Question

Global, regional, and country-level estimates of hepatitis C infection among people who have recently injected drugs

Jason Grebely1 , Sarah Larney2 , Amy Peacock2 , Samantha Colledge2 , Janni Leung2,3 , Matthew Hickman4 , Peter Vickerman4 , Sarah Blach5 , Evan B. Cunningham1 , Kostyantyn Dumchev6 , Michael Lynskey7 , Jack Stone4 , Adam Trickey4 , Homie Razavi5 , Richard P. Mattick2, Michael Farrell2 , Gregory J. Dore1 & Louisa Degenhardt2

The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia,1 National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia,2 School of Public Health, Faculty of Medicine, University of Queensland, QLD, Australia,3 Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK,4 CDA Foundation, Lafayette, CO, USA,5 Ukrainian Institute on Public Health Policy, Kiev, Ukraine6 and National Addiction Centre, King’s College London, London, UK7

ABSTRACT

Background and Aims Peoplewho 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 livingwith 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 livingwith HCV. These datawere combinedwith a systematic reviewof 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 (1.5million, 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.

Keywords Estimates, HCV, IDU, injecting drug use, PWID, viraemic.

Correspondence to: Jason Grebely, The Kirby Institute, Level 6, Wallace Wurth Building, UNSW Sydney, Sydney, NSW 2052, Australia. E-mail: [email protected] Submitted 8 January 2018; initial review completed 29 March 2018; final version accepted 12 July 2018

INTRODUCTION

The World Health Organization (WHO) has set a goal to eliminate hepatitis C virus (HCV) as a global public health threat by 2030 [1]. Between 2015 and 2030, WHO targets include reducing new HCV infections by 80%, the number of HCV deaths by 65% and increasing HCV diag- noses from 20 to 90%, and eligible people receiving HCV treatment from < 5 to 80%. People who inject drugs represent a priority population for HCV elimination, given the high prevalence and incidence in this group [2–7].

We previously estimated the global, regional and country-level prevalence of HCV (viraemic infections) [8]. In 2015, the global prevalence of HCV infection was estimated to be 1.0% [95% uncertainty interval (UI) = 0.8–1.1], corresponding to 71.1 million (62.5– 79.4) people living with HCV [8]. We also estimated the global, regional and country-level HCV antibody prevalence among people with recent injecting drug use (previous 12 months). Among the estimated 15.6 million (UI = 10.2–23.7 million) people with recent injecting drug use aged 15–64 years globally, it is estimated

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

HCV PREVENTION doi:10.1111/add.14393

that 52.3% (UI = 42.4–62.1%) are HCV-antibody positive, representing 8.2 million people who have recently injected drugs (UI= 4.7–12.4million)with past or presentHCV [7]. Given that 25% of people clear HCV infection spontane- ously [9], estimates are needed on the prevalence and num- bers of people with recent injecting drug use who are living with HCV infection (viraemic infection).

There are no previous estimates at the global, regional and country levels of the HCV RNA (ribonucleic acid) prev- alence among people with recent injecting drug use, the number of people with recent injecting drug use who are living with HCV infection (HCV RNA detectable or viraemic) or the proportion of people with recent injecting drug use among all people livingwith HCV infection. These data are crucial to monitor progress of global HCVelimina- tion efforts and identify high-burden settings to enable ap- propriate targeting of prevention and treatment strategies to achieve the WHO HCV targets.

The aim of this study was to estimate the global HCV RNA prevalence (viraemic infections) among people who have recently injected drugs; the numbers of people with recent injecting drug use living with HCV infection; and the proportion of people who have recently injected drugs among all people living with HCV at global, regional and country levels.

METHODS

Study design and procedures

This analysis utilized data from two published studies. The first study was a systematic review to estimate the number of people with recent injecting drug use and the HCV antibody (anti-HCV) prevalence among people who have recently (previous 12 months) injected drugs [7]. The second study was a systematic review and modelling study to estimate the global viraemic HCV prevalence [8].

The first systematic review estimated global, regional and country-level prevalence of injecting drug use among people aged 15–64 years and the prevalence of HIV, HCV and hepatitis B virus (HBV) among people with recent injecting drug use in 2015 [7]. This review was performed consistent with the GATHER (Guidelines for Accurate and Transparent Health Estimates Reporting) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple search strategies [7] were used to identify papers and reports published since previous reviews of IDU prevalence (from 2008) [10] and of HCV among people who inject drugs (PWID) (from 2011) [2]. Without language restrictions, peer-reviewed databases (MEDLINE, Embase and PsycINFO) and grey lit- erature were searched systematically, and data requests disseminated to international experts and agencies. We searched for data on IDU prevalence and the prevalence of HIV, HCV and HBV among people with recent injecting

drug use. Eligible data on prevalence of IDU, HIVantibody, HBsAg and HCVantibody among PWID were selected and, where multiple estimates were available, pooled for each country via random-effects meta-analysis. Data on HCV RNA prevalence among people with recent injecting drug use were also extracted. Global, regional and country-level estimates of the HCV antibody (anti-HCV) prevalence among people with recent injecting drug use were used for the current study [7].

The second systematic review estimated global, re- gional and country levels of viraemic HCV prevalence in 2015 [8]. Data published between 1 January 2000 and 31 March 2016 were identified through searches of elec- tronic peer-reviewed literature databases, PubMed and Embase [8]. Non-indexed government reports, personal communication with country experts and additional stud- ies identified through manual searches of references noted in publications were included where better data were not available. Papers were scored on the degree to which they could be extrapolated to the general population, the sam- ple size and the year of analysis. A Microsoft Excel-based (version 2007) Markov-type model was populated with the highest-scoring epidemiological data for each country, used to estimate HCV prevalence over time (including in 2015). A Delphi process was used to gain country expert consensus and validate inputs. Further details of data extraction, scoring of data sources, Delphi process and modelling have been published [8]. Global, regional and country-level estimates of the numbers of people with viraemic HCV infection were used for the current study [7].

Statistical analysis

First, we sought to estimate the prevalence of viraemic HCV infection (detectable HCV RNA) among people with recent injecting drug use at global, regional and country levels. As shown in Table 1, 48% (98 of 206) of countries had available data on HCV antibody prevalence among people with recent injecting drug use (n = 374 studies) compared to only 9% (19 of 206) of countries with avail- able data on HCV RNA prevalence among people with recent injecting drug use (n = 32 studies). Compared to studies of HCV antibody prevalence among people with recent injecting drug use (n = 374), studies of HCV RNA prevalence among people with recent injecting (n = 32) were less often estimate-grade A (multi-site seroprevalence study with > 1 sample types) (6.3 versus 21.9%) and national samples (6.2% versus 20.6%). Given the poor availability of data on HCV RNA prevalence, we sought to estimate the HCV viraemic proportion (those living with HCV infection) by using estimates of the prevalence of HCV antibodies among people with recent injecting drug use within each country [7] and multiplying by an

151

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

estimate of the proportion developing viraemic HCV infec- tion [9]. The proportion with viraemic HCV infection among those who were HCV antibody-positive [75%; 95% confidence interval (CI) = 71%, 79%] was estimated using data from a well-characterized merged data set of nine international cohorts of people who had recently injected drugs who had acquired acute HCV infection, and were followed prospectively for spontaneous HCV clearance and viraemic infection [9]. The number of people with recent injecting drug use with viraemic HCV infection was then estimated by multiplying the number of people with recent injecting drug use who were HCV antibody positive by the HCV viraemic prevalence.

Ninety-five per cent UIs were estimated using Monte Carlo simulation taking 100000 draws. A binomial distri- bution was used because the parameters of interest were

proportions (product of IDU proportion among the popula- tion and HCV proportion among PWID). Estimated sample sizes were derived based on the 95% CIs and standard er- rors of proportion estimates in each country. The simulated UIs incorporated the uncertainty of estimates.

Following the collation of country-specific estimates, es- timates of regional and global viraemic HCV infection among people with recent injecting drug use were derived. Region-specific, weighted estimates of the prevalence of HCV were made using all the observed estimates and 95% CI of estimates in each country within that region and deriving a weighted estimate and UI taking into ac- count country population size. Regional estimates were then used to estimate the global prevalence.

The proportion of people with recent injecting drug use among all people living with HCV infection was computed by dividing the total number of people with recent injecting drug use living with HCV by the total number of all people living with HCV for countries where both estimates were available. As above, 95% UIs were simulated taking 100000 draws carrying forward the standard errors for both people with recent injecting drug use living with HCV and the total HCV viraemic infection prevalence estimates.

RESULTS

Sufficient data were identified to enable estimates of the HCV viraemic prevalence among people with recent injecting drug use in 98 countries, and to estimate the pop- ulation size of people with recent injecting drug use living with HCV in 76 countries. Sufficient data were identified to enable estimates of the number of people living with HCV overall in 98 countries. There were sufficient data to estimate the number of people with recent injecting drug use as a proportion of all people living with HCV in 55 countries.

Results are shown by region in Table 2 and by country in Table 3. Globally, we estimate that in 2015, 39.2% (UI = 31.6–47.0) of people with recent injecting drug use have HCV viraemic infection, representing 6.1 million (UI = 3.4–9.2) people with recent injecting drug use living with HCV infection globally. Of the 71.1million (UI = 62.5– 79.4million) people livingwith HCV infection (Table 2), we estimate that 8.5% (UI = 4.6–13.1) are people with recent injecting drug use (Table 2).

At the regional level, HCV viraemic prevalence among people with recent injecting drug use varied from 16.3% (UI = 12.7–20.1) in sub-Saharan Africa to 48.6% (UI = 42.0–55.2) in eastern Europe (Table 2). The largest estimated numbers of people with recent injecting drug use living with HCV infection were in East and Southeast Asia (1.5 million, UI = 1.0–2.1), eastern Europe (1.5 mil- lion, UI = 0.7–2.4) and North America (1.0 million,

Table 1 Quality of evidence of countries with available hepatitis C virus (HCV) antibody prevalence and HCV RNA prevalence data among recent people who inject drugs (PWID).

HCVantibody prevalence among recent PWID (n = 374)

HCV RNA prevalence among recent PWID (n = 32)

Countries with available data

98/206 (47.6%)

19/206 (9.2%)

Estimate-gradeb

A 82 (21.9%) 2 (6.3%) B1 225 (60.2%) 20 (62.5%) B2 13 (3.6%) 1 (3.1%) C 54 (14.4%) 8 (25.0%) U – 1 (3.1%)

Geographic coverage National sample 77 (20.6%) 2 (6.2%) Subnational sample 87 (23.3%) 11 (34.4%) City sample 210 (56.1%) 19 (59.4%)

Literature typea

A1 128 (34.2%) 30 (93.75%) A2 4 (1.1%) –

B2 147 (39.3%) –

B3 81 (21.7%) –

C 8 (2.2%) 2 (6.25%) D 6 (1.6%) –

aGrading for literature type: A1 = peer-reviewed journal article; A2 = ab- stract of published article only; B1 = published book/report/monograph from scholarly or commercial publisher; B2 = published book/report/mono- graph from international governmental or monitoring organization (e.g. UN, WHO, EMCDDA); B3 = published book/report/monograph from other source [e.g. government, non-governmental organization (NGO), university, research centre]; C = conference abstract; D = other unpublished report (in- cluding website downloads); E = e-mail and private correspondence; F = ARQ. bGrading for estimate grade: A = multi-site seroprevalence study with > 1 sample types (e.g. needle-syringe programmes, drug treatment centres, incarcerated IDUs); B1 = seroprevalence study, single sample type and multiple sites; B2 = seroprevalence study, multiple sample types and a single site; C = seroprevalence study, single sample type; D = registration or notification of cases of hepatitis/HIV infection; E = prevalence study using self-reported hepatitis/HIV status; ungraded = estimate with methodology unknown.

152 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 2

R eg io na

la nd

gl ob al es tim

at es

of th e pr ev al en ce

of he pa tit is C vi ru s (H CV

)v ir ae m ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e, th e nu

m be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n,

th e to ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n an

d th e pr op or tio

n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n.

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e

liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

To ta lp op ul at io n liv in g

w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

Ea st er n Eu

ro pe

48 .6

(4 2. 0,

55 .2 )

1 46

6 50

0 (6 99

50 0,

2 37

7 00

0) 8 18

1 00

0 (6

30 4 00

0, 8 25

0 00

0) 17

.9 (8 .2 ,3

0. 9)

W es te rn

Eu ro pe

39 .9

(3 5. 7,

44 .1 )

40 2 50

0 (2 64

50 0,

55 7 00

0) 2 34

7 00

0 (1

96 9 00

0, 3 28

9 00

0) 17

.2 (9 .9 ,3

0. 4)

Ea st an

d So ut he as t A si a

37 .7

(2 8. 2,

47 .5 )

1 50

6 00

0 (1

01 9 50

0, 2 07

8 50

0) 16

31 3 00

0 (1 2 63

6 00

0, 17

24 2 00

0) 9. 2 (5 .8 ,1

3. 8)

So ut h A si a

28 .9

(1 3. 4,

47 .5 )

29 6 00

0 (1 14

50 0,

51 8 00

0) 15

61 7 50

0 (1 3 34

1 00

0, 20

18 2 00

0) 1. 9 (0 .7 ,3

.6 )

Ce nt ra lA

si a

40 .5

(3 6. 5,

44 .5 )

11 4 00

0 (6 9 00

0, 16

5 00

0) 2 51

6 00

0 (2

01 0 00

0, 2 74

9 00

0) 4. 5 (2 .6 ,6

.9 )

Ca ri bb ea n

47 .6

(4 0. 2,

55 .1 )

37 50

0 (2 2 50

0, 55

00 0)

22 5 50

0 (1 83

00 0,

31 5 00

0) 16

.7 (8 .9 ,3

0. 6)

La tin

A m er ic a

46 .4

(4 3. 1,

49 .8 )

84 6 00

0 (6 17

50 0,

1 09

2 50

0) 3 85

4 00

0 (3

13 1 00

0, 3 94

8 00

0) 22

.0 (1 5. 3,

30 .4 )

N or th

A m er ic a

40 .5

(2 9. 2,

51 .7 )

96 0 00

0 (3 98

00 0,

1 67

9 50

0) 3 14

8 00

0 (2

42 9 00

0, 4 03

4 00

0) 30

.5 (1 1. 7,

56 .7 )

Pa ci fi c Is la nd

st at es

an d Te rr ito

ri es

a 41

.4 (3 2. 4,

50 .5 )

90 00

(5 50

0, 14

00 0)

11 7 50

0 (1 01

00 0,

37 6 00

0) 7. 9 (1 .9 ,1

1. 1)

A us tr al as ia

42 .8

(3 8. 9,

46 .8 )

49 50

0 (3 5 50

0, 65

00 0)

27 8 50

0 (2 20

00 0,

29 7 00

0) 17

.7 (1 2. 1,

25 .2 )

Su b- Sa ha

ra n A fr ic a

16 .3

(1 2. 7,

20 .1 )

22 5 00

0 (4 5 50

0, 45

8 50

0) 9 89

3 50

0 (7

60 5 00

0, 15

11 2 00

0) 2. 3 (0 .5 ,5

.9 )

M id dl e Ea st an

d N or th

A fr ic a

36 .1

(2 9. 2,

43 .2 )

12 6 00

0 (6 5 00

0, 19

9 50

0) 8 62

5 50

0 (6

83 8 00

0, 9, 15

5 00

0) 1. 5 (0 .7 ,2

.4 )

G lo ba l

39 .2

(3 1. 6,

47 .0 )

6 06

3 50

0 (3

43 4 50

0, 9 24

6 00

0) 71

14 6 00

0 (6 2 47

2 00

0, 79

40 4 00

0) 8. 5 (4 .6 ,1

3. 1)

U I=

un ce rt ai nt y in te rv al (s ee

M et ho

ds fo rd

et ai ls of es tim

at io n) .N

um be ro

fp eo pl e w ith

re ce nt

in je ct in g dr ug

us e w ith

vi ra em

ic H CV

in fe ct io n ar e ro un

de d to th e ne ar es t5

00 .T ot al po pu

la tio

n nu

m be rw

ith vi ra em

ic H CV

in fe ct io n ar e ro un

de d to

th e ne ar es t1

00 0.

a N ot e th at

no es tim

at es

of th e pr ev al en

ce of an

ti- H CV

am on

g pe op le w ho

in je ct dr ug

s ha

ve be en

lo ca te d fo r th e Pa

ci fi c Is la nd

s an

d Te rr ito

ri es ,s o th e w ei gh

te d ob se rv ed

gl ob al pr ev al en ce

w as

us ed

he re .C

on si de ra bl e ca ut io n

sh ou

ld be

us ed

w ith

th es e es tim

at es .

153

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3

Co un

tr y- le ve le st im

at es

of th e pr ev al en ce

of he pa tit is C vi ru s (H CV

)v ir ae m ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e, th e nu

m be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n,

th e to ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n an

d th e pr op or tio

n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n.

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

Ea st er n Eu

ro pe

A rm

en ia

32 .0

(2 2. 0,

42 .3 )

40 00

(1 50

0, 85

00 )

N K

N G

A ze rb ai ja n

46 .6

(3 4. 9,

58 .0 )

20 00

0 (1 4 00

0, 27

00 0)

19 0 00

0 (1 25

00 0,

21 2 00

0) 10

.6 (6 .6 ,1

7. 3)

Be la ru s

43 .7

(3 2. 3,

55 .1 )

18 00

0 (7 00

0, 31

50 0)

N K

N G

Bo sn ia an

d H er ze go vi na

30 .0

(2 0. 7,

39 .5 )

N K

N K

N K

Bu lg ar ia

51 .5

(4 7. 3,

55 .8 )

95 00

(7 50

0, 11

50 0)

87 00

0 (4 6 00

0, 11

2 00

0) 11

.0 (6 .9 ,2

0. 4)

Cz ec h R ep ub

lic 13

.7 (1 0. 9,

16 .7 )

65 00

(5 00

0, 80

00 )

43 00

0 (2 2 00

0, 48

50 0)

15 .0

(9 .2 ,2

8. 6)

Es to ni a

59 .4

(4 9. 8,

68 .4 )

50 00

(2 50

0, 85

00 )

18 00

0 (1 1 50

0, 20

00 0)

28 .2

(1 2. 6,

53 .0 )

G eo rg ia

51 .8

(4 2. 9,

60 .5 )

59 50

0 (1 2 50

0, 11

9 50

0) 16

5 00

0 (1 20

00 0,

16 9 00

0) 36

.1 (7 .4 ,7

6. 9)

H un

ga ry

35 .0

(2 2. 9,

47 .2 )

15 00

(5 00

,2 50

0) 52

50 0 (2 8 50

0, 55

50 0)

2. 7 (1 .1 ,5

.6 )

La tv ia

55 .8

(4 9. 8,

61 .7 )

80 00

(6 00

0, 10

00 0)

43 00

0 (2 8 00

0, 50

00 0)

18 .1

(1 1. 8,

29 .1 )

Li th ua

ni a

30 .8

(2 8. 1,

33 .7 )

15 00

(5 00

,2 50

0) 32

50 0 (2 0 00

0, 38

50 0)

4. 5 (2 .0 ,8

.6 )

M ol do va

37 .5

(2 5. 5,

49 .7 )

45 00

(2 50

0, 70

00 )

N K

N G

Po la nd

44 .0

(4 0. 5,

47 .6 )

N K

18 4 00

0 (1 36

00 0,

22 4 00

0) N K

R om

an ia

62 .9

(5 8. 7,

67 .0 )

51 00

0 (3 6 00

0, 67

50 0)

54 7 00

0 (3 97

00 0,

56 6 00

0) 9. 3 (6 .0 ,1

4. 2)

R us si an

Fe de ra tio

n 51

.6 (4 4. 2,

58 .9 )

96 9 50

0 (4 63

00 0,

1 57

0 50

0) 4 74

8 00

0 (3 ,2 38

00 0,

4 96

0 00

0) 20

.4 (9 .3 ,3

7. 2)

Sl ov ak ia

42 .1

(2 6. 6,

57 .7 )

85 00

(3 50

0, 14

50 0)

33 00

0 (2 0 00

0, 37

50 0)

25 .4

(9 .6 ,5

2. 0)

U kr ai ne

40 .4

(3 6. 3,

44 .6 )

12 9 00

0 (5 4 00

0, 22

2 00

0) N K

N G

W es te rn

Eu ro pe

A lb an

ia 25

.5 (2 0. 1,

31 .1 )

15 00

(1 00

0, 25

00 )

N K

N G

A nd

or ra

N K

N K

N K

N K

A us tr ia

45 .7

(4 0. 6,

50 .9 )

85 00

(6 00

0, 11

50 0)

21 00

0 (6 00

0, 30

50 0)

40 .2

(2 0. 1,

10 0. 0)

Be lg iu m

43 .8

(3 4. 9,

52 .6 )

11 50

0 (7 00

0, 16

50 0)

64 50

0 (2 3 00

0, 75

50 0)

17 .8

(8 .7 ,4

5. 8)

Cr oa tia

27 .5

(2 1. 0,

34 .2 )

15 00

(1 00

0, 25

00 )

26 00

0 (1 6 50

0, 28

50 0)

6. 7 (4 .0 ,1

1. 3)

D en m ar k

31 .9

(2 6. 8,

37 .2 )

55 00

(4 00

0, 65

00 )

19 50

0 (1 4 50

0, 19

50 0)

27 .2

(1 8. 8,

39 .5 )

En gl an

d 23

.1 (2 0. 0,

26 .3 )

48 50

0 (4 1 50

0, 56

00 0)

16 8 00

0 (9 1 00

0, 21

1 00

0) 28

.9 (1 8. 8,

51 .8 )

Fi nl an

d 55

.2 (5 1. 2,

59 .4 )

95 00

(7 00

0, 12

50 0)

22 50

0 (1 6 00

0, 26

00 0)

41 .6

(2 7. 4,

62 .8 )

Fr an

ce 48

.0 (4 4. 5,

51 .5 )

39 50

0 (3 1 50

0, 47

50 0)

19 4 00

0 (9 2 50

0, 22

2 00

0) 20

.2 (1 2. 4,

40 .1 )

FY R (F or m er

Yu go sl av

R ep ub

lic ) M ac ed on

ia 46

.6 (4 3. 4,

49 .9 )

25 00

(1 50

0, 30

00 )

N K

N G

(C on

ti nu

es )

154 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

G er m an

y 48

.7 (4 4. 6,

53 .0 )

64 00

0 (1 3 50

0, 12

9 00

0) 20

5 00

0 (9 0 00

0, 31

3 00

0) 31

.3 (6 .2 ,8

0. 6)

G re ec e

49 .2

(4 5. 4,

53 .1 )

25 00

(2 00

0, 30

00 )

13 2 00

0 (8 2 00

0, 16

9 00

0) 1. 9 (1 .2 ,3

.1 )

G re en la nd

– –

N K

–

Ic el an

d 47

.3 (4 3. 8,

50 .8 )

50 0 (<

50 0,

50 0)

10 00

(1 00

0, 10

00 )

N R

Ir el an

d 56

.0 (5 2. 5,

59 .4 )

50 00

(3 50

0, 60

00 )

29 50

0 (2 0 00

0, 42

50 0)

16 .2

(1 0. 0,

28 .9 )

It al y

43 .4

(3 8. 8,

48 .1 )

14 8 50

0 (9 8 50

0, 20

5 00

0) 68

0 00

0 (4 55

00 0,

1 64

1 00

0) 21

.8 (7 .6 ,3

3. 9)

Li ec ht en st ei n

– –

N K

–

Lu xe m bo ur g

61 .0

(5 5. 9,

66 .1 )

15 00

(1 00

0, 15

00 )

55 00

(3 50

0, 60

00 )

25 .2

(1 6. 6,

41 .1 )

M al ta

18 .9

(1 0. 4,

28 .4 )

< 50

0 (<

50 0,

50 0)

10 00

(1 00

0, 15

00 )

N R

M on

ac o

N K

N K

N K

N K

M on

te ne gr o

32 .6

(2 9. 4,

35 .9 )

50 0 (5 00

,5 00

) N K

N K

N et he rl an

ds 41

.5 (3 6. 7,

46 .3 )

15 00

(1 00

0, 20

00 )

16 50

0 (5 00

0, 25

50 0)

8. 3 (4 .2 ,2

2. 9)

N or th er n Ir el an

d N K

N K

N K

N K

N or w ay

48 .6

(4 4. 5,

52 .8 )

40 00

(3 50

0, 50

00 )

21 00

0 (1 5 00

0, 24

50 0)

19 .4

(1 3. 8,

28 .1 )

Po rt ug

al 65

.8 (5 9. 1,

72 .2 )

10 50

0 (9 00

0, 12

00 0)

89 00

0 (7 4 00

0, 12

0 00

0) 11

.7 (8 .2 ,1

8. 1)

Sa n M ar in o

N K

N K

N K

N K

Sc ot la nd

39 .1

(3 3. 8,

44 .5 )

60 00

(5 00

0, 75

00 )

N K

N G

Se rb ia

19 .4

(1 6. 5,

22 .6 )

55 00

(4 50

0, 70

00 )

N K

N G

Sl ov en ia

22 .9

(1 9. 6,

26 .2 )

15 00

(1 00

0, 20

00 )

65 00

(4 50

0, 70

00 )

21 .3

(1 3. 3,

33 .5 )

Sp ai n

53 .3

(5 0. 2,

56 .3 )

55 00

(2 00

0, 95

00 )

38 6 00

0 (2 02

00 0,

62 0 00

0) 1. 4 (0 .5 ,3

.6 )

Sw ed en

61 .3

(5 7. 6,

64 .9 )

50 00

(< 50

0, 20

00 0)

37 50

0 (2 8 00

0, 43

50 0)

13 .3

(0 .0 ,4

6. 6)

Sw itz er la nd

55 .9

(5 1. 0,

60 .9 )

75 00

(6 00

0, 95

00 )

78 00

0 (4 5 50

0, 87

00 0)

9. 7 (6 .3 ,1

6. 7)

W al es

20 .1

(1 7. 2,

23 .0 )

N K

N K

N K

Ea st an

d So ut h Ea st A si a

Br un

ei D ar us sa la m

N K

N K

N K

N K

Ca m bo di a

N K

N K

25 7 00

0 (1 47

00 0,

27 2 00

0) N K

Ch in a

32 .3

(2 0. 8,

44 .3 )

82 8 00

0 (4 93

00 0,

1 22

8 50

0) 9 79

5 00

0 (6

67 5 00

0, 10

83 2 00

0) 8. 5 (4 .6 ,1

4. 3)

In do ne si a

66 .9

(6 2. 2,

71 .5 )

12 7 50

0 (1 03

00 0,

15 3 00

0) 1 28

9 00

0 (4 43

00 0,

2 04

6 00

0) 9. 9 (5 .5 ,2

4. 9)

Ja pa n

48 .6

(4 0. 8,

56 .3 )

17 9 00

0 (1 30

50 0,

23 4 50

0) 85

7 00

0 (3 64

00 0,

1 02

4 00

0) 20

.9 (1 1. 7,

46 .5 )

La o PD

R N K

N K

N K

N K

M al ay si a

50 .3

(4 6. 2,

54 .5 )

14 2 00

0 (1 16

00 0,

16 9 50

0) 38

2 00

0 (2 40

00 0,

40 5 00

0) 37

.1 (2 5. 2,

59 .2 )

(C on

ti nu

es )

155

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

M on

go lia

N K

N K

19 4 00

0 (1 31

00 0,

23 7 00

0) N K

M ya nm

ar 22

.2 (1 9. 9,

24 .5 )

38 50

0 (2 5 50

0, 53

00 0)

N K

N G

N or th

K or ea

– –

N K

–

Ph ili pp in es

26 .4

(1 2. 8,

41 .6 )

65 00

(3 00

0, 11

50 0)

61 4 00

0 (3 53

00 0,

65 1 00

0) 1. 1 (0 .4 ,2

.3 )

R ep ub

lic of K or ea

36 .3

(3 1. 7,

41 .0 )

N K

23 1 00

0 (1 48

00 0,

26 1 00

0) N K

Si ng

ap or e

31 .9

(2 8. 9,

35 .0 )

N K

N K

N K

Ta iw an

68 .2

(6 4. 4,

72 .0 )

N K

48 9 00

0 (3 10

00 0,

87 7 00

0) N K

Th ai la nd

66 .4

(6 0. 6,

71 .9 )

34 00

0 (1 2 50

0, 60

00 0)

46 3 00

0 (2 55

00 0,

48 7 00

0) 7. 4 (2 .6 ,1

6. 1)

Ti m or

Le st e

N K

N K

N K

N K

V ie t N am

43 .8

(3 1. 8, 5 5. 7)

70 50

0 (4 7 00

0, 98

00 0)

1 06

6 00

0 (5 80

00 0,

1 11

6 00

0) 6. 6 (3 .7 ,1

2. 5)

So ut h A si a

A fg ha

ni st an

28 .4

(2 0. 7,

36 .3 )

39 50

0 (2 3 00

0, 60

00 0)

18 3 00

0 (8 5 00

0, 25

8 00

0) 21

.5 (1 0. 5,

46 .9 )

Ba ng

la de sh

25 .4

(1 6. 9,

34 .4 )

17 50

0 (1 1 50

0, 24

00 0)

N K

N G

Bh ut an

N K

N K

N K

N K

In di a

30 .0

(2 5. 2,

34 .9 )

59 00

0 (3 8 00

0, 84

00 0)

6, 24

5 00

0 (4

74 8 00

0, 10

95 7 00

0) 0. 9 (0 .4 ,3

.0 )

Ir an

33 .1

(2 1. 4,

45 .2 )

52 00

0 (2 9 50

0, 81

00 0)

19 9 00

0 (1 29

00 0,

22 6 00

0) 26

.2 (1 3. 2,

47 .0 )

M al di ve s

0. 5 (0 .0 ,1

.4 )

< 50

0 (<

50 0,

< 50

0) N K

N G

N ep al

33 .4

(2 3. 1,

43 .8 )

12 00

0 (8 00

0, 15

50 0)

N K

N G

Pa ki st an

27 .4

(0 .0 ,6

0. 6)

11 6 00

0 (<

50 0,

17 3 50

0) 7 17

2 00

0 (5

36 3 00

0, 7 48

7 00

0) 1. 6 (0 .5 ,3

.1 )

Sr iL an

ka N K

N K

N K

N K

Ce nt ra lA

si a

K az ak hs ta n

44 .1

(3 9. 8,

48 .4 )

49 50

0 (3 0 00

0, 71

50 0)

50 8 00

0 (3 34

00 0,

57 2 00

0) 9. 8 (5 .4 ,1

6. 7)

Ky rg yz st an

32 .9

(2 9. 9,

36 .0 )

95 00

(5 50

0, 13

50 0)

N K

N G

Ta jik is ta n

46 .0

(4 1. 9,

50 .2 )

11 00

0 (6 50

0, 15

50 0)

N K

N G

Tu rk m en is ta n

N K

N K

N K

N K

U zb ek is ta n

38 .8

(3 4. 7,

43 .0 )

36 50

0 (2 2 50

0, 53

00 0)

1 29

2 00

0 (9 02

00 0,

1 52

4 00

0) 2. 8 (1 .6 ,4

.6 )

Ca ri bb ea n

A nt ig ua

an d Ba

rb ud

a –

– N K

–

Ba ha

m as

N K

N K

N K

N K

Ba rb ad os

– –

N K

–

Be rm

ud a

N K

N K

N K

N K

(C on

ti nu

es )

156 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

Co m m on

w ea lth

of Pu

er to

R ic o

58 .8

(5 3. 9,

63 .7 )

16 50

0 (1 0 00

0, 24

00 0)

35 50

0 (2 3 00

0, 60

50 0)

46 .6

(2 2. 1,

10 0. 0)

Cu ba

– –

35 00

0 (1 3 50

0, 77

00 0)

–

D om

in ic a

– –

N K

–

D om

in ic an

R ep ub

lic N K

N K

68 00

0 (4 1 50

0, 10

8 00

0) N K

G re na

da –

– N K

–

H ai ti

N K

N K

N K

N K

Ja m ai ca

N K

N K

N K

N K

Sa in t K itt s an

d N ev is

– –

N K

–

Sa in t Lu

ci a

– –

N K

–

St V in ce nt

an d th e

G re na

di ne s

– –

N K

–

Tr in id ad

an d To ba go

– –

N K

–

La tin

A m er ic a

A rg en tin

a 41

.0 (3 7. 5,

44 .4 )

33 00

0 (3 0 00

0, 36

00 0)

32 6 00

0 (1 44

00 0,

49 0 00

0) 10

.1 (6 .3 ,2

1. 0)

Be liz e

– –

N K

–

Bo liv ia

N K

N K

N K

N K

Br az il

47 .9

(4 4. 3,

51 .5 )

46 1 00

0 (3 36

50 0,

59 6 50

0) 1 78

7 00

0 (1

29 3 00

0, 1 89

6 00

0) 25

.8 (1 7. 2,

38 .5 )

Ch ile

N K

N K

56 50

0 (3 1 00

0, 94

00 0)

N K

Co lo m bi a

21 .6

(1 9. 3,

24 .0 )

N K

40 9 00

0 (2 72

00 0,

43 6 00

0) N K

Co st a R ic a

N K

N K

N K

N K

Ec ua

do r

N K

N K

N K

N K

El Sa lv ad or

N K

N K

N K

N K

G ua

te m al a

N K

N K

N K

N K

G uy

an a

N K

N K

N K

N K

H on

du ra s

N K

N K

N K

N K

M ex ic o

71 .5

(6 7. 3,

75 .5 )

10 7 50

0 (7 0 50

0, 14

9 00

0) 53

2 00

0 (3 04

00 0,

55 7 00

0) 20

.2 (1 1. 4,

37 .2 )

N ic ar ag ua

N K

N K

N K

N K

Pa na

m a

N K

N K

12 50

0 (7 50

0, 13

50 0)

N K

Pa ra gu

ay 7. 4 (5 .8 ,9

.0 )

N K

N K

N K

Pe ru

N K

N K

16 7 00

0 (9 9 00

0, 18

2 00

0) N K

(C on

ti nu

es )

157

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

Su ri na

m e

N K

N K

N K

N K

U ru gu

ay 16

.4 (1 4. 1,

18 .9 )

10 00

(< 50

0, 25

00 )

N K

N G

Ve ne

zu el a

N K

N K

11 8 00

0 (5 8 50

0, 12

6 00

0) N K

N or th

A m er ic a

Ca na

da 52

.9 (4 4. 5,

61 .2 )

65 00

0 (5 0 00

0, 82

00 0)

21 2 00

0 (1 36

00 0,

24 6 00

0) 30

.7 (2 0. 2,

49 .3 )

U ni te d St at es

39 .8

(2 8. 4,

51 .3 )

89 5 00

0 (3 53

50 0,

1 60

1 50

0) 2 93

6 00

0 (2

23 1 00

0, 3 82

6 00

0) 30

.5 (1 0. 9,

58 .9 )

Pa ci fi c Is la nd

St at es

an d Te rr ito

ri es

A m er ic an

Sa m oa

N K

N K

N K

N K

Fe de ra lS ta te s of M ic ro ne si a

N K

N K

N K

N K

Fi ji

N K

N K

50 0 (<

50 0,

30 00

) N K

Fr en ch

Po ly ne si a

N K

N K

N K

N K

G ua

m N K

N K

N K

N K

K ir ib at i

N K

N K

N K

N K

M ar sh al lI sl an

ds N K

N K

N K

N K

N au

ru –

– N K

–

N ew

Ca le do ni a

N K

N K

N K

N K

N or th er n M ar ia na

Is la nd

s N K

N K

N K

N K

Pa la u

N K

N K

N K

N K

Pa pu

a N ew

G ui ne a

N K

N K

94 50

0 (7 0 50

0, 32

8 00

0) N K

Sa m oa

N K

N K

< 50

0 (<

50 0,

50 0)

N K

So lo m on

Is la nd

s N K

N K

N K

N K

To ng

a N K

N K

N K

N K

Tu va lu

– –

N K

–

Va nu

at u

N K

N K

N K

N K

A us tr al as ia

A us tr al ia

40 .1

(3 6. 9,

43 .5 )

37 50

0 (2 7 50

0, 48

50 0)

23 0 00

0 (1 78

00 0,

24 4 00

0) 16

.2 (1 1. 1,

23 .2 )

N ew

Ze al an

d 53

.9 (4 6. 8,

61 .1 )

12 00

0 (8 00

0, 16

50 0)

48 50

0 (3 0 00

0, 62

50 0)

25 .0

(1 4. 7,

42 .9 )

Su b- Sa ha

ra n A fr ic a

A ng

ol a

N K

N K

N K

N K

Be ni n

N K

N K

N K

N K

Bo ts w an

a –

– N K

–

(C on

ti nu

es )

158 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

Bu rk in a Fa so

N K

N K

24 7 00

0 (1 89

00 0,

25 6 00

0) N K

Bu ru nd

i N K

N K

12 0 00

0 (9 3 00

0, 45

9 00

0) N K

Ca m er oo n

N K

N K

16 4 00

0 (1 17

00 0,

18 4 00

0) N K

Ca pe

Ve rd e

N K

N K

N K

N K

Ce nt ra lA

fr ic an

R ep ub

lic –

– 15

50 0 (1 1 00

0, 17

50 0)

–

Ch ad

N K

N K

16 2 00

0 (1 11

00 0,

18 4 00

0) N K

Co m or os

– –

N K

–

Co ng

o (K in sh as a)

N K

N K

N K

N K

Co te

d’ Iv oi re

1. 3 (0 .0 ,7

.1 )

< 50

0 (<

50 0,

< 50

0) N K

N G

D jib ou

ti N K

N K

N K

N K

Eq ua

to ri al G ui ne a

– –

N K

–

Er itr ea

– –

N K

–

Et hi op ia

N K

N K

64 7 00

0 (4 10

00 0,

72 6 00

0) N K

G ab on

N K

N K

12 4 00

0 (9 0 00

0, 12

9 00

0) N K

G am

bi a

N K

N K

17 00

0 (1 0 00

0, 27

00 0)

N K

G ha

na 30

.1 (2 5. 8,

34 .4 )

N K

39 9 00

0 (3 05

00 0,

94 4 00

0) N K

G ui ne a

N K

N K

N K

N K

G ui ne a- Bi ss au

– –

N K

–

K en ya

12 .3

(7 .4 ,1

7. 7)

40 00

(1 00

0, 75

00 )

11 5 00

0 (4 2 50

0, 12

6 00

0) 3. 3 (0 .7 ,9

.7 )

Le so th o

– –

N K

–

Li be ri a

N K

N K

N K

N K

M ad ag as ca r

4. 2 (1 .8 ,7

.0 )

50 0 (<

50 0,

30 00

) 56

00 0 (3 9 00

0, 81

00 0)

1. 2 (0 .0 ,5

.2 )

M al aw

i N K

N K

N K

N K

M al i

N K

N K

N K

N K

M au

ri ta ni a

– –

N K

–

M au

ri tiu

s 72

.8 (6 8. 8,

76 .7 )

50 00

(1 50

0, 95

00 )

N K

N G

M oz am

bi qu

e 50

.3 (4 6. 2,

54 .4 )

14 50

0 (<

50 0,

31 00

0) N K

N G

N am

ib ia

– –

N K

–

N ig er

N K

N K

N K

N K

N ig er ia

4. 3 (2 .1 ,6

.8 )

11 50

0 (2 00

0, 27

00 0)

2 55

3 00

0 (1

90 2 00

0, 2 65

1 00

0) 0. 5 (0 .0 ,1

.1 )

R ep ub

lic of th e Co

ng o

– –

N K

–

(C on

ti nu

es )

159

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

Ta bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

R w an

da N K

N K

N K

N K

Sa o To m e an

d Pr in ci pe

– –

N K

–

Se ne ga l

29 .5

(2 2. 9,

36 .3 )

65 00

(1 50

0, 13

50 0)

N K

N K

Se yc he lle s

31 .5

(2 7. 2,

36 .0 )

50 0 (5 00

,5 00

) N K

N G

Si er ra

Le on

e N K

N K

N K

N K

So m al ia

N K

N K

N K

N K

So ut h A fr ic a

N K

N K

35 6 00

0 (2 27

00 0,

44 1 00

0) N K

Sw az ila nd

N K

N K

N K

N K

To go

N K

N K

N K

N K

U ga nd

a N K

N K

N K

N K

U ni te d R ep ub

lic of Ta nz an

ia 20

.8 (1 6. 4,

25 .4 )

71 50

0 (4 1 00

0, 10

8 00

0) N K

N G

Za m bi a

N K

N K

N K

N K

Zi m ba bw

e N K

N K

N K

N K

M id dl e Ea st an

d N or th

A fr ic a

A lg er ia

N K

N K

38 8 00

0 (1 40

00 0,

67 4 00

0) N K

Ba hr ai n

N K

N K

17 00

0 (1 1 00

0, 17

50 0)

N K

Cy pr us

37 .3

(3 2. 9,

41 .8 )

< 50

0 (<

50 0,

< 50

0) N K

N G

Eg yp t

37 .1

(2 6. 7,

47 .5 )

N K

5 62

5 00

0 (4

00 70

00 ,6

04 4 00

0) N K

Ir aq

N K

N K

85 50

0 (6 0 50

0, 96

50 0)

N K

Is ra el

34 .0

(2 8. 3,

39 .9 )

N K

10 0 00

0 (6 0 00

0, 10

3 00

0) N K

Jo rd an

N K

N K

24 50

0 (1 0 50

0, 29

00 0)

N K

K uw

ai t

N K

N K

N K

N K

Le ba no

n 17

.6 (1 0. 5,

25 .2 )

N K

75 00

(3 00

0, 18

00 0)

N K

Li by an

A ra b Ja m ah

ir iy a

70 .9

(6 6. 4,

75 .2 )

15 00

(5 00

,2 00

0) 41

50 0 (3 2 00

0, 43

00 0)

3. 3 (1 .7 ,5

.5 )

M or oc co

40 .4

(2 5. 4,

55 .8 )

12 50

0 (5 50

0, 21

00 0)

26 3 00

0 (1 90

00 0,

32 8 00

0) 4. 7 (1 .9 ,8

.5 )

O cc .P

al es tin

ia n Te rr .

31 .2

(2 6. 3,

36 .2 )

N K

N K

N K

O m an

N K

N K

15 50

0 (1 2 00

0, 17

50 0)

N K

Q at ar

N K

N K

37 50

0 (2 9 50

0, 40

00 0)

N K

Sa ud

iA ra bi a

58 .3

(5 3. 7,

63 .0 )

N K

10 6 00

0 (7 8 50

0, 19

0 00

0) N K

So ut h Su

da n

– –

N K

–

Su da n

N K

N K

N K

N K

(C on

ti nu

es )

160 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

UI = 0.4–1.7). The proportion of people with recent injecting drug use among all people living with HCV infection ranged from 1.5% (UI = 0.7–2.4) in the Middle East and North Africa to 30.5% (UI = 11.7–56.7) in North America (Table 2). Regions with people with recent injecting drug use comprising > 10% of all people living with HCV infection included Latin America (22.0%, UI = 15.3–30.4), eastern Europe (17.9%, UI = 8.2–30.9), Australasia (17.7%, UI = 12.1–25.2), the Caribbean (16.7%, 8.9–30.6) and western Europe (17.2%, UI = 9.9–30.4).

At the country level, there was very marked variation in the estimates of HCV viraemic prevalence between countries, ranging from 0.5% (UI = 0.0–1.4; Maldives) to 72.8% (UI = 68.8–76.7; Mauritius) (Fig. 1 and Table 3). The HCV viraemic prevalence was 60–80% in 10 countries, 40–< 60% in 38 countries and < 40% in 50 countries. The largest populations of people with recent injecting drug use living with HCV infection were in Russia (969500; UI = 463000–1570500), the United States (895000; UI = 353500–1601500), China (828000; UI = 493000–1228500) and Brazil (461000, UI = 336500–596500) (Fig. 2 and Table 3); together, these countries accounted for 51% of people with recent injecting drug use living with HCV infection. The top 25 countries accounting for 82% of all people with recent injecting drug use living with HCV infection globally are shown in Fig. 3. The proportion of people with recent injecting drug use among all people living with HCV infec- tion varied between 0.9% (UI = 0.4–3.0; India) and 46.6% (UI = 22.1–100.0; Commonwealth of Puerto Rico) (Fig. 4 and Table 3). The proportion of people with recent injecting drug use among all people living with HCV infection was < 10% in 21 countries, ≥ 10–< 20% in 11 countries and ≥ 20% in 23 countries.

DISCUSSION

This study estimated that there are 6.1 million (UI = 3.4–9.2) people with recent injecting drug use living with HCV infection world-wide, comprising 8.5% (UI = 4.6–13.1) of all HCV infections globally. There was considerable variation in the prevalence of HCV infection among people with recent injecting drug use at regional and country levels, and in the proportion of all HCV infection among people with recent injecting drug use. These findings highlight countries and regions where a focus upon HCV prevention and treatment among people with recent injecting drug use will be required if HCV elimination targets are to be met.

The greatest numbers of people with recent injecting drug use living with HCV infection are in eastern Europe, East and Southeast Asia and North America. Half of all people with recent injecting drug use living with HCVTa

bl e 3.

(C on

tin ue d)

R eg io n an d co un tr y

Pr ev al en ce of H CV

vi ra em

ic in fe ct io n am

on g pe op le w ith

re ce nt

in je ct in g dr ug

us e % (U

I)

N um

be r of pe op le w ith

re ce nt

in je ct in g dr ug

us e liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I) To ta lp op ul at io n liv in g w ith

H CV

vi ra em

ic in fe ct io n (U

I)

Pr op or tio n of pe op le w ith

re ce nt

in je ct in g dr ug

us e am

on g th e

to ta lp op ul at io n w ith

H CV

vi ra em

ic in fe ct io n % (U

I)

Sy ri an

A ra b R ep .

2. 5 (0 .9 ,4

.3 )

N K

55 4 00

0 (2 45

00 0,

65 3 00

0) N K

Tu ni si a

21 .8

(1 9. 0,

24 .7 )

N K

10 8 00

0 (2 5 00

0, 12

3 00

0) N K

Tu rk ey

33 .7

(3 0. 7,

36 .7 )

N K

49 2 00

0 (2 71

00 0,

76 3 00

0) N K

U ni te d A ra b Em

ir at es

N K

N K

13 1 00

0 (5 0 00

0, 15

9 00

0) N K

Ye m en

N K

N K

21 1 00

0 (1 43

00 0,

25 8 00

0) N K

N K = no

es tim

at e of pr ev al en ce

of th at

H CV

w as

lo ca te d, ye t ev id en

ce of

in je ct in g dr ug

us e oc cu rr in g in

th at

co un

tr y w as

id en

tifi ed ;–

= no

ev id en ce

lo ca te d th at

in je ct in g dr ug

us e w as

oc cu rr in g in

th is co un

tr y; N R = un

ce rt ai nt y w as

no t

es tim

at ed

ar ou

nd th e es tim

at e; N G = no

es tim

at e of H CV

am on

g th e ge ne ra lp op ul at io n w as

av ai la bl e. PW

ID = pe op le w ho

in je ct

dr ug

s; U I = un

ce rt ai nt y in te rv al (s ee

m et ho

ds fo r de ta ils

of es tim

at io n) .

161

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

infection are from just four countries: the Russian Federa- tion, the United States, China and Brazil. Further, the top 25 countries account for 82% of all people with recent injecting drug use living with HCV infection globally. Although PWID are a critical population for HCV

elimination in many settings, concerted efforts to increase access to prevention and treatment for people with recent injecting drug use in these countries will be pivotal to the success of global HCVelimination efforts. Key among these will be harm reduction measures to prevent incident

Figure 1 Estimated prevalence of hepatitis C virus (HCV) viraemic infection among people with recent injecting drug use, by country [Colour figure can be viewed at wileyonlinelibrary.com]

Figure 2 Estimated number of people with recent injecting drug use living with hepatitis C virus (HCV) viraemic infection, by country [Colour figure can be viewed at wileyonlinelibrary.com]

162 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

infections [11] and increased testing, linkage to care and uptake of directly acting anti-viral therapy among people with recent injecting drug use [12,13].

Countries or territories where it is estimated that at least one-third of people living with HCV infection are peo- ple with recent injecting drug use include Georgia, Austria, Finland, Malaysia and Puerto Rico. In a further 16 coun- tries, at least one-quarter of people living with HCV infec- tion are people with recent injecting drug use. However, there are also 21 countries where the proportion of people living with HCVare people with recent injecting drug use is < 10%. Collectively, these data highlight the variation in the proportion of overall viraemic HCV infection occurring among people with recent injecting drug use globally, reflecting the differing epidemiology of HCV in different settings. As such, different types of prevention, testing and treatment strategies will be needed to address HCV elimination targets according to the epidemiology within a given country. It should also be noted that there were 124 countries and territories where injecting drug use is known to occur, but no data were available to assess the proportion of people with HCV infection who are people with recent injecting drug use.

This study was limited to estimates among people with recent injecting drug use and will not include those who have even ‘temporarily’ or permanently ceased injecting. As such, this study underestimates the proportion of infec- tions that occur among PWID within an overall epidemic, given that some infections due to injecting drug use will be among people with a history of injecting who have ceased injecting. It is critical to consider people who have recently injected drugs aswell as thosewho have ceased injecting in the design of strategies to address HCV.

There are several limitations to this study. The search may have missed some literature (particularly grey literature), despite our wide scope of online searchers and requests for information from people across many coun- tries. To address this possibility, we liaised with the WHO, Global Fund, United Nations Office on Drugs and Crime (UNODC) and Joint United Nations Programme on HIV and AIDS (UNAIDS) staff to contact experts within coun- tries and obtain reports that were not available online. However, we doubt that any missed papers will alter these findings in a meaningful fashion.

Errors may have been made in data extraction and interpretation. To reduce such errors, all sources and data

Figure 3 Countries with the greatest total number of people with hepatitis C virus (HCV) viraemic infection among people with recent injecting drug use globally. The size of the bubble represents the total proportion of hepatitis C viraemic infections that among people with recent injecting drug use. X indicates that data were not available to calculate the total proportion of viraemic HCV infections among people with recent injecting drug use [Colour figure can be viewed at wileyonlinelibrary.com]

163

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

from which the final estimates were derived were double- checked by at least two reviewers prior to inclusion with a further round prior to finalization with a third reviewer. We have online interactive presentations of these data at (https://ndarc.med.unsw.edu.au/resource/global-epidemiol- ogy-injecting-drug-use-2017) to ensure full transparency and to increase the potential for people to interact with the estimates and results, and suggest additional data sources. We encourage feedback at [email protected].

Although the review team searched for publications in multiple languages, we may have missed documents in languages in which we are not fluent. Those with access to data or papers/reports in other languages should con- tact us. It is also important to acknowledge a number of features of our approach to synthesis and imputation of es- timates, driven by the gaps in data available. Although there has been a clear increase in efforts to quantify the ex- tent of IDU and HCV among PWID, there are still major gaps in data in some regions. A hierarchical grading sys- tem was used to evaluate estimates based on geographical generalizability (e.g. frommultiple sites) and across various populations of PWID (e.g. treatment and non-treatment samples). Exclusion of estimates based on a study’s meth- odology grade was applied only to estimates of IDU and anti-HCV prevalence. Nonetheless, our recent approach, which involved pooling estimates, and our more sophisti- cated approach to estimating uncertainty around all our estimates, including our method of estimating uncertainty around imputed estimates, are both improvements upon previous reviews.

A limitation is the lack of country-level data to estimate the viraemic HCV prevalence (98 countries), numbers of people living with HCV (76 countries) and the proportion among the overall population living with HCV among people with recent injecting drug use (55 countries). Data were sparse in regions such as the Caribbean, Latin America, Pacific Island States and Territories, sub-Saharan Africa and the Middle East and North Africa. The estimates for these regions should be interpreted with caution, and highlights that further work is needed to improve estimates in countries from these regions.

In this study, data on HCVantibody prevalence [multi- plied by an estimate of the proportion of people with HCV antibodies who would have active viraemia, 0.75 (95% CI = 0.71, 0.79)] was used to estimate the viraemic HCV prevalence, instead of actual data on HCVRNAprevalence. We opted for this approach because the data on HCVanti- body prevalence were of higher quality and coverage, and there were few countries for which any data were available for HCV RNA (Table 1). Instead, we used data on the estimated viraemic prevalence from a well-defined series of nine prospective cohorts of acute HCV infection among people who inject drugs with well-characterized events of spontaneous clearance [9]. Although this provides an ex- tremely accurate estimate of the proportion who progress to viraemic infection, the limitation is that this approach may have either over- or underestimated the true preva- lence of viraemic infection in people with recent injecting drug use in various settings. In some regions, increased re-infection risk and/or higher HIV prevalence may result

Figure 4 Estimated proportion of people with recent injecting drug use among the total population with hepatitis C virus (HCV) viraemic infection, by country [Colour figure can be viewed at wileyonlinelibrary.com]

164 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

in a higher viraemic prevalence, and our approach may have underestimated the viraemic prevalence [14]. Conversely, it is known that some factors (e.g. female sex) increase spontaneous clearance and can reduce the viraemic prevalence, which might have overestimated the viraemic prevalence observed. Also, these analyses did not take into consideration clearance due to HCV treat- ment, which might have led to an overestimation of the prevalence and numbers of people with recent injecting drug use living with HCV infection. However, this is also unlikely to have affected these estimates, as uptake of HCV treatment among PWID was very low prior to 2015 [15–19]. This study clearly demonstrates the need to inte- grate HCV RNA testing into future studies of HCV among people with recent injecting drug use to enable the evalua- tion of viraemic HCV RNA prevalence to improve national, regional and global estimates, particularly given that larger numbers of PWID are initiating HCV treatment (and will be anti-HCV positive, but HCV RNA-negative).

Denominator data are also subject to limitations. General population datamay be in error for some countries where accurate census data are lacking. Population sizes of people with recent injecting drug use were based on the best available empirical estimates for each country, but there is often considerable uncertainty around estimates of this population, which translates to uncertainty in esti- mates of the number of PWID with HCV infection and the proportion of HCV infections occurring among people with recent injecting drug use. Estimates of HCV viraemia in people with recent injecting drug use incorporated the uncertainties in the IDU population size, anti-HCV preva- lence estimate and viraemia multiplier. However, estimates of the prevalence of recent IDU and of HCV prevalence both in people with recent injecting drug use and in the general population are subject to biases, which may be responsible for some estimates that do not seem correct. Further, the extracted data were often from a single year and changes in injecting drug-user populations and HCV incidence could not be measured. This highlights the importance of continuing to improve country-level estimates of people with recent injecting drug use and those with viraemic HCV infection.

Irrespective of these limitations, this review advances our understanding of HCV prevalence and disease burden among people with recent injecting drug use. Accurate estimates of the prevalence and burden of viraemic HCV infection among people with recent injecting drug use are crucial to guide policy and practice and guide the devel- opment of strategies to enhance testing, linkage to care and treatment in this population. This review highlights that concerted efforts will be required in countries with large numbers of people infected with HCV to achieve global HCVelimination among PWID. Further, it highlights that strategies to achieve a reduction in HCV burden will

need to be tailored to the individual country, based on the HCV epidemiology and the proportion of overall infections occurring in people with recent injecting drug use. Collec- tively, these data will inform mathematical modelling to identify strategies to increase diagnosis and treatment and reduce the number of new infections to achieve HCV elimination at a country level. Further work is needed to understand more clearly the population size of people with a history of injecting drug use and the prevalence of viraemic HCV infection and burden in those with former, but not recent, injecting drug use.

Declaration of interests

J.G. is a consultant/adviser and has received research grants from AbbVie, Bristol-Myers Squibb, Cepheid, Gilead Sciences and Merck/MSD. G.D. is a consultant/adviser and has received research grants from Abbvie, Abbot Diagnostics, Bristol Myers Squibb, Cepheid, Gilead, GlaxoSmithKline, Merck, Janssen and Roche. S.B. and H. R. have not received any remuneration. The CDA Founda- tion and the Polaris Observatory has not received any funding from commercial organizations. J.S. reports non- financial support from Gilead Sciences. During the past 3 years, LD has received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior, Mundipharma, and Seqirus. S.L. has received investigator-initiated untied educational grants from Indivior. A.P. has received investigator-initiated untied educational grants fromMundipharma and Seqirus. E.B.C. received PhD funding from the Canadian Network on Hepatitis C. M.H. reports personal fees from Gilead, Abbvie and MSD.

Acknowledgements

The Australian National Drug and Alcohol Research Centre, UNSW Sydney, provided some funding towards the costs of this systematic review. The Open Society Foun- dation, World Health Organization, the Global Fund, and UNAIDS provided funding towards the systematic review to estimate the number of people with recent injecting drug use and the HCV antibody prevalence among people who have recently injected drugs. The John C Martin Foundation provided funding towards the system- atic review and modelling study to estimate the global viraemic HCV prevalence L.D. and R.P.M. are supported by Australian National Health and Medical Research Council (NHMRC) Principal Research Fellowships. S.L. is supported by an NHMRC Career Development Fellowship. A.P. is supported by an NHMRC Early Career Fellowship. J.L. acknowledges funding from the Bill & Melinda Gates Foundation. The Kirby Institute is funded by the Australian Government Department of Health and Ageing. The views expressed in this publication do not necessarily represent

165

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

the position of the Australian Government. J.G. is sup- ported by an NHMRC Career Development Fellowship. C. D. is supported by an NHMRC Practitioner Fellowship. J.S. acknowledges funding from a PhD scholarship from the Engineering and Physical Sciences Research Council (EPSRC). E.B.C. acknowledges funding from Canadian Net- work on Hepatitis C (CanHepC). A.T. has received PhD funding from the National Institute for Health Research (NIHR). M.H. and P.V. acknowledge support from NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions at the University of Bristol. P.V. acknowledges support from the NIHR HPRU in Blood-Borne and Sexually Transmitted Infections at University College London and National Institute for Drug Abuse (grant number R01 DA037773–01A1). We thank the research assistants who assisted with searches for and extraction of data from the eligible papers in this review: Erin Yong, Gabrielle Gib- son, Griselda Buckland, Harriet Townsend, Julia Stadum and Laura Sergeant (NDARC, UNSW) and Diana Sergiienko (Ukrainian Institute of Public Health Policy). We also thank Mary Kumvaj, the librarian who provided specialist advice on our search strategy and search strings for the peer-reviewed literature searches. Finally, we thank the individuals who provided encouragement and support in various ways throughout the conduct of this study, including circulating requests for data, provision of in-country contacts and assistance with locating data: Annette Verster (WHO), Daniel Wolfe (Open Society Foundations), Andre Noor (EMCDDA), Eleni Kalamara (EMCDDA), Mauro Guarinieri (Global Fund), Christoforos Mallouris (UNAIDS), Susie McLean, Catherine Cook [Harm Reduction International(HRI)], Maria Phelan (HRI), Katie Stone (HRI), Riku Lehtovuori (UNODC), Keith Sabin (UNAIDS), Jinkou Zhao (Global Fund), Vladimir Poznyak (WHO) and Gilberto Gerra (UNODC). Assistance in sourc- ing and verifying data was provided by many individuals from government, non-government and research organiza- tions around the world, for which we are thankful. These individuals are listed in the Appendix (p. 154).

References

1. World Health Organization (WHO). Global Hepatitis Report 2017. Geneva: WHO; 2017.

2. Nelson P. K., Mathers B.M., Cowie B., Hagan H., Des Jarlais D., Horyniak D. et al. Global epidemiology of hepatitis B and hep- atitis C in people who inject drugs: results of systematic reviews. Lancet 2011; 378: 571–83.

3. Morris M. D., Shiboski S., Bruneau J., Hahn J. A., Hellard M., Prins M. et al. Geographic differences in temporal incidence trends of hepatitis C virus infection among people who inject drugs: the InC3 collaboration. Clin Infect Dis 2017; 64: 860–9.

4. Wiessing L., Ferri M., Grady B., Kantzanou M., Sperle I., Cullen K. J. et al. Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic re- view of data for scaling up treatment and prevention. PLoS One 2014; 9: e103345.

5. Hagan H., Pouget E. R., Des Jarlais D. C., Lelutiu-Weinberger C. Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place. Am J Epidemiol 2008; 168: 1099–109.

6. Page K., Morris M. D., Hahn J. A., Maher L., Prins M. Injection drug use and hepatitis C virus infection in young adult injec- tors: using evidence to inform comprehensive prevention. Clin Infect Dis 2013; 57: S32–S38.

7. Degenhardt L., Peacock A., Colledge S., Leung J., Grebely J., Vickerman P. et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage sys- tematic review. Lancet Glob Health 2017; 5: e1192–e1207.

8. The Polaris Observatory HCVCollaborators. Global prevalence and genotype distribution of hepatitis C virus infection in 2015: amodelling study. Lancet Gastroenterol Hepatol2017;2: 161–76.

9. Grebely J., Page K., Sacks-Davis R., van der Loeff M. S., Rice T. M., Bruneau J. et al. The effects of female sex, viral genotype, and IL28B genotype on spontaneous clearance of acute hep- atitis C virus infection. Hepatology 2014; 59: 109–20.

10. Mathers B. M., Degenhardt L., Phillips B., Wiessing L., Hickman M., Strathdee S. A. et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 2008; 372: 1733–45.

11. Platt L., Minozzi S., Reed J., Vickerman P., HaganH., French C. et al. Needle and syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane review and meta- analysis. Addiction 2017; https://doi.org/10.1111/add.14012.

12. Bajis S., Dore G. J., Hajarizadeh B., Cunningham E. B., Maher L., Grebely J. Interventions to enhance testing, linkage to care and treatment uptake for hepatitis C virus infection among people who inject drugs: a systematic review. Int J Drug Policy 2017; 47: 34–46.

13. Grebely J., Dore G. J., Morin S., Rockstroh J. K., Klein M. B. Elimination of HCVas a public health concern among people who inject drugs by 2030—what will it take to get there? J Int AIDS Soc 2017; 20: 22146.

14. Smith D. J., Jordan A. E., Frank M., Hagan H. Spontaneous vi- ral clearance of hepatitis C virus (HCV) infection among people who inject drugs (PWID) and HIV-positive men who have sex with men (HIV+ MSM): a systematic review and meta-analysis. BMC Infect Dis 2016; 16: 471.

15. Alavi M., Raffa J. D., Deans G. D., Lai C., KrajdenM., Dore G. J., et al. Continued low uptake of treatment for hepatitis C virus infection in a large community-based cohort of inner city res- idents. Liver Int 2014; 34: 1198–206.

16. Iversen J., Grebely J., Topp L., Wand H., Dore G., Maher L. Up- take of hepatitis C treatment among people who inject drugs attending needle and syringe programs in Australia, 1999– 2011. J Viral Hepatol 2014; 21: 198–207.

17. Mehta S. H., Genberg B. L., Astemborski J., Kavasery R., Kirk G. D., Vlahov D. et al. Limited uptake of hepatitis C treatment among injection drug users. J Community Health 2008; 33: 126–33.

18. Grebely J., Raffa J. D., Lai C., Krajden M., Kerr T., Fischer B., et al. Low uptake of treatment for hepatitis C virus infection in a large community-based study of inner city residents. J Vi- ral Hepatol 2009; 16: 352–8.

19. Strathdee S. A., Latka M., Campbell J., O’Driscoll P. T., Golub E. T., Kapadia F. et al. Factors associated with interest in initi- ating treatment for hepatitis C virus (HCV) infection among young HCV-infected injection drug users. Clin Infect Dis 2005; 40: S304–S312.

166 Jason Grebely et al.

© 2018 Society for the Study of Addiction Addiction, 114, 150–166

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.