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Introduction: Globally, hepatitis B virus (HBV) is a leading cause of liver disease. People who inject drugs (PWID) are at greater risk than the general population of contracting HBV. This risk could depend on societal factors in different countries. We investigated the associations between country-level chronic HBV prevalence in PWID with national indicators of development and prevalence of HIV and hepatitis C virus (HCV)., Methods: We used global systematic review data on chronic HBV prevalence (hepatitis B surface antigen-positive) among PWID and country-level sociodemographic characteristics from online databases. National random-effects meta-analysis estimates of HBV prevalence were the outcome in linear regression models testing for associations with country-level characteristics., Results: The study included 131,710 PWID from 304 estimates in 55 countries: the pooled HBV prevalence among PWID in the countries analysed was 4.5% (95% CI 3.9-5.1), the highest regional pooled prevalence was in East and Southeast Asia (17.6% [13.3-22.3]), and the lowest was in Western Europe (1.7% [1.4-2.1]). In multivariable models, no indicators of development were associated with HBV prevalence, but there was evidence of positive associations between HBV prevalence in the general population and among PWID, and evidence of HIV and HCV prevalence in PWID being associated with HBV prevalence in PWID: multivariable coefficients 0.03 (95% CI 0.01-0.04); p < 0.001, and 0.01 (95% CI 0.00-0.03); p = 0.01, respectively., Discussion and Conclusions: HBV prevalence among PWID was associated with HIV and HCV prevalence among PWID and background HBV prevalence in the general population, highlighting the need for improving harm reduction in PWID and implementation of HBV vaccination, especially where HBV is endemic., (© 2023 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

The World Health Organisation has established a goal of eliminating the hepatitis C virus (HCV) as a public health threat by 2030. Considerable effort is being directed towards research to support and enhance HCV treatment uptake among people who inject drugs, but there is a distinct lack of attention given to gender in this work. We argue that a gender lens is needed to make visible the limitations of current HCV elimination research, and support the development of innovative, inclusive approaches to HCV treatment. Partnerships between researchers and people who inject drugs are essential in this work, particularly in the development and evaluation of programs by and for women who inject drugs. Failure to acknowledge the gendered dimensions of HCV elimination risks entrenching gender disparities in access to treatment and cure., Competing Interests: Declarations of Interest SL has received an untied educational grant from Indivior unrelated to this work. NKM has received unrestricted research grants from Gilead and Merck unrelated to this work. CT has received speaker fees from Gilead and Abbvie and unrestricted research grants from Merck. AM and ADM have no conflicts of interest to report., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: Awareness of hepatitis C virus (HCV) status among people who inject drugs is critical to ensure linkage to care and reduce transmission risk. Testing pathways, confusion about results and possible reinfection raise potential for discordance between perceived and actual HCV status among people who inject drugs. We evaluated self-reported and serologically confirmed HCV status concordance among a sample of Australian people who inject drugs., Methods: Data were collected in May-June 2018 from participants in Canberra and Sydney, Australia, who had injected drugs at least monthly in the past 6 months. Participants completed a structured interview assessing self-reported HCV status and provided a dried blood spot sample for HCV RNA testing., Results: Of 103 participants, 95% self-reported ever receiving antibody testing, 58% of whom reported having received RNA testing. Seventy-three percent of participants reported never having been told that they had HCV, 18% reported current infection and 9% did not know their current status. According to dried blood spot RNA testing, 20% were currently infected. Over a quarter of the sample (28%, n = 29) did not accurately report their HCV status, half of whom were unaware of a current infection., Discussion and Conclusions: With over one-quarter of the sample in our study not accurately reporting their current HCV status, our findings reinforce the importance of regular testing for active infection, and the need for improved health literacy on HCV antibody and RNA test results, HCV status post-treatment and reinfection risk., (© 2021 Australasian Professional Society on Alcohol and other Drugs.)

Background: Understanding factors associated with engagement across the hepatitis C virus (HCV) cascade of care (CoC) among people who inject drugs (PWID) is critical for developing targeted interventions to enhance engagement and further HCV elimination efforts. We describe the CoC among Australian PWID, and identify factors associated with engagement at each stage., Methods: As part of the 2018 and 2019 Illicit Drug Reporting System, Australians who regularly inject drugs reported lifetime HCV antibody and RNA testing, treatment uptake and completion. Multivariable logistic regression identified characteristics associated with outcomes., Results: Of 1499 participants, 87% reported antibody testing. Of those, 70% reported RNA testing, of whom 60% reported being RNA positive. Among those, 76% reported initiating treatment, 78% of whom completed. Incarceration history (adjusted odds ratio 1.90; 95% confidence interval 1.28-2.82), current opioid agonist treatment (OAT) (1.99; 1.14-3.47), and recent alcohol and other drug (AOD) counselling (2.22; 1.27-3.88) were associated with antibody testing. Incarceration history (1.42; 1.07-1.87), and current OAT (2.07; 1.51-2.86) were associated with RNA testing. Current OAT (1.92; 1.22-3.03) and recent AOD counselling (1.91; 1.16-3.13) were associated with treatment uptake. Methamphetamine as drug injected most often in the last month was associated with reduced odds of antibody (0.41; 0.25-0.66) and RNA testing (0.54; 0.40-0.74), compared to heroin., Conclusion: CoC engagement amongst Australian PWID is encouraging, with AOD service engagement associated with testing and treatment. Further efforts to reach those not service engaged, particularly those not receiving OAT or who predominantly inject methamphetamine, are needed to achieve HCV elimination targets., (Copyright © 2021. Published by Elsevier B.V.)

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 that assessed the association between OAT and HCV testing, treatment, and treatment outcomes (direct-acting antiviral [DAA] therapy only) among PWID (in the past year). Meta-analysis was used to pool estimates., Results: Of 9877 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 1 study. Current/recent OAT was associated with an increased odds of recent HCV antibody testing (4 studies; odds ratio (OR), 1.80; 95% confidence interval [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: OAT 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., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: The World Health Organization (WHO) aim to eliminate hepatitis C virus (HCV) as a public health threat by 2030. People who inject drugs (PWID) are a key risk group for HCV transmission globally. We explored socio-demographic and ecological variables associated with HCV antibody (anti-HCV) prevalence among samples of PWID., Methods: We systematically searched for and screened journal articles and online reports published between January 2011 and June 2017. Serologically confirmed anti-HCV prevalence among PWID and other study-level socio-demographic variables were extracted. Country-level ecological indicators were sourced from online databases. We used generalized linear models to investigate associations between anti-HCV prevalence estimates and other study-level and country-level variables., Results: There were 223 studies from 84 countries contributing 569 estimates of anti-HCV prevalence among PWID. Among study-level indicators, higher levels of anti-HCV prevalence were associated with higher HIV prevalence (B = 0.20; 95 % Confidence Interval [95 %CI] = 0.12, 0.29, p < 0.001) and year of data collection (B=-0.08; 95 %CI=-0.15, -0.02; p = 0.011). At a national level, higher Human Development Index scores (B=4.37; 95 %CI=0.12, 8.63, p = 0.044) were associated with higher levels of anti-HCV in samples., Implications: Serological surveillance data are increasingly available globally; however, there are still geographical gaps in quantification of HCV prevalence among PWID that must be addressed to inform efforts to achieve HCV elimination. Anti-HCV prevalence was lower in samples of PWID from countries with lower Human Development Index scores, which points to an opportunity to provide targeted intervention and potentially control transmission rates of infection in countries characterized by poor population health, education, and income., Competing Interests: Declaration of Competing Interest SL has received investigator-initiated untied educational grants from Indivior. LD has received investigator-initiated untied educational grants for studies of opioid medications in Australia from Reckitt Benckiser, Indivior, Mundipharma and Seqirus. AP has received investigator-initiated untied educational grants from Mundipharma and Seqirus. JG is a consultant/advisor and has received research grants from Abbvie, Cepheid, Gilead Sciences and Merck/MSD. MH reports honoraria for speaking at meetings from Gilead, Abbve, and MSD. JS reports non-financial support from Gilead Sciences, outside the submitted work. PV reports honoraria for speaking at meetings from Gilead, Abbve, and unrestricted research funding from Gilead., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: People who inject drugs (PWID) do so at varying frequencies. More frequent injecting is associated with skin and soft tissue infection, blood borne viruses, and overdose. The aims of this review are to estimate the prevalence of injecting frequency among PWID and compare these estimates to current needle-syringe distribution coverage estimates, and identify socio-demographic and risk characteristics, and harms associated with daily or more injecting., Methods: We conducted a systematic review of the peer-reviewed and grey literature from 2008 to 2018 and extracted needle-syringe distribution coverage data from a recent systematic review. We generated country-, region-, and global-level estimates of daily or more injecting. We also ran meta-regression analyses to determine associations between daily or more injecting and socio-demographic characteristics, injecting risk behaviour, non-fatal overdose, injection site skin infection, and blood borne virus prevalence., Results: Our search resulted in 61,077 sources, from which 198 studies were eligible for inclusion in this review. There were 74 countries with estimates for injecting frequency. Globally, we estimated that 68.1% (95%CI 64.5-71.6%) of PWID, equating to approximately 10.5 (95% UI 6.8-15.0) million people, inject daily or more frequently. There was a higher percentage of participants reporting daily or more injecting among samples with shorter injecting careers, more male participants and higher reporting of opioids as their main drug injected. Daily or more injecting was also associated with samples reporting a higher prevalence of HIV and hepatitis C antibody (anti-HCV), non-fatal overdose, and receptive needle sharing in the previous month., Implications: WHO recently recommended a needle-syringe distribution target of 300 needles per PWID per year which is unlikely to be sufficient for the majority of PWID injecting daily or more who are out of drug treatment., Funding: The Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, University of New South Wales., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives. To determine the number of people who inject drugs (PWID) in Canada and the annual coverage of opioid agonist treatment (OAT) and needle-and-syringe provision for PWID. Methods. We estimated the number of PWID in 11 of 13 Canadian provinces and territories in 2011 by using indirect multiplier methods based on provincial and territorial methadone recipient totals and proportion of surveyed PWID receiving methadone. We modeled annual increases for 2011 to 2016 on Quebec and British Columbia longitudinal data. We calculated needle-and-syringe coverage (World Health Organization [WHO] recommendation: ≥ 200 per PWID) and OAT coverage (WHO recommendation: ≥ 40 per 100 PWID) per province and territory annually. Results. An estimated 130 000 individuals in Canada (0.55%) injected drugs in 2011, increasing to 171 900 individuals (0.70%) in 2016. Needle-and-syringe coverage increased from 193 to 291 per PWID, and OAT coverage increased from 55 to 66 per 100 PWID over the study period. Conclusions. While the number of PWID increased between 2011 and 2016, OAT coverage remained high, and needle-and-syringe coverage generally improved over time. Public Health Implications. These data will inform public health surveillance, service planning, and resource allocation, and assist monitoring of treatment and harm-reduction coverage outcomes.

The World Health Organization (WHO) recently produced guidelines advising a treat-all policy for HCV to encourage widespread treatment scale-up for achieving HCV elimination. We modelled the prevention impact achieved (HCV infections averted [IA]) from initiating this policy compared with treating different subgroups at country, regional and global levels. We assessed what country-level factors affect impact. A dynamic, deterministic HCV transmission model was calibrated to data from global systematic reviews and UN data sets to simulate country-level HCV epidemics with ongoing levels of treatment. For each country, the model projected the prevention impact (in HCV IA per treatment undertaken) of initiating four treatment strategies; either selected randomly (treat-all) or targeted among people who inject drugs (PWID), people aged ≥35, or those with cirrhosis. The IA was assessed over 20 years. Linear regression was used to identify associations between IA per treatment and demographic factors. Eighty-eight countries (85% of the global population) were modelled. Globally, the model estimated 0.35 (95% credibility interval [95%CrI]: 0.16-0.61) IA over 20 years for every randomly allocated treatment, 0.30 (95%CrI: 0.12-0.53) from treating those aged ≥35 and 0.28 (95%CrI: 0.12-0.49) for those with cirrhosis. Globally, treating PWID achieved 1.27 (95%CrI: 0.68-2.04) IA per treatment. The IA per randomly allocated treatment was positively associated with a country's population growth rate and negatively associated with higher HCV prevalence among PWID. In conclusion, appreciable prevention benefits could be achieved from WHO's treat-all strategy, although greater benefits per treatment can be achieved through targeting PWID. Higher impact will be achieved in countries with high population growth., (© 2019 John Wiley & Sons Ltd.)

Background: Globally, China is the largest country by population and contributes substantially to the burden of people who inject drugs (PWID). The aims of this study were to estimate the prevalence of HIV, hepatitis C virus (HCV) and hepatitis B virus (HBV) among PWID at the national and subnational level in China and examine characteristics of PWID., Methods: We undertook a systematic review of studies published from 2008 to 2017 on HIV, HCV, and HBV seroprevalence among PWID, and characteristics of PWID in Mainland China, Hong Kong, Macao and Taiwan. Meta-analyses were conducted to generate pooled prevalence estimates by province, region, and nationally., Results: Eighty-five papers were included. The pooled HIV, HCV antibody and HBV prevalence among PWID in China was 10.5% (95% confidence interval [95%CI]: 8.6%-12.5%), 71.6% (65.7%-77.6%) and 19.6% (13.7%-25.5%), respectively. In Mainland China, HIV prevalence was highest in the Southwest (14.4%, 10.5%-18.4%) and lowest in the North (1.3%, 0.4%-3.4%). Xinjiang Province had the highest HIV prevalence (42.6%, 35.5%-49.8%). HCV antibody prevalence was highest in the Southwest (77.7%, 69.9%-85.4%), followed by South (76.2%, 65.9%-86.4%). Sichuan had the highest HCV antibody prevalence (91.7%, 86.6%-95.3%), followed by Guangxi (86.1%, 81.8%-90.4%). HBsAg prevalence among PWID was highest in South (25.3%, 14.6%-36.0%), followed by Central (20.8%, 17.4%-24.1%). HBsAg prevalence ranged from 2.4% (0.6-5.9%) in Guizhou to 40.0% (33.7%-46.6%) in Shannxi Province. In China, women and young people accounted for 21.3% and 23.1% of PWID, respectively. It was estimated that 96.1% of PWID injected opioids mainly, and recent injecting risk and sexual risk was reported by 28.5% and 36.7%., Conclusion: There is a large burden of HIV, HCV and HBV prevalence among PWID in China, with considerable geographic variation. The disease burden of viral hepatitis is particularly high, implying that effective management should be integrated into harm reduction interventions among PWID in China., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Women-specific factors exist that increases vulnerability to drug-related harms from injection drug use, including blood-borne viruses (BBVs), but gender-based differences in BBV prevalence have not been systematically examined., Methods: We conducted meta-analyses to estimate country, regional, and global prevalence of serologically confirmed human immunodeficiency virus (HIV), hepatitis C virus (HCV; based on detection of anti-HCV antibody), and hepatitis B virus (HBV; based on detection of HBV surface antigen) in people who inject drugs (PWID), by gender. Gender-based differences in the BBV prevalence (calculated as the risk among women relative to the risk among men) were regressed on country-level prevalence and inequality measures (Gender inequality index, Human development index, Gini coefficient, and high, low or middle income of the country)., Results: Gender-based differences varied by countries and regions. HIV prevalence was higher among women than men in sub-Saharan Africa (relative risk [RR], 2.8; 95% confidence interval [CI], 1.8-4.4) and South Asia (RR, 1.7; 95% CI, 1.1-2.7); anti-HCV was lower among women in the Middle East and North Africa (RR, 0.6; 95% CI, .5-.7) and East and Southeast Asia (RR, 0.8; 95% CI, .7-.9). Gender-based differences varied with country-levels of the BBV prevalence in the general population, human development, and income distribution., Conclusion: HIV was more prevalent in women who inject drugs as compared to their male counterparts in some countries, but there is variation between and within regions. In countries where women are at higher risks, there is a need to develop gender-sensitive harm-reduction services for the particularly marginalized population of women who inject drugs., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: WHO aims to eliminate the hepatitis C virus (HCV) as a public health threat by 2030. Injection drug use is an important risk factor for HCV transmission, but its contribution to country-level and global epidemics is unknown. We estimated the contribution of injection drug use to risk for HCV epidemics globally, regionally, and at country level., Methods: We developed a dynamic deterministic HCV transmission model to simulate country-level HCV epidemics among people who inject drugs and the general population. Each country's model was calibrated using country-specific data from UN datasets and systematic reviews on the prevalence of HCV and injection drug use. The population attributable fraction of HCV transmission associated with injection drug use was estimated-defined here as the percentage of HCV infections prevented if additional HCV transmission due to injection drug use was removed between 2018 and 2030., Findings: The model included 88 countries (85% of the global population). The model predicted 0·23% (95% credibility interval [CrI] 0·16-0·31) of the global population were injection drug users in 2017, and 8% (5-12) of prevalent HCV infections were among people who currently inject drugs. Globally, if the increased risk for HCV transmission among people who inject drugs was removed, an estimated 43% (95% CrI 25-67) of incident HCV infections would be prevented from 2018 to 2030, varying regionally. This population attributable fraction was higher in high-income countries (79%, 95% CrI 57-97) than in countries of low and middle income (38%, 24-64) and was associated with the percentage of a country's prevalent HCV infections that are among people who inject drugs., Interpretation: Unsafe injecting practices among people who inject drugs contribute substantially to incident HCV infections globally. Any intervention that can reduce HCV transmission among people who inject drugs will have a pronounced effect on country-level incidence of HCV., Funding: None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background and Aims: People who have recently injected drugs are a priority population in efforts to achieve hepatitis C virus (HCV) elimination. This study estimated the prevalence and number of people with recent injecting drug use living with HCV, and the proportion of people with recent injecting drug use among all people living with HCV infection at global, regional and country-levels., Methods: Data from a global systematic review of injecting drug use and HCV antibody prevalence among people with recent (previous year) injecting drug use were used to estimate the prevalence and number of people with recent injecting drug use living with HCV. These data were combined with a systematic review of global HCV prevalence to estimate the proportion of people with recent injecting drug use among all people living with HCV., Results: There are an estimated 6.1 million [95% uncertainty interval (UI) = 3.4-9.2] people with recent injecting drug use aged 15-64 years living with HCV globally (39.2% viraemic prevalence; UI = 31.6-47.0), with the greatest numbers in East and Southeast Asia (1.5 million, UI = 1.0-2.1), eastern Europe (1.5 million, UI = 0.7-2.4) and North America (1.0 million, UI = 0.4-1.7). People with recent injecting drug use comprise an estimated 8.5% (UI = 4.6-13.1) of all HCV infections globally, with the greatest proportions in North America (30.5%, UI = 11.7-56.7), Latin America (22.0%, UI = 15.3-30.4) and eastern Europe (17.9%, UI = 8.2-30.9)., Conclusions: Although, globally, 39.2% of people with recent injecting drug use are living with hepatitis C virus (HCV) and 8.5% of all HCV infections occur globally among people with recent injecting drug use, there is wide variation among countries and regions., (© 2018 Society for the Study of Addiction.)

Background: This study evaluated cause-specific mortality trends including liver-related mortality among people with a hepatitis B virus (HBV) and hepatitis C virus (HCV) notification in New South Wales, Australia., Methods: Notifications 1993-2012 were linked to cause-specific mortality records 1993-2013., Results: Among 57,929 and 92,474 people with a HBV and HCV notification, 4.8% and 10.0% died since 1997. In early 2010s, 28% and 33% of HBV and HCV deaths were liver-related, 28% and 17% were cancer-related (excluding liver cancer), and 5% and 15% were drug-related, respectively. During 2002-2012, annual HBV-related liver death numbers were relatively stable (53 to 68), while HCV-related liver death numbers increased considerably (111 to 284). Age-standardised HBV-related liver mortality rates declined from 0.2 to 0.1 per 100 person-years (PY) (P < 0.001); however, HCV-related rates remained stable (0.2 to 0.3 per 100 PY, P = 0.619). In adjusted analyses, older age was the strongest predictor of liver-related mortality [birth earlier than 1945, HBV adjusted hazard ratio (aHR) 28.1, 95% CI 21.0, 37.5 and; HCV aHR 31.9, 95% CI 26.8, 37.9], followed by history of alcohol-use disorder (HBV aHR 7.0, 95% CI 5.5, 8.8 and; HCV aHR 8.3, 95% CI 7.6, 9.1)., Conclusions: Declining HBV-related liver mortality rates and stable burden suggest an impact of improved antiviral therapy efficacy and uptake. In contrast, the impact of interferon-containing HCV treatment programs on liver-related mortality individual-level risk and population-level burden has been limited. These findings also highlight the importance of HBV/HCV public health interventions that incorporate increased antiviral therapy uptake, and action on health risk behaviors.

Background: Hepatitis C virus (HCV) infection is highly prevalent among prisoners and this prevalence estimates reach 64% among prisoners who inject illicit drugs. Prisons are important sites for HCV transmission in the absence of access to sterile injecting equipment; hence, it can be transmitted between prisoners who share contaminated needles and syringes. We aimed to estimate the prevalence of risk factors for anti-HCV prevalence, with particular interest on injecting behavior, and to assess correlates of anti-HCV positivity among Mexico City prisoners., Methods: Cross-sectional study based on information -collected in three male and two female prisons in Mexico City during 2010-2011- about sexually transmitted infections, socio-demographics, criminal history, substance use, vitamin injection, tattooing, among others (n=3,910). Weighted multivariable adjusted logistic regression models were estimated to assess the overall and differential odds for anti-HCV due to injecting behavior., Results: Overall prevalence of anti-HCV was 3.3%. This figure rose to 43.1% among prisoners with a history of illicit drug injection. Prisoners with history of vitamin injection showed a similar prevalence of anti-HCV (43.8%). After stratifying by substance injected, the adjusted odds ratio was 9.8 (95% CI: 4.0, 23.8) for illicit drug injection and 11.9 (95% CI: 5.8, 23.8) for illicit drug and vitamin injection., Conclusion: Based on data from the most populous prisons in Mexico City, this study showed that anti-HCV is highly prevalent among prisoners with history of injecting behavior. In this sense, injecting behavior per-se, independent of the substance used, is associated with increased odds of anti-HCV positivity., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Sharing of equipment used for injecting drug use (IDU) is a substantial cause of disease burden and a contributor to blood-borne virus transmission. We did a global multistage systematic review to identify the prevalence of IDU among people aged 15-64 years; sociodemographic characteristics of and risk factors for people who inject drugs (PWID); and the prevalence of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) among PWID., Methods: Consistent with the GATHER and PRISMA guidelines and without language restrictions, we systematically searched peer-reviewed databases (MEDLINE, Embase, and PsycINFO; articles published since 2008, latest searches in June, 2017), searched the grey literature (websites and databases, searches between April and August, 2016), and disseminated data requests to international experts and agencies (requests sent in October, 2016). We searched for data on IDU prevalence, characteristics of PWID, including gender, age, and sociodemographic and risk characteristics, and the prevalence of HIV, HCV, and HBV among PWID. Eligible data on prevalence of IDU, HIV antibody, HBsAg, and HCV antibody among PWID were selected and, where multiple estimates were available, pooled for each country via random effects meta-analysis. So too were eligible data on percentage of PWID who were female; younger than 25 years; recently homeless; ever arrested; ever incarcerated; who had recently engaged in sex work, sexual risk, or injecting risk; and whose main drugs injected were opioids or stimulants. We generated regional and global estimates in line with previous global reviews., Findings: We reviewed 55 671 papers and reports, and extracted data from 1147 eligible records. Evidence of IDU was recorded in 179 of 206 countries or territories, which cover 99% of the population aged 15-64 years, an increase of 31 countries (mostly in sub-Saharan Africa and the Pacific Islands) since a review in 2008. IDU prevalence estimates were identified in 83 countries. We estimate that there are 15·6 million (95% uncertainty interval [UI] 10·2-23·7 million) PWID aged 15-64 years globally, with 3·2 million (1·6-5·1 million) women and 12·5 million (7·5-18·4 million) men. Gender composition varied by location: women were estimated to comprise 30·0% (95% UI 28·5-31·5) of PWID in North America and 33·4% (31·0-35·6) in Australasia, compared with 3·1% (2·1-4·1) in south Asia. Globally, we estimate that 17·8% (10·8-24·8) of PWID are living with HIV, 52·3% (42·4-62·1) are HCV-antibody positive, and 9·0% (5·1-13·2) are HBV surface antigen positive; there is substantial geographic variation in these levels. Globally, we estimate 82·9% (76·6-88·9) of PWID mainly inject opioids and 33·0% (24·3-42·0) mainly inject stimulants. We estimate that 27·9% (20·9-36·8) of PWID globally are younger than 25 years, 21·7% (15·8-27·9) had recently (within the past year) experienced homelessness or unstable housing, and 57·9% (50·5-65·2) had a history of incarceration., Interpretation: We identified evidence of IDU in more countries than in 2008, with the new countries largely consisting of low-income and middle-income countries in Africa. Across all countries, a substantial number of PWID are living with HIV and HCV and are exposed to multiple adverse risk environments that increase health harms., Funding: Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, World Health Organization, the Global Fund, and UNAIDS., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: People who inject drugs (PWID) are a key population affected by the global HIV and hepatitis C virus (HCV) epidemics. HIV and HCV prevention interventions for PWID include needle and syringe programmes (NSP), opioid substitution therapy (OST), HIV counselling and testing, HIV antiretroviral therapy (ART), and condom distribution programmes. We aimed to produce country-level, regional, and global estimates of coverage of NSP, OST, HIV testing, ART, and condom programmes for PWID., Methods: We completed searches of peer-reviewed (MEDLINE, Embase, and PsycINFO), internet, and grey literature databases, and disseminated data requests via social media and targeted emails to international experts. Programme and survey data on each of the named interventions were collected. Programme data were used to derive country-level estimates of the coverage of interventions in accordance with indicators defined by WHO, UNAIDS, and the UN Office on Drugs and Crime. Regional and global estimates of NSP, OST, and HIV testing coverage were also calculated. The protocol was registered on PROSPERO, number CRD42017056558., Findings: In 2017, of 179 countries with evidence of injecting drug use, some level of NSP services were available in 93 countries, and there were 86 countries with evidence of OST implementation. Data to estimate NSP coverage were available for 57 countries, and for 60 countries to estimate OST coverage. Coverage varied widely between countries, but was most often low according to WHO indicators (<100 needle-syringes distributed per PWID per year; <20 OST recipients per PWID per year). Data on HIV testing were sparser than for NSP and OST, and very few data were available to estimate ART access among PWID living with HIV. Globally, we estimate that there are 33 (uncertainty interval [UI] 21-50) needle-syringes distributed via NSP per PWID annually, and 16 (10-24) OST recipients per 100 PWID. Less than 1% of PWID live in countries with high coverage of both NSP and OST (>200 needle-syringes distributed per PWID and >40 OST recipients per 100 PWID)., Interpretation: Coverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics., Funding: Open Society Foundations, The Global Fund, WHO, UNAIDS, United Nations Office on Drugs and Crime, Australian National Drug and Alcohol Research Centre, University of New South Wales Sydney., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: People who inject drugs (PWID) often do not receive confirmatory RNA testing following positive HCV antibody testing. Expanding access to adequate testing and assessment will improve the progression of patients through the HCV care cascade with the potential to improve diagnosis as well as linkage to treatment. We aimed to determine current utilisation of general practitioners (GPs) by PWID in Australia compared to other settings for HCV testing and post-test discussions., Methods: A national sample (n=888) of people who had injected drugs regularly in the past 6 months was interviewed about HCV antibody, RNA testing, and post-test discussions, and the settings where these took place., Results: The majority of participants (n=735; 93%) reported antibody testing. Among participants who reported a positive result (n=435), 54% identified their regular GP as the setting where their most recent antibody test was conducted. Confirmatory RNA testing was reported by 60% (n=274) of those who reported being antibody positive. Among those who reported RNA testing (n=257), the most common setting reported was their regular GP (48%). There were no differences in the proportions who recalled post-test discussions at GPs compared to other settings., Conclusion: HCV testing was most frequently undertaken by participants' regular GP. GPs are currently providing testing and post-test discussions at similar proportions to other more specialised settings. However, RNA testing is incomplete for more than one-third of the antibody positive PWID interviewed. Our findings suggest that the general practice setting is a common and accessible setting for PWID to access HCV testing. Targeting GPs to improve follow-up of positive antibody tests may help to improve patient progression through the HCV care cascade., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Previous estimates of the burden of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among people who inject drugs have not included estimates of the burden attributable to the consequences of past injecting. We aimed to provide these estimates as part of the Global Burden of Disease (GBD) Study 2013., Methods: We modelled the burden of HBV and HCV (including cirrhosis and liver cancer burden) and HIV at the country, regional, and global level. We extracted United Nations data on the proportion of notified HIV cases by transmission route, and estimated the contribution of injecting drug use (IDU) to HBV and HCV disease burden by use of a cohort method that recalibrated individuals' history of IDU, and accumulated risk of HBV and HCV due to IDU. We estimated data on current IDU from a meta-analysis of HBV and HCV incidence among injecting drug users and country-level data on the incidence of HBV and HCV between 1990 and 2013. We calculated estimates of burden of disease through years of life lost (YLL), years of life lived with disability (YLD), deaths, and disability-adjusted life-years (DALYs), with 95% uncertainty intervals (UIs) calculated for each metric., Findings: In 2013, an estimated 10·08 million DALYs were attributable to previous exposure to HIV, HBV, and HCV via IDU, a four-times increase since 1990. In total in 2013, IDU was estimated to cause 4·0% (2·82 million DALYs, 95% UI 2·4 million to 3·8 million) of DALYs due to HIV, 1·1% (216 000, 101 000-338 000) of DALYs due to HBV, and 39·1% (7·05 million, 5·88 million to 8·15 million) of DALYs due to HCV. IDU-attributable HIV burden was highest in low-to-middle-income countries, and IDU-attributable HCV burden was highest in high-income countries., Interpretation: IDU is a major contributor to the global burden of disease. Effective interventions to prevent and treat these important causes of health burden need to be scaled up., Funding: Bill & Melinda Gates Foundation and Australian National Health and Medical Research Council., (Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Hepatitis C virus (HCV) is highly prevalent among correctional populations. We aimed to explore racial and ethnic disparities in hepatitis C antibody (anti-HCV) prevalence in U.S. correctional populations., Methods: We systematically searched the literature for reports of anti-HCV prevalence among U.S. jail and prison populations, by race and ethnicity. We calculated summary prevalence estimates for non-Hispanic White, non-Hispanic Black, Hispanic, and "Other" race/ethnicity jail detainees and prisoners and determined the proportion of anti-HCV positive persons from racial/ethnic minority backgrounds., Results: Few studies reported anti-HCV prevalence data by race and ethnicity, and they suffered from methodologic weaknesses. Anti-HCV prevalence was highest among non-Hispanic Whites (35% [95% CI: 28%, 43%; k = 9], compared to 26% [95% CI: 21%, 32%; k = 10] among racial and ethnic minorities). However, the majority (63%) of persons with anti-HCV were from racial and ethnic minority backgrounds., Conclusions: Racial and ethnic minority persons appear to comprise the majority of HCV burden in U.S. correctional settings. Universal screening and treatment of HCV infection in correctional settings may impact on community-level health disparities., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Although hepatitis C (HCV) infection is common among prisoners, relatively few undergo evaluation for treatment. This study reports the prevalence of chronic infection and the genotype distribution among an incarcerated population. HCV antibody testing was provided to adults entering Pennsylvania prisons; confirmatory and genotype testing were offered to those eligible for treatment. Antibody prevalence among 101,727 individuals was 18.1%. Among 7,633 individuals who underwent confirmatory testing, 69.3% had detectable RNA. Among 3,247 individuals who underwent genotype testing, genotype 1 was the most common (76.6%). The rate of chronic infection after HCV exposure is similar to that reported in the community, as is genotype distribution. Correctional facilities provide access to a population with a high disease burden, creating a public health opportunity for evaluation and treatment., (© The Author(s) 2015.)

There is considerable interest in determining the impact that increased uptake of treatment for hepatitis C virus (HCV) infection will have on the burden of HCV among people who inject drugs (PWID). An understanding of the size of the population of PWID, rates of injecting cessation and HCV prevalence and incidence within the PWID population is essential for such exercises. However, these parameters are often uncertain. In this paper we review methods for estimating the size of the population of PWID and related parameters, taking into account the uncertainty that exists around data on the natural history of injecting drug use; consider issues in the estimation of HCV prevalence among PWID; and consider the importance of opioid substitution therapy and prisons as settings for the prevention and treatment of HCV infection among PWID. These latter two points are illustrated through examples of ongoing work in England, Scotland and Australia. We conclude that an improved understanding of the size of PWID populations, including current and former PWID and parameters related to injecting drug use and settings where PWID may be reached, is necessary to inform HCV prevention and treatment strategies., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Strategies are needed to enhance screening of hepatitis C virus (HCV) infection among people who inject drugs to improve engagement in HCV treatment, and stem the growing burden of HCV-related morbidity and mortality., Methods: We linked routinely collected data on enrolment in opioid substitution therapy (OST) and HCV notifications. We calculated rates of incident HCV notifications, and compared rates in and out of OST., Results: Following adjustment for sex, age and calendar period, rates of incident HCV notification were significantly higher during periods of OST, compared to periods out of OST (adjusted incident rate ratio: 1.91; 95% confidence interval: 1.86, 1.97). This effect was seen across multiple treatment periods., Conclusions: HCV screening in OST settings increases detection of HCV infection among people who inject drugs., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: We described hepatitis C virus antibody (anti-HCV) prevalence in a state prison system and retrospectively evaluated the case-finding performance of targeted testing of the 1945 to 1965 birth cohort in this population., Methods: We used observational data from universal testing of Pennsylvania state prison entrants (June 2004-December 2012) to determine anti-HCV prevalence by birth cohort. We compared anti-HCV prevalence and the burden of anti-HCV in the 1945 to 1965 birth cohort with that in all other birth years., Results: Anti-HCV prevalence among 101,727 adults entering prison was 18.1%. Prevalence was highest among those born from 1945 to 1965, but most anti-HCV cases were in people born after 1965. Targeted testing of the 1945 to 1965 birth cohort would have identified a decreasing proportion of cases with time., Conclusions: HCV is endemic in correctional populations. Targeted testing of the 1945 to 1965 birth cohort would produce a high yield of positive test results but would identify only a minority of cases. We recommend universal anti-HCV screening in correctional settings to allow for maximum case identification, secondary prevention, and treatment of affected prisoners.

Purpose: The purpose of this paper is to consider the potential benefits and challenges of applying a strategy of "seek, test, treat and retain" (STTR) to hepatitis C virus (HCV) in the US criminal justice system., Design/methodology/approach: The authors draw on the published literature to illustrate how each component of STTR could be applied to HCV in the US criminal justice system, and describe challenges to the implementation of this strategy., Findings: The burden of morbidity and mortality associated with chronic HCV infection in the USA is increasing and without significantly increased treatment uptake, will likely continue to do so for several decades. The authors argue that the US criminal justice system is an ideal focus for HCV case finding and treatment due to a high prevalence of infection and large volume of individuals in contact with this system. STTR would identify large numbers of HCV infections, leading to opportunities for secondary prevention and primary care. Important challenges to the implementation of STTR include treatment costs and training of prison medical providers., Originality/value: This paper highlights opportunities to address HCV in the US criminal justice system.

Unlabelled: People detained in prisons and other closed settings are at elevated risk of infection with hepatitis C virus (HCV). We undertook a systematic review and meta-analysis with the aim of determining the rate of incident HCV infection and the prevalence of anti-HCV among detainees in closed settings. We systematically searched databases of peer-reviewed literature and widely distributed a call for unpublished data. We calculated summary estimates of incidence and prevalence among general population detainees and detainees with a history of injection drug use (IDU), and explored heterogeneity through stratification and meta-regression. The summary prevalence estimates were used to estimate the number of anti-HCV positive prisoners globally. HCV incidence among general detainees was 1.4 per 100 person-years (py; 95% confidence interval [CI]: 0.1, 2.7; k = 4), and 16.4 per 100 py (95% CI: 0.8, 32.1; k = 3) among detainees with a history of IDU. The summary prevalence estimate of anti-HCV in general detainees was 26% (95% CI: 23%, 29%; k = 93), and in detainees with a history of IDU, 64% (95% CI: 58%, 70%; k = 51). The regions of highest prevalence were Central Asia (38%; 95% CI 32%, 43%; k = 1) and Australasia (35%; 95% CI: 28%, 43%; k = 9). We estimate that 2.2 million (range: 1.4-2.9 million) detainees globally are anti-HCV positive, with the largest populations in North America (668,500; range: 553,500-784,000) and East and Southeast Asia (638,000; range: 332,000-970,000)., Conclusion: HCV is a significant concern in detained populations, with one in four detainees anti-HCV-positive. Epidemiological data on the extent of HCV infection in detained populations is lacking in many countries. Greater attention towards prevention, diagnosis, and treatment of HCV infection among detained populations is urgently required., (Copyright © 2013 by the American Association for the Study of Liver Diseases.)

Background: Mortality rates are elevated among heroin-dependent populations compared to the general population. Liver disease is emerging as an important contributor to mortality as the heroin-dependent population ages. Two major risk factors for liver disease are hepatitis C virus infection and chronic heavy alcohol use. Both of these are highly prevalent among heroin dependent people, but their relative contribution to liver-related mortality is poorly understood., Methods: Data recording all prescriptions of opioid substitution treatment in New South Wales, Australia, 1997-2005, were linked to the National Death Index. Crude and standardised mortality rates and standardised mortality ratios were calculated for liver-related and other major causes of death. Frequency counts were obtained for viral hepatitis and alcohol mentions in underlying liver deaths., Results: There were 208 underlying liver deaths for a CMR of 72.4 per 100,000 py (95% CI 62.9, 82.9), and liver deaths occurred at 9.8 times the general population rate (95% CI 8.5, 11.2). There were increases in liver-related mortality over time. Viral hepatitis was mentioned in three-quarters (n=156, 76%), and alcohol in 43% (n=90) of underlying liver deaths., Conclusions: Liver-related deaths were shown to be increasing in this heroin-dependent population, and the majority of these deaths involved chronic viral hepatitis infection. Increased uptake of treatment for hepatitis C virus infection is crucial to reducing the burden of liver-related mortality in this population. Hepatitis B vaccination, and screening of OST patients for alcohol use disorders and delivery of brief interventions as clinically indicated may also be of benefit., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background and Aims: Needlestick injuries are an occupational hazard for prison officers. This study aimed to assess the presence of hepatitis C virus (HCV) in syringes found in prisons., Methods: Sixty-nine syringes found in prisons were tested for HCV RNA using previously published methods., Results: Three syringes tested positive for HCV RNA., Conclusion: Compared to the prevalence of HCV among injecting drug users in prisons, few syringes were found to contain HCV RNA. It is likely that conditions under which syringes are kept in prisons are not favorable for survival of detectable HCV RNA. Further work is needed to establish the risk of HCV transmission posed by needlestick injuries in prison settings.

The author argues that despite abundant research on morbidity and mortality of people released from prison, limited progress has been made in improving health outcomes for such individuals. Topics include the high risk of drug overdose in people recently released from prison, a case-control study by Binswager et al. indicating risk factors for post-release mortality of prisoners such as substance use disorders and mental illness, and the need for interventions supporting people re-entering society.

Background: Dependence upon one substance may increase vulnerability for dependence on other substances. This study aimed to i) examine the association between opioid dependence and alcohol use and dependence; and ii) identify demographic, mental health, substance use, and alcohol-related withdrawal, physical health complications, and treatment correlates of comorbid alcohol and opioid dependence versus the former only.Methods: In this case-control study, 1475 participants with opioid dependence recruited from opioid substitution therapy (OST) clinics and 516 non-opioid dependent matched participants completed a structured interview covering psychiatric history, substance dependence, child maltreatment, and history of alcohol use. Analyses were mainly concentrated on cases (n = 696) and controls (n = 194) reporting lifetime alcohol dependence.Results: Cases with opioid dependence had higher rates of lifetime alcohol dependence than controls. Binary logistic regression analyses showed comorbid cases reported greater socio-economic disadvantage, poorer psychiatric history, greater incidence of dependence on other substances, earlier onset of regular drinking and alcohol dependence, and greater severity of alcohol dependence (relative to controls with alcohol dependence only). Comorbid cases were also more likely to report endorsement of certain DSM-IV criteria (i.e., legal problems due to alcohol and desire/inability to cut down use), specific withdrawal symptoms (e.g., tachycardia, hallucinations), using other substances to relieve withdrawal symptoms, and experiencing liver disease/jaundice. Rates of lifetime treatment engagement were low overall.Conclusions: Though strongly associated with alcohol dependence and alcohol-related harms, people with a history of opioid dependence have complex social and clinical backgrounds, which appear to be important factors associated with higher levels of alcohol dependence. [ABSTRACT FROM AUTHOR]

As Rhode Island's only needle exchange program, ENCORE (Education, Needle Exchange, Counseling, Outreach, and REferrals) serves a wide range of clients infected or at risk for infection with hepatitis C virus (HCV). Through its on-site and outreach platforms across Rhode Island, ENCORE is in a unique position to serve at-risk individuals who may not otherwise present for prevention, testing and care for HCV, as well as human immunodeficiency virus (HIV). In this article, we discuss the role of needle exchange programs in preventing HCV transmission, and provide an overview of the history and current operations of ENCORE. [ABSTRACT FROM AUTHOR]

• Universal coverage of DAAs has been introduced in Canada in 2018. • Treatment initiation rates have increased among PWID. • Barriers such as male gender, cocaine use and incarceration persist. • Contact with a PCP and engagement in OAT's facilitator effects have plateaued. Barriers to HCV treatment initiation persisted after the introduction of direct-acting antivirals (DAAs) in Canada among people who inject drugs (PWID); whether DAA universal coverage lifted these barriers remain unknown. We assessed the evolution of HCV treatment initiation and associated factors among PWID in Montreal, Canada, comparing eras of IFN-based regimens (2011-2013), of DAA restricted access (2014-02/2018), and universal coverage (03/2018-03/2020). We included chronically HCV-infected participants followed in a community-based PWID cohort in Montreal, Canada between 2011 and 03/2020 and collected data at 3-month intervals. Time-updated Cox regressions were conducted to examine 9 variables of interest associated with treatment initiation overall and for each of the three eras. Of 276 participants, 126 initiated treatment during follow-up. Yearly initiation increased from 3% in 2011 to 19% in 2016, and 54% in 2018. PWID aged >40 (vs. ≤40) were twice as likely to initiate treatment in 2014-02/2018 (HR: 2.02 95%CI: [1.24-3.28]) but not in other periods (2011-2013: 0.55 [0.25-1.22]; 03/2018-03/2020: 1.14 [0.59-2.22])). Odds of initiation were lower for men than women in all periods, with women three times more likely to be treated under universal coverage (0.30 [0.11-0.77] vs 2011-2013: 0.67 [0.25-1.78] and 2014-02/2018: 0.75 [0.42-1.35]). Recent incarceration was negatively associated with initiation throughout all periods (2011-2013: 0.57 [0.13-2.43]; 2014-03/2018: 0.39 [0.17-0.91]; 03/2018-03/2020: 0.25 [0.07-0.83]). Barriers associated with high injection frequency appear to have diminished since DAA introduction (2014-02/2018: 0.71 [0.42-1.20]; 03/2018-03/2020: 1.05 [0.52-2.11] vs. 2011-2013: 0.26 [0.08-0.88]). Contact with a primary care physician and engagement in opioid agonist therapy were positively associated with treatment initiation, though estimates were attenuated under universal coverage relative to previous eras. Treatment initiation rates have increased since the introduction of universal DAA coverage, though barriers such as incarceration persist. [ABSTRACT FROM AUTHOR]