Hepatitis C infection among injecting drug users in England 2000 to 2008: Is a national hepatitis C

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Hepatitis C infection among injecting drug users
in England 2000 to 2008 Is a national hepatitis
C action plan making a difference?

• Vivian Hope1,2, Fortune Ncube1, Andrea Marongui1,
  John V Parry1,2.
• 1. Centre for Infections, Health Protections
  Agency, London, UK
• 2. Centre for Research on Drugs Health
  Behaviour, London School of Hygiene Tropical
  Medicine, London, UK

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Hepatitis C Strategy Action PlanEngland.

• Hepatitis C Strategy for England
• A consultative document that formed part of the
  implementation of the infectious disease
  strategy.
• Includes three National Outcome Indicators.
• Consultation August to November 2002.
• The Hepatitis C Action Plan for England
• Implements the Hepatitis C Strategy for England,
  it was published in July 2004.
• Built on feedback from Consultation.
• Set out actions to deliver the Strategy.
• National Outcome Indicators should detect
  impacts.

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Hepatitis C Action Plan EnglandFour Actions

• Action 1 Surveillance and research
• Key issue Improve surveillance and research so
  that trends in hepatitis C infection and the
  effectiveness of prevention measures can be
  monitored.
• Action 2 Increasing awareness and reducing
  undiagnosed infections
• Key issue An estimated five out of every six
  people with chronic hepatitis C are unaware of
  their infection. This requires action to increase
  awareness of hepatitis C amongst health
  professionals, the public and high-risk groups
  and the promotion of testing in a range of
  accessible clinical and community settings.
• Action 3 High-quality health and social care
  services
• Key issue High-quality services for the
  assessment and treatment of all patients with
  hepatitis C needs to be co-ordinated and
  accessible across the country.
• Action 4 Prevention
• Key issue There is evidence of ongoing
  transmission of hepatitis C, particularly among
  injecting drug users. Prevention efforts need to
  be intensified to reduce the spread of hepatitis
  C in at-risk populations.

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National Outcome IndicatorsVoluntary
Confidential testing

• The routine offer of a test to injecting drug
  users and health promotion activities to
  encourage others to seek testing should increase
  the proportion of people who have their infection
  diagnosed.
• Two National Outcome Indicators will be used to
  track increased testing, both indicators should
  increase
• The proportion of those attending treatment and
  support agencies for injecting drug users who are
  aware of their hepatitis C infection
• Monitoring data Unlinked Anonymous Prevalence
  Monitoring Programme
• The total number of laboratory confirmed
  hepatitis C infection reports
• Monitoring data Laboratory reports to the Health
  Protection Agency

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National Outcome IndicatorsPrevention

• Tracking a reduction in new (incident) infections
  in injecting drug users would be an ideal means
  of measuring the effect of improvements in
  prevention of hepatitis C infection. However, as
  incident infections usually pass unnoticed, a
  reduction in the prevalence of hepatitis C in
  recent injectors is proposed as a proxy.
• The National Outcome Indicator for prevention is
  therefore
• A reduction in the prevalence of hepatitis C in
  injecting drug users who started to inject in the
  last three years (recent injectors).
• Monitoring data Unlinked Anonymous Prevalence
  Monitoring Programme

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Terms

• Recent initiates
• Those who report first injected during the last
  three calendar years.
• So in 2008 those who report first injected in
  2006, 2007, or 2008 would be recent initiates.
• VCT Voluntary Confidential Test , i.e. named
  diagnostic test.
• HCV Hepatitis C Virus
• IDUs Injecting Drug Users

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Aim

• To explore the success of the Action Plan in
  reducing HCV transmission among IDUs and
  increasing their uptake of VCT.
• By examining
• the prevalence of antibodies to HCV (anti-HCV)
  among recently initiated IDUs in contact with
  specialist services.
• the uptake of VCT for HCV among all IDUs in
  contact with specialist services, and the
  proportion of IDUs with HCV aware of their
  infection.
• Data for the nine year period (2000 to 2008)
  centred on the launch of the Action Plan is used
  to examine trends.

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Data Source

• Data from the national unlinked-anonymous survey
  of IDUs.
• This survey recruits a sample of IDUs from about
  50 specialist services across England each year.
  
• Participants provide an oral-fluid sample (tested
  for anti-HCV) and complete a short questionnaire
  (inc. VCT for HCV and result of last test).
• Overall around 2,800 current former IDUs,
  including around 400 recent initiates, are
  recruited each year from England.

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Analyses

• Multivariate analyses undertaken.
• Characteristics found to be associated
  univariately were entered into a logistic
  regression model (forward stepwise with inclusion
  assessed using the likelihood ratio with
  probability for inclusion of 0.05 and exclusion
  of 0.1).
• All analyses were undertaken in SPSS 17.

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Prevalence among Recent Initiates

• Overall anti-HCV prevalence among the recent
  initiates was 18 (619/3,463) over the nine year
  period.
• Prevalence was 11 (73/672) in 2000, similar to
  that in the late 1990s.
• Prevalence increased in the early part of the
  decade, and was 20 in 2003. This increase was
  significant in a multivariable analysis.
• Prevalence was 22 in 2008 (adjusted odds ratio
  1.59, 95CI 1.08-1.87) almost the same as in
  2004 (20).
• Other variables in the model and associations
  prevalence increased with age was higher among
  those ever imprisoned, ever using a needle
  exchange, and ever having a HCV VCT and
  prevalence also varied by region.

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HCV infection among recently initiated injecting
drug users, England 2000-08
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Any indication of a reduction in HCV transmission?

• So far, none!
• All recent initiates in 2008 would have started
  injecting at least 18 months after launch of
  Action Plan in 2004.
• But sample size for recent initiates is small
  limiting the power to detect changes.
• Impact of on incidence may take a while to
  appear.
• Activities to improve Harm Reduction services
  have e.g. Recent NICE guidance on NEX.

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Uptake of VCT over time.Ever having a VCT for
HCV.

• Among all IDUs participating in the survey uptake
  VCT for HCV increased from 49 in 2000 to 77 in
  2008 (adj-OR 2.99, 95CI 2.61-3.42).
• VCT uptake was 67 in 2004.
• Among the recent initiates uptake of VCT for HCV
  increased from 26 in 2000 to 62 in 2008
  (adj-OR 3.75, 95CI 2.76-5.09).
• VCT uptake was 45 in 2004.
• Other variables in the model gender, age, ever
  imprisoned, ever using a needle exchange, HCV
  status, ever prescribed treatment for drug use,
  region and ever received used needles/syringes
• Other variables in the model gender, ever
  imprisoned, ever using a needle exchange, HCV
  status, ever prescribed treatment for drug use,
  and region.

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Reporting ever having a VCT for HCV among IDUs,
England 2000-08
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Awareness of having HCV infection

• Awareness of having HCV infection increased among
  all IDUs in the survey from 39 in 2000 to 51 in
  2004 (adj-OR 1.38, 95CI 1.11-1.71).
• There has been no change since then with 49
  aware in 2008 (adj-OR 1.49, 95CI 1.21-1.86).
• Among recent initiates the proportion with
  anti-HCV aware of their infection did not change
  significantly over time in multi-variable
  analysis (24,143/587 overall).
• Other variables in the model gender, age, ever
  using a needle exchange, ever prescribed
  treatment for drug use, region, and ever received
  used needles/syringes.
• Variables in the model ever prescribed
  treatment for drug use, region, and ever received
  used needles/syringes.

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Anti-HCV positive IDUs reporting a positive VCT
result England 2000-08
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Any Impact on VCT uptake and awareness of HCV
infection?

• Yes, well may be!
• The increase in ever having a VCT that started
  before the Action Plan was implemented has been
  sustained.
• Impact on awareness of having HCV infection more
  limited.
• Data not presented but proportion of those ever
  tested reporting last VCT for HCV during previous
  2 years has not changed over time.
• Need more regular VCT (screening) for HCV among
  IDUs.
• Expanding use of DBS (to over come difficulties
  with venopuncture)

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Conclusions

• The HCV Action Plan
• may have helped sustain an ongoing increase in
  the uptake of VCT for HCV among IDUs, but little
  improvement in the proportion IDUs with HCV who
  are aware of their infection
• has, as yet, had no apparent impact on HCV
  transmission among IDUs.
• There is clearly a need to continued improve
  coverage of preventive interventions and offer of
  regular VCT for HCV to IDUs.

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Acknowledgements

• We would like to thank
• the specialist services for drug users which
  collaborate in the UA Survey, all the IDUs who
  took part in this survey
• Merrington Omakalwala Jacquelyn Njoroge for
  their administrative support and
• the staff who process and test the oral fluid
  samples, especially Bharati Patel.