Jeffrey V. Lazarus

Hepatitis C Virus Infection Epidemiology among People Who Inject Drugs in Europe: A Systematic Review of Data for Scaling Up Treatment and Prevention

Background People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed. Methods and Findings We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7–28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally ‘difficult to treat’ genotypes (G1+G4) showed large variation (median 53, IQR 43–62). Twelve countries reported on HCV chronicity (median 72, IQR 64–81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2–28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38–64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5–15). Burden of disease, where assessed, was high and will rise in the next decade. Conclusion Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.

Sexuality education in Europe: an overview of current policies

Comprehensive sexuality education is one of the most important tools to ensure that young people have the information they need to make healthy and informed choices. The aim of this article is, firstly, to outline general issues about sexuality education pertaining to curriculum content, the didactic methods used, agencies involved, political support, coverage and adequacy of provision and barriers to effective sexuality education in Europe. Secondly, the current state of sexuality education in most European Union member states and Norway is described, enabling a Europe-wide comparison of country experiences in the field. This reveals a wide variety of didactic methods and policies that have shaped the provision of sexuality education and the ease and difficulties with which the subject can be implemented, and at what age and in what form it is available.

HIV and people over 50 years old in Europe.

Objective The aim of the study was to report on HIV and older people in the European Region, including new data stratified by subregion and year.

HIV/AIDS knowledge and condom use among Somali and Sudanese immigrants in Denmark.

Aims: This study explores the knowledge, attitudes and practices among Somali and Sudanese immigrants in Denmark with regard to HIV/AIDS and condom use. Material and methods: A 78-item questionnaire, divided into five thematic sections, was given to 192 purposively selected Sudanese and Somalis of both sexes, aged 18—49, who had lived in Denmark for one or more years. It was administered in Arabic and Somali in four locations and supplemented by 13 semi-structured interviews. Results: Education, sex, and nationality, but not length of residence in Denmark, were positively associated with knowledge about HIV/AIDS. Less than half of both men and women scored more than 70% on the knowledge portion of the questionnaire, while Sudanese knew more than Somalis. Men had a more negative attitude towards condoms than women, but greater knowledge about them. One-third of the women reported never having seen or heard of a condom, and almost half had never received information about condoms. Both sexes preferred receiving such information from the TV or friends instead of family doctors or HIV-positive individuals. Conclusions: This study suggests that knowledge about HIV/ AIDS is low in these two Danish immigrant groups, both of which are characterized by reported incidence rates that are higher than the national average. The groups receive little information, while condom knowledge is particularly low among poorly educated women, and men have a negative attitude to condom use. The findings indicate a need for targeted, culturally sensitive HIV/AIDS information and advice.

Critical interactions between the Global Fund-supported HIV programs and the health system in Ghana.

The support of global health initiatives in recipient countries has been vigorously debated. Critics are concerned that disease-specific programs may be creating vertical and parallel service delivery structures that to some extent undermine health systems. This case study of Ghana aimed to explore how the Global Fund-supported HIV program interacts with the health system there and to map the extent and nature of integration of the national disease program across 6 key health systems functions. Qualitative interviews of national stakeholders were conducted to understand the perceptions of the strengths and weaknesses of the relationship between Global Fund-supported activities and the health system and to identify positive synergies and unintended consequences of integration. Ghana has a well-functioning sector-wide approach to financing its health system, with a strong emphasis on integrated care delivery. Ghana has benefited from US

Tuberculosis-HIV co-infection: Policy and epidemiology in 25 countries in the WHO European region.

175 million of approved Global Fund support to address the HIV epidemic, accounting for almost 85% of the National AIDS Control Program budget. Investments in infrastructure, human resources, and commodities have enabled HIV interventions to increase exponentially. Global Fund-supported activities have been well integrated into key health system functions to strengthen them, especially financing, planning, service delivery, and demand generation. Yet, with governance and monitoring and evaluation functions, parallel structures to national systems have emerged, leading to inefficiencies. This case study demonstrates that interactions and integration are highly varied across different health system functions, and strong government leadership has facilitated the integration of Global Fund-supported activities within national programs.

Restrictions for reimbursement of interferon-free direct-acting antiviral drugs for HCV infection in Europe

The aims of this study were to collect and review tuberculosis (TB)–HIV data for Europe and to provide an overview of current health policies addressing co‐infection.

A systematic review of Hepatitis C virus treatment uptake among people who inject drugs in the European Region.

All-oral direct-acting antiviral drugs (DAAs) for hepatitis C virus, which have response rates of 95% or more, represent a major clinical advance. However, the high list price of DAAs has led many governments to restrict their reimbursement. We reviewed the availability of, and national criteria for, interferon-free DAA reimbursement among countries in the European Union and European Economic Area, and Switzerland. Reimbursement documentation was reviewed between Nov 18, 2016, and Aug 1, 2017. Primary outcomes were fibrosis stage, drug or alcohol use, prescriber type, and HIV co-infection restrictions. Among the 35 European countries and jurisdictions included, the most commonly reimbursed DAA was ombitasvir, paritaprevir, and ritonavir, with dasabuvir, and with or without ribavirin (33 [94%] countries and jurisdictions). 16 (46%) countries and jurisdictions required patients to have fibrosis at stage F2 or higher, 29 (83%) had no listed restrictions based on drug or alcohol use, 33 (94%) required a specialist prescriber, and 34 (97%) had no additional restrictions for people co-infected with HIV and hepatitis C virus. These findings have implications for meeting WHO targets, with evidence of some countries not following the 2016 hepatitis C virus treatment guidelines by the European Association for the Study of Liver.

Optimal HIV testing and earlier care: the way forward in Europe

BackgroundFifteen million adults in the World Health Organization European Region are estimated to have active hepatitis C infection. Intravenous drug use is a major hepatitis C transmission route in this region, and people who inject drugs (PWID) constitute a high-risk and high-prevalence population. A systematic review was conducted to assess levels of hepatitis C treatment uptake among PWID in Europe.MethodsSearches in MEDLINE and EMBASE were carried out for articles in any language published between 1 January 2000 and 31 December 2012. Articles were included in the review if they presented original research findings about hepatitis C treatment uptake levels among people who reported injecting drugs currently or formerly, as well as those who reported using drugs currently or formerly (mode of consumption not specified). Treatment uptake data were extracted if uptake was measurable in relation to the number of patients who either: (a) tested HCV antibody-positive; (b) tested positive for HCV-RNA; or (c) tested positive for HCV-RNA and met additional treatment criteria.ResultsTwenty-five articles from 12 countries were included in the review. Among groups of drug-using study participants who were hepatitis C antibody-positive, the median treatment uptake level was 17%, and among those who were hepatitis C RNA-positive, the median was 30%. In the 11 studies reporting specifically on treatment uptake among current and former injecting drug users, hepatitis C RNA-positive study populations had a median treatment uptake level of 32%. Only one study reported on treatment uptake for current drug users.ConclusionsThis systematic review indicates that hepatitis C treatment uptake is relatively low among drug users in several European countries, and also points to considerable knowledge gaps regarding treatment uptake levels in this population. There was large variability in treatment uptake levels, suggesting that there may be major differences between and within countries in relation to treatment availability, drug-using populations in need of treatment, and the existence of integrated health care services targeting drug users. Stronger national hepatitis C treatment policies are needed, along with efforts to increase knowledge and reduce misconceptions among physicians regarding the feasibility and importance of treating drug users who have hepatitis C.

Health service delivery models for the provision of antiretroviral therapy in sub‐Saharan Africa: a systematic review

The articles in this supplement were developed from a recent pan‐European conference entitled ‘HIV in Europe 2007: Working together for optimal testing and earlier care’, which took place on 26–27 November in Brussels, Belgium. The conference, organized by a multidisciplinary group of experts representing advocacy, clinical and policy areas of the HIV field, was convened in an effort to gain a common understanding on the role of HIV testing and counselling in optimizing diagnosis and the need for earlier care. Key topics discussed at the conference and described in the following articles include: current barriers to HIV testing across Europe, trends in the epidemiology of HIV in the region, problems associated with undiagnosed infection and the psychosocial barriers impacting on testing. The supplement also provides a summary of the World Health Organizations recommendations for HIV testing in Europe and an outline of an indicator disease‐guided approach to HIV testing proposed by a committee of experts from the European AIDS Clinical Society (EACS). We hope that consideration of the issues discussed in this supplement will help to shift the HIV field closer towards our ultimate goal: provision of optimal HIV testing and earlier care across the whole of the European region.