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  Conference on Retroviruses
and Opportunistic Infections
Boston USA
March 8-11, 2020
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Falling Cirrhosis and HCV Viremia in Baltimore PWID, Maybe Reflecting DAAs
  CROI 2020, March 8-11, 2020, Boston
Mark Mascolini
Rates of cirrhosis and detectable HCV are dropping in Baltimore-area people who inject drugs (PWID), according to a 1661-person analysis [1]. Self-reported treatment with direct-acting antivirals (DAAs) is on the rise.
World Health Organization (WHO) HCV elimination targets include cutting HCV incidence by 30% in 2020 and by 90% in 2030 (versus 2015). WHO wants HCV-related mortality to drop by 65%. Meeting these goals in the United States means treating people who inject drugs, who account for most new HCV infections in the country. But this population can be hard to reach, said researchers at the University of California, San Diego and Johns Hopkins University, who conducted this study. They asked two questions:
1. Are we seeing population-level declines in liver disease among people who inject drugs?
2. Can these declines be attributed to expanded DAA-based therapy for HCV?
The analysis involved people in the ALIVE cohort, a community-based group of drug injectors in and out of care. They make twice-yearly study visits for biological and behavioral assessments. Researchers focused this analysis on 1661 people who had a positive HCV antibody test.
The study group included 1432 people with cirrhosis and 229 without cirrhosis. Median age was younger in the no-cirrhosis group (49 versus 52, P < 0.01), which included a significantly lower proportion of blacks (78% versus 87%, P < 0.01), and a significantly lower proportion with HIV (32% versus 46%, P < 0.01). Small proportions of people without and with cirrhosis had previous treatment for HCV (4% versus 7%, P = 0.01).
In 2006 average probability of cirrhosis stood at 12% in the study group. That rate rose gradually but consistently to 2015, around the start of the DAA era. Self-reported DAA treatment climbed from below 5% in this cohort in 2014, to about 10% in 2015, 25% in 2016, 35% in 2017, and 40% in 2018. Among treated people, median duration since being treated measured 1 year.
As DAA use grew in this Baltimore-area group, the proportion with detectable HCV fell from about 80% in 2015 to 40% in 2018. Over the same 2015-2018 span, average probability of cirrhosis waned by 2.8% yearly, from about 15% in 2015 to below 10% in 2018.
A multivariable model adjusted for sex, alcohol use, body mass index, HBV infection, and recruitment cohort determined that every 5 years of age doubled the odds of cirrhosis overall (adjusted odds ratio [aOR] 2.12, 95% confidence interval [CI] 1.85 to 2.42). But each year since DAA therapy more than halved odds of cirrhosis (aOR 0.44, 95% CI 0.35 to 0.56). Each year since DAA therapy also independently lowered log mean liver stiffness (adjusted beta -0.12, 95% CI -0.14 to -0.10). That translated into an average least square means 0.89 kPa lower liver stiffness for each additional year since DAA therapy.
The drops in cirrhosis and HCV detectability in blood--coupled with increasing self-reported DAA therapy—"indicate DAAs are likely reducing liver morbidity among the population of people who inject drugs in Baltimore," the researchers concluded. They expect a continuing decline in liver disease as access to DAAs widens.
1. Cepeda JA, Thomas DL, Gicquelais R, et al. Individual and population-level impact of HCV treatment among people who inject drugs. Conference on Retroviruses and Opportunistic Infections (CROI). March 8-11, 2020. Boston. Abstract 122.