Comprehensive needle and syringe program and opioid agonist therapy reduce HIV and hepatitis c virus acquisition among people who inject drugs in different settings: A pooled analysis of emulated trials

Abstract

Background and Aims Although the Netherlands, Canada and Australia were early adopters of harm reduction for people who inject drugs (PWID), their respective HIV and hepatitis C (HCV) epidemics differ. We measured the pooled effect of needle and syringe program (NSP) and opioid agonist therapy (OAT) participation on HIV and HCV incidence in these settings. Design For each cohort, we emulated the design and statistical analysis of a target trial using observational data. Setting and Participants We included PWID at risk of HIV or HCV infection from the Amsterdam Cohort Studies (1985–2013), Vancouver Injection Drug Users Study (1997–2009) and Melbourne Injecting Drug User Cohort Study (SuperMIX) (2010–2021). Measurements Separately for each infection and cohort (only HCV in SuperMIX), marginal structural models were used to compare the effect of comprehensive (on OAT and 100% NSP coverage or on OAT only if no recent injection drug use) versus no/partial NSP/OAT (no OAT and/or <100% NSP coverage) participation. Pooled hazard ratios (HR) and 95% CI were calculated using random‐effects meta‐analysis. Findings We observed 94 HIV seroconversions and 81 HCV seroconversions among 2023 and 430 participants, respectively. Comprehensive NSP/OAT led to a 41% lower risk of HIV acquisition (pooled HR = 0.59, 95% CI = 0.36–0.96) and a 76% lower risk of HCV acquisition (pooled HR = 0.24, 95% CI = 0.11–0.51), compared with no/partial NSP/OAT, with little heterogeneity between studies for both infections (I2 = 0%). Conclusions In the Netherlands, Canada and Australia, comprehensive needle and syringe program and opioid agonist therapy participation appears to substantially reduce HIV and hepatitis C acquisition compared with no or partial needle and syringe program/opioid agonist therapy participation. These findings from an emulated trial design reinforce the critical role of comprehensive access to harm reduction in optimizing infection prevention for people who inject drugs.

“No, my name’s not on the lease at all”: an interpretive phenomenological analysis of unstable housing and hepatitis C among people who inject drugs

“…OAT is a well-established form of harm reduction and is associated with a reduced risk of hepatitis C among people who inject drugs (van Santen et al , 2023). However, evidence also indicates people who are homeless face more barriers to OAT than people who are housed (McLaughlin et al , 2021), and this was also true for our participants.…”

“…Likewise, people who continue to inject drugs are a key population group at risk of new hepatitis C infection. This is despite the availability of a range of evidence-based harm reduction interventions including sterile needle and syringe programs (NSP) and opioid agonist therapy (OAT), both of which have been shown to reduce the risk of hepatitis C (van Santen et al , 2023). OAT and NSP however remain underfunded and, in many cases, opposed outright in a range of settings globally with only five countries worldwide defined as providing adequate coverage of both (Colledge-Frisby et al , 2023).…”

An Automated Text Messaging Intervention to Reduce Substance Use Self-Stigma (Project RESTART): Protocol for a Feasibility and Acceptability Pilot Study

“…Non-medical use of controlled substances is a leading cause of morbidity and mortality in the United States, with 107,941 reported overdose deaths in 2022 and increasing rates of hepatitis C, endocarditis, and other infectious diseases in people who use drugs (PWUD) [1][2][3]. Although evidence-based treatment and harm reduction services are associated with reduced burden of disease [4][5][6][7][8][9][10], they remain underused; in the United States, only 6.5% of people with substance use disorders received past-year treatment in 2021 [11]. The role of stigma in the epidemic has come increasingly into focus among policymakers and interventionists [12][13][14][15][16].…”