral treatment, HIV pre‐exposure prophylaxis, opioid agonist treatment, viral load monitoring, HIV and sexually transmitted infections testing, condoms and syringes. Indirect impacts include significant collateral damage arising from prevention measures which restrict human rights, increase or impose criminal penalties, and expand police powers to target vulnerable and criminalized populations. Significant heterogeneity in the COVID‐19 pandemic, the underlying HIV epidemic and the ability of key populations to protect themselves means that people who inject drugs and sex workers face particular challenges, including indirect impacts as a result of police targeting, loss of income and sometimes both. Geographical variations mean that transgender people and men who have sex with men in regions like Africa and the middle east remain criminalized, as well as stigmatized and discriminated against, increasing their vulnerability to adverse outcomes in relation to COVID‐19.Conclusions: Disruptions to both licit and illicit supply chains, loss of income and livelihoods and changes in behaviour as a result of lockdowns and physical distancing have the potential to exacerbate the impacts of the COVID‐19 pandemic on key populations. While these impacts will vary significantly, human‐rights approaches to COVID‐19 emergency laws and public health prevention measures that are population‐specific and sensitive, will be key to reducing adverse health outcomes and ensuring that no one is left behind.