Background and Aims: Direct-acting antivirals (DAAs) are highly effective in treating hepatitis C. However, there is concern that cure rates may be lower, and reinfection rates higher, among people who inject drugs. We conducted a systematic review of treatment outcomes achieved with DAAs in people who inject drugs (PWID).Hepatitis C (HCV) is a blood-borne virus, which in high-income countries is primarily transmitted amongst people who inject drugs (PWID). 1,2 Curing HCV reduces mortality and improves quality of life. 3,4 Treating PWID also reduces the risk of transmission, and is an essential component of achieving the World Health Organization HCV elimination targets. 5 Despite recommendations that PWID receive treatment, 6-8 this population continues to be excluded; both by individual practitioners, 9 and at a systemic level. 10,11 Our 2013 systematic review of interferon/ribavirin therapy found that PWID receiving treatment had high levels of adherence (82%, 95% CI 74%-89%), low-treatment discontinuation (22%, 95% CI 16%-27%), and similar SVR rates (56%, 95% CI 50%-61%) to non-PWID in realworld settings. 12 A systematic review of treatment outcomes in people reporting recent drug use, including a subgroup of people who inject drugs, found that this population achieves relatively high rates of cure with DAAs. 13 Despite the effectiveness of DAAs, concerns about reinfection in PWID have been raised and may partially account for practitioner unwillingness to prescribe DAA therapy to this population. 9Low rates of reinfection were observed among those PWID treated with interferon-based therapies, 12,14 but this may be different in the DAA era. Indeed, given that DAA treatments are significantly more effective and tolerable than interferon-based therapies, it is possible that the availability of DAA treatment may result in an increase in the number of people with ongoing risk behaviour who achieve cure, and in turn increase the total population at risk of reinfection.Several studies have investigated DAA therapy outcomes amongst PWID, including reinfection, but the number of recent PWID included in each study is small (range: 23-163). [15][16][17][18][19][20][21][22][23][24][25][26][27] We conducted a systematic review and meta-analysis to measure SVR, treatment discontinuation, adherence, and reinfection amongst recent PWID and OST recipients treated with DAAs.Methods: A search strategy was used to identify studies that reported sustained viral response (SVR), treatment discontinuation, adherence or reinfection in recent PWID and/or opioid substitution therapy (OST) recipients. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis of proportions was used to estimate pooled SVR and treatment discontinuation rates. The pooled relative risk of achieving SVR and pooled reinfection rate were calculated using generalized mixed effects linear models. Results:The search identified 8075 references; 26 were eligible for inclusion. The pooled SVR for recent PWID was 88% (95% CI, 83%-92%) and 91% (95% C...

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BackgroundPeople who inject drugs (PWID) are most at risk of hepatitis C virus infection in Australia. The introduction of transient elastography (TE) (measuring hepatitis fibrosis) and direct acting antiviral medications will likely alter the experience of living with hepatitis C. We aimed to explore positive and negative influences on wellbeing and stress among PWID with hepatitis C.MethodsThe Treatment and Prevention (TAP) study examines the feasibility of treating hepatitis C mono-infected PWID in community settings. Semi-structured interviews were conducted with 16 purposively recruited TAP participants. Participants were aware of their hepatitis C seropositive status and had received fibrosis assessment (measured by TE) prior to interview. Questions were open-ended, focusing on the impact of health status on wellbeing and self-reported stress. Interviews were voice recorded, transcribed verbatim and thematically analysed, guided by Mishel’s (1988) theory of Uncertainty in Illness.ResultsIn line with Mishel’s theory of Uncertainty in Illness all participants reported hepatitis C-related uncertainty, particularly mis-information or a lack of knowledge surrounding liver health and the meaning of TE results. Those with greater fibrosis experienced an extra layer of prognostic uncertainty. Experiences of uncertainty were a key motivation to seek treatment, which was seen as a way to regain some stability in life. Treatment completion alleviated hepatitis C-related stress, and promoted feelings of empowerment and confidence in addressing other life challenges.ConclusionTE scores seemingly provide some certainty. However, when paired with limited knowledge, particularly among people with severe fibrosis, TE may be a source of uncertainty and increased personal stress. This suggests the need for simple education programs and resources on liver health to minimise stress.