Hepatitis C virus (HCV) related liver fibrosis in people who inject drugs (PWID) at the Stockholm Needle Exchange – evaluated with liver elasticity

Abstract

Background and aims: Sharing of unsterile injection equipment among people who inject drugs (PWID) is the major transmission-route for hepatitis C (HCV). HCV is highly prevalent in PWID in the Stockholm needle exchange programme (NEP). The frequency of advanced liver fibrosis among the participants is, however, unknown. Methods: From December 2016 to April 2018, all participants with chronic hepatitis C infection (CHC) were offered liver fibrosis evaluation at the Stockholm NEP, including liver stiffness measurement (LSM), a medical history and expanded blood tests to evaluate APRI and FIB-4 scores. Results: A total of 2037 individuals were enrolled of whom 964 (47.3%) had CHC. LSM was performed in 203 (21.1%) of eligible participants of whom 85% had mild fibrosis (LSM 9.4 kPa) and 15% advanced fibrosis (LSM 9.5 kPa). APRI >1 and FIB-4 > 3.25 only identified 30% of participants with advanced fibrosis. However, all 31(100%) participants with advanced fibrosis were detected when APRI >1 was combined with an age of 40 years and an injection drug use (IDU) duration of 15 years. Conclusions: We found that the diagnostic work-up for advanced fibrosis can be simplified with this combination of easily available factors. This allows identification of PWID in need of immediate HCV treatment to prevent further disease progression. Furthermore, LSM can be avoided among PWID with mild fibrosis, identified by age <40 years combined with IDU duration of <15 years and APRI score <1. This strategy enhances the HCV care cascade where LSM is not easily available, and will thus facilitate HCV treatment initiation.

Decentralisation of hepatitis C virus care into community settings: A key approach on the path to elimination

“…Previous work suggests that approximately 10–20% of patients will develop cirrhosis within 20–30 years 15 . More recently evidence suggested significantly less advanced disease in younger cohorts, although here the mean age here is 44 (std 9) therefore slightly older 16,17 . Additionally, 16% of the cohort is noted to ingest >6 drinks/day, although this is not adjusted for ABV(%), but there is strong correlation between alcohol ingestion of >40 g/day in those with HCV and more aggressive fibrogenesis 18,19 .…”

“…15 More recently evidence suggested significantly less advanced disease in younger cohorts, although here the mean age here is 44 (std 9) therefore slightly older. 16,17 Additionally, 16% of the cohort is noted to ingest >6 drinks/day, although this is not adjusted for ABV(%), but there is strong correlation between alcohol ingestion of >40 g/day in those with HCV and more aggressive fibrogenesis. 18,19 This is important, as it may allow for improved stratification of those with least risk of advanced fibrosis proceeding direct to treatment.…”

Real-world hepatitis C treatment outcomes and reinfections among people who inject drugs at a needle and syringe program in Stockholm, Sweden

“…The Stockholm NSP has previously been described in detail [ 30 , 32 , 33 , 41 ]. Briefly, the Stockholm NSP is a multi-center (two fixed sites and one mobile unit) low-threshold program with a multidisciplinary care approach and staffed by physicians, counselors, midwifes and nurses specialized in infectious diseases and substance use.…”

“…LSM cutoffs were 7 kPa and ≥ 12.5 kPa for significant liver fibrosis and cirrhosis, respectively [ 42 ]. In cases where FibroScan was not accessible, the algorithm; APRI score < 1.0 in combination with < 15 years duration of IDU and an age < 35 years was used to exclude advanced fibrosis/cirrhosis [ 41 ].…”

“…Based on our previous research [ 30 , 32 , 33 , 41 , 44 ], nine sociodemographic-, drug- and HCV-related determinants were selected (described in detail in Table 1 ) for analyses. Demographic data are presented as proportions, mean or median levels with ranges and interquartile ranges (IQR).…”