Insights on the Russian HCV care cascade: minimal HCV treatment for HIV/HCV co-infected PWID in St. Petersburg
© The Author(s) 2016
Received: 3 May 2016
Accepted: 28 September 2016
Published: 11 October 2016
The human immunodeficiency virus (HIV) epidemic in Russia, driven by injection drug use, has seen a steady rise in the past two decades. Hepatitis C virus (HCV) infection is highly prevalent in people who inject drugs (PWID). The study aimed to describe the current frequency of HCV testing and treatment among HIV-infected PWID in St. Petersburg, Russia.
This study examined baseline data from the “Linking Infectious and Narcology Care” (LINC) and “Russia Alcohol Research Collaboration on HIV/AIDS” (Russia ARCH) studies. Participants included in this analysis were HIV-infected with a history of injection drug use. Descriptive statistics were performed to assess frequency of HCV testing and treatment.
Participants (n = 349 [LINC], 207 [Russia ARCH]) had a mean age of 33.8 years (IQR: 31–37) in LINC and 33.0 (IQR: 30–36) in Russia ARCH; 26.6 % (LINC) and 29.0 % (Russia ARCH) were female; 100 % were Caucasian. Nearly all participants had been tested for HCV (98.9 % in LINC, 97.1 % in Russia ARCH). Almost all reported being diagnosed HCV positive (98.9 % in LINC, 97.1 % in Russia ARCH). Only 2.3 % of LINC and 5.0 % of Russia ARCH participants reported ever receiving HCV treatment.
Among these cohorts of HIV-infected PWID in St. Petersburg, Russia, as of 2015 nearly all reported being tested for HCV and testing positive, while only 3.3 % received any HCV treatment. In this new era of effective HCV pharmacotherapy, an enormous chasm in the HCV treatment cascade in Russia exists providing substantial opportunities for curing HCV in HIV-infected Russians with a history of injection drug use.
The studies described were registered with ClinicalTrials.gov through the National Institutes of Health: Linking Infectious and Narcology Care in Russia (LINC) - NCT01612455, registered 1 June 2012, first participant enrolled 3 July 2012; Alcohol’s Impact on Inflammatory Markers in HIV Disease - Russia ARCH Cohort - NCT01614626, registered 25 May 2012, first participant enrolled 15 November 2012.
KeywordsHIV HCV PWID Russia
Worldwide, hepatitis C virus (HCV) infection is estimated to affect 80 million people , placing them at risk for liver cirrhosis, hepatocellular carcinoma, and associated morbidity and mortality . In most parts of the world, HCV transmission occurs through parenteral exposure, including via injection drug use (IDU) . HCV is highly prevalent among people who inject drugs (PWID) through the sharing of contaminated injection paraphernalia .
Following the collapse of the former Soviet Union in the 1990s and the Afghan war, Russia experienced increased access to heroin and an upsurge in injection drug use among young adults along with subsequent risk for related viral infections . Harm reduction programs exist in Russia, but are inadequate . Access to needle exchange programs is limited and fear of law enforcement leads to reluctance to carry needles. Currently, opioid agonist treatments are illegal in Russia and thus unavailable for those persons with opioid use disorders [7, 8]. As a result, the prevalence of HIV and HCV among Russian PWID is among the highest in the world. It is estimated that a quarter of PWID in Russia have HIV , while the vast majority have HCV . A recent study of HCV prevalence in eight Russian cities reported that PWID in St. Petersburg had the highest prevalence of HCV (90 %) . Recent estimates of HCV prevalence in Russia suggest that 3–4 % of the population is infected [1, 11–13].
With new, direct-acting HCV agents offering attainable sustained virologic response (SVR) or cure, understanding the HCV cascade of care is paramount. The HCV cascade of care describes successive steps of healthcare specific to HCV that result in optimal health outcomes. Areas of the HCV cascade of care include initial screening, confirmatory viral load testing, linkage to care, staging of disease, initiation of therapy, and receipt and adherence to therapy . Deficits along the care continuum have been reported in numerous countries including the U.S., Canada, Australia, and India, particularly among PWID [15–19]. Less is known about gaps in other countries, including Russia, which has one of the largest populations of HIV-infected PWID .
Given the confluence of the ongoing Russian epidemic of HCV and HIV co-infection and the new effective HCV treatments, we investigated care for HCV among HIV-infected Russian PWID in St. Petersburg, Russia. Specifically, we evaluated the frequency of HCV screening and treatment, hypothesizing that screening would far exceed treatment in this population.
This analysis is a descriptive, observational study on self-reported HCV testing and treatment among HIV-infected Russian PWID. We analyzed data collected from two studies in St. Petersburg, Russia: LINC and Russia ARCH, for which study methods have been previously published [21, 22]. Linking Infectious and Narcology Care (LINC), is a randomized controlled trial testing a peer-led strengths-based case management intervention to link HIV-infected PWID hospitalized at a narcology (addiction) hospital to HIV medical care in St. Petersburg, Russia. Participants were recruited from inpatient wards at the City Addiction Hospital (CAH) in St. Petersburg, Russia from July 2012 through May 2014. Russia Alcohol Research Collaboration on HIV/AIDS (Russia ARCH) is an observational cohort that aims to evaluate the longitudinal association between alcohol consumption and biomarkers of microbial translocation and inflammation. Participants were recruited between November 2012 and June 2015 from clinical HIV and addiction sites, non-clinical sites and snowball sampling in St. Petersburg, Russia. Eligibility criteria for both studies included the following: 1) 18–70 years of age; 2) HIV-infection; 3) having two contacts to assist with follow-up; 4) living within 100 km of St. Petersburg and 5) having a telephone. For LINC, additional criteria included being hospitalized at the narcology hospital, history of injection drug use, and not currently being on antiretroviral therapy (ART) (prior history of ART was not an exclusion). For Russia ARCH being ART-naïve (i.e. never having been on ART) was an eligibility criteria. All study participants provided informed consent and Institutional Review Boards of Boston University Medical Campus and First St. Petersburg Pavlov State Medical University approved the LINC and Russia ARCH studies.
For this analysis, the Russia ARCH sample was limited to participants who were not previously enrolled in the LINC study and who were categorized as PWID (i.e., participant reported at least one of the following: used needles to inject drugs prior to HIV diagnosis or past 30-day IDU). Using responses from the baseline questionnaire, we assessed the following: previous testing of HCV , location of HCV testing , date of HCV testing , physician reported HCV status , prior treatment for HCV , and date of HCV treatment initiation , demographics, HIV risk behaviors  and substance use [24–29]. Questions about HCV testing were worded in the following manner: “Have you ever been tested for the hepatitis C virus?”, and “Has a doctor ever told you that you had the hepatitis C virus?” As such, questions did not refer to the specific diagnostic test done (i.e. screening antibody or HCV viral load). Not all questions were asked in both surveys.
The total sample included 556 HIV-infected Russian adult PWID (n = 349 [LINC], 207 [Russia ARCH]). Details of enrollment are presented in Additional file 1: Figure S1 and Additional file 2: Figure S2. In LINC 382 potential participants were assessed, and of those, 349 were found to be eligible and were enrolled and included in the analysis. In Russia ARCH 556 persons were assessed, and of those 365 were found to be eligible and 364 were enrolled. Of those, 90 were also participants in LINC, 13 subsequently disenrolled from the study, and 54 were not known to be injection drug users, and were therefore excluded from this analysis, leaving 207 in the sample. Only 1 % of persons screened for LINC were excluded for current ART use, and 13 % of Russia ARCH persons screened were excluded for past or current ART.
Baseline demographic characteristics of HIV-infected Russian PWID in LINC (n = 349) and Russia ARCH (n = 207)
Median Age (IQR)
Secondary Education or lower
Married or living with partner
Other (includes retired, homemaker)
Median Monthly Income (IQR)
Median Years Since HIV Diagnosis (IQR)
Median CD4 Cell Count (IQR)
n = 329
n = 143
N = 472
ART (current or past)
Past 12-month drug dependence
n = 344
Past 30-day injection drug use
n = 198a
Past 12-month alcohol dependence
HCV testing among HIV-infected Russian PWID in LINC (n = 349) and Russia ARCH (n = 207)
HCV Diagnosis (Physician Notified)
Time since HCV diagnosis
n = 345
≤ 6 months
≥ 12 months
Location of HCV testing
n = 345
Needle exchange program
Drug treatment program
HCV Treatment among HCV/HIV-co-infected Russian PWID in LINC (n = 345) and Russia ARCH (n = 201)
HCV treatment status
Current HCV treatment
Past HCV treatment
Refused to answer
Time of HCV treatment initiation
n = 8
≤ 6 months
≥ 12 months
Was SVR achieved
n = 10
Among eight reporting prior HCV treatment in LINC, 7 (87.5 %) initiated treatment ≥ 12 months prior. Of 10 with prior HCV treatment in Russia ARCH, 5 (50.0 %) reported achieving SVR and 3 (30.0 %) had unknown outcomes (Table 3). The median age of the 8 HIV-HCV co-infected PWID in LINC receiving HCV treatment was 32.6 (IQR 31.15-34.4), 5 (62.5 %) were never married, all 8 (100 %) were male, 1 (12.5 %) was working part-time, and 5 (62.5 %) completed secondary education or lower. Among ten Russia ARCH participants who reported receiving HCV treatment, the median age was 31.5 (IQR 29-35), 4 (40 %) were married or living with a partner, 6 (60 %) were male, 3 (30 %) were working part-time or full-time, and 9 (90 %) completed secondary education or lower.
This study of two St. Petersburg Russian cohorts of HIV-infected PWID found an enormous gap between testing and receipt of HCV treatment, revealing a “chasm” in the hepatitis C virus (HCV) care cascade. This study found that nearly all participants reported being screened and informed that they had been HCV-infected, suggesting that screening efforts are robust in this population of PWID with HIV. In contrast to nearly ubiquitous rates of screening, few patients (LINC = 2.3 %, Russia ARCH = 5.0 %) reported ever receiving treatment. This points to a chasm with regard to not meeting European Association for the Study of the Liver (EASL) guidelines for prioritizing HCV treatment for PWID  and recommendations set forth by Grebely et al. . Based on these results it appears that there is a substantial opportunity to improve care, and corresponding health outcomes, among HIV/HCV co-infected PWID in Russia.
The finding that HCV infection was nearly universal among these HIV-infected PWID in St. Petersburg is consistent with prior literature. Globally, Russia has among the highest burdens of HCV co-infection among PWID with HIV . The HIV epidemic in Russia is primarily driven through parenteral drug use, and in this context, the prevalence of HCV infection, which almost invariably precedes infection with HIV, will be extremely high to omnipresent . Indeed, modeling studies suggest that in countries where HIV is driven by injecting behavior, the prevalence of HCV can be used as a measure of HIV risk , and Russia has a high prevalence of HCV among PWID (50–90 %) [4, 10]. Therefore, it is not surprising that nearly all (97–99 %) of these HIV-infected PWID reported being told that they had HCV. However, it is unlikely that in all cases the diagnosis was confirmed with HCV RNA testing. Due to cost constraints, and the fact that patients frequently have to pay out of pocket for these tests, HCV RNA and genotype testing are uncommonly performed in Russia . Given that approximately 25 % of HCV-infected people will spontaneously clear their infection , the true prevalence of current HCV infection, rather than past infection with HCV, in this sample was likely lower than reported.
This study demonstrates a large discrepancy between rates of testing and treatment among this population of HIV-infected PWID, many of whom were being treated for their opioid use disorders, which may explain their high testing rates. It appears that efforts to test these high risk patients for HCV infection are successful and thorough. However, despite these high rates of HCV testing, it appears that only a very small fraction (3.3 %) of these HIV-infected PWID can access treatment. In contrast, another study not focused on HIV-infected persons reported lower rates of HCV diagnosis in Russia (40 %), but also low rates of treatment (< 0.1 %) . Similarly, in other countries, such as the U.S., Canada, Australia, and India, it appears that HCV testing efforts often fall short, with many persons, including PWID, being unaware of their infection [17–19, 37–40]. The estimated proportion of persons treated for HCV in the U.S. is also low, 9 % reported in a recent meta-analysis , and HIV/HCV co-infected are often not referred for treatment . It may be worth questioning the rationale for such an aggressive HCV testing program, given the limited effort to provide HCV treatment. The potential that awareness of HCV diagnosis positively impacts an individual’s risk behaviors is another rationale for testing; however the evidence for this impact is mixed [38, 42, 43].
A limitation of this study is that HCV status was based on self-report. Also, we did not specify the nature of prior HCV testing in the questionnaire, nor ask about confirmatory viral load or genotype testing. Given the expense of confirmatory HCV viral load testing, it is likely that most participants only had an antibody test. Another limitation is that this study is based on secondary analysis of existing data from two other studies, which included eligibility criteria that participants could not be on ART. Therefore, the sample may not be fully representative of all co-infected PWID in St. Petersburg. The sample might potentially be biased toward patients who are difficult to link to care. However, there were relatively small numbers of participants who were ineligible because of ART use: in LINC 1 %, and in Russia ARCH 13 %. It is likely the sample may be potentially biased toward younger, newly diagnosed HIV-infected PWID with higher CD4 cell counts not meeting criteria for treatment. Russian guidelines at the time of study stated that ART should be initiated for any patients with CD4 cell counts below 350 cells/mm3. At baseline, approximately half of the participants in the combined sample had baseline counts below that threshold, and over time we have observed that nearly one quarter of the sample has initiated ART. Another limitation is that we did not ask participants about specific treatments received; therefore, we cannot be sure that the few patients who reported being treated had actually received standard treatment (as opposed to vitamins or other supplements). However, the exact wording of the question (“Have you taken medication to treat hepatitis C, like Interferon and Ribavirin?”) implied anti-HCV treatment that was the standard at the time.
This study was conducted largely before the arrival of direct-acting antiviral (DAA) therapies, when interferon based therapies were used. Of concern is that countries like Russia, which are transitioning from the classification of middle to high income (and thus restricted from generic medications), may be particularly challenged to afford new therapies for HCV. However, the study result speaks to a great need for treatment among co-infected PWID in Russia, particularly given the challenge of meeting WHO’s targets for the goal of “elimination of viral hepatitis as a major public health threat by 2030” . Given that persons who are co-infected with HIV/HCV are at greater risk for having progression of their HCV-related liver disease to cirrhosis and hepatocellular carcinoma, the need is more urgent to address treatment in this population in order to mitigate morbidity and avoid downstream costs [45–47]. Furthermore, treatment of HCV in this PWID population holds the potential to prevent HCV transmission (“treatment as prevention”) [47–49]. Study results also indicate a need for expanded ART as an important initial step in engagement of care.
Among HIV-infected PWID in St. Petersburg, Russia, nearly all persons reported having been tested and found to have been infected with HCV, yet few (3.3 %) had ever been treated for their HCV infection. As such, the treatment chasm in the Russian HCV cascade of care among these HIV-infected PWID points to the great need for expanded HCV treatment in this population.
City Addiction Hospital
Hepatitis c virus
Human immunodeficiency virus
Injection drug use
Linking Infectious and Narcology Care
People Who Inject Drugs
- Russia ARCH:
Russia Alcohol Research Collaboration on HIV/AIDS
Sustained virologic response
The project described was supported by grants R01DA032082 from the National Institute on Drug Abuse, U01AA020780, U01AA021989, U24AA020778, and U24AA020779 from the National Institute on Alcohol Abuse and Alcoholism. The authors wish to thank Sally Bendiks for her help in the submission, as well as the study participants for their contributions to research.
The project described was supported by grants R01DA032082 from the National Institute on Drug Abuse, U01AA020780, U01AA021989, U24AA020778, and U24AA020779 from the National Institute on Alcohol Abuse and Alcoholism. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism or the National Institutes of Health.
Availability of data and materials
The datasets supporting the conclusions of this article are included within the article.
JIT and SCK conceived the study question, led the analytic planning and wrote the first draft of the manuscript. EK led the Russian team and was the principal investigator in Russia. DL was the infectionist and co-investigator on the study. CEC provided data management and conducted the analyses. NG was the project manager in the United States. JHS was the principal investigator of the parent study. All authors contributed to developing the analytic plan, reviewed, revised, and approved the submitted manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
All study participants provided informed consent and Institutional Review Boards of Boston University Medical Campus and First St. Petersburg Pavlov State Medical University approved the LINC and Russia ARCH studies.
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- Gower E, Estes C, Blach S, Razavi-Shearer K, Razavi H. Global epidemiology and genotype distribution of the hepatitis C virus infection. J Hepatol. 2014;61:S45–57.View ArticlePubMedGoogle Scholar
- Di Bisceglie AM. Natural history of hepatitis C: its impact on clinical management. Hepatology. 2000;31:1014–8.View ArticlePubMedGoogle Scholar
- Alter MJ. Epidemiology of hepatitis C virus infection. World J Gastroenterol. 2007;13:2436–41.View ArticlePubMedPubMed CentralGoogle Scholar
- Nelson PK, Mathers BM, Cowie B, Hagan H, Des JD, Horyniak D, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet. 2011;378:571–83.View ArticlePubMedPubMed CentralGoogle Scholar
- Kalichman SC, Kelly JA, Sikkema KJ, Koslov AP, Shaboltas A, Granskaya J. The emerging AIDS crisis in Russia: review of enabling factors and prevention needs. Int J STD AIDS. 2000;11:71–5.View ArticlePubMedGoogle Scholar
- Samet JH. Russia and human immunodeficiency virus--beyond crime and punishment. Addiction. 2011;106:1883–5.View ArticlePubMedGoogle Scholar
- Sarang A, Rhodes T, Platt L. Access to syringes in three Russian cities: implications for syringe distribution and coverage. Int J Drug Policy. 2008;19 Suppl 1:S25–36.View ArticlePubMedGoogle Scholar
- Krupitsky E, Zvartau E, Woody G. Use of naltrexone to treat opioid addiction in a country in which methadone and buprenorphine are not available. Curr Psychiatry Rep. 2010;12:448–53.View ArticlePubMedPubMed CentralGoogle Scholar
- Jolley E, Rhodes T, Platt L, Hope V, Latypov A, Donoghoe M, et al. HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy. BMJ Open. 2012;2:e001465.View ArticlePubMedPubMed CentralGoogle Scholar
- Heimer R, Eritsyan K, Barbour R, Levina OS. Hepatitis C virus seroprevalence among people who inject drugs and factors associated with infection in eight Russian cities. BMC Infect Dis. 2014;14 Suppl 6:S12.View ArticlePubMedGoogle Scholar
- Wedemeyer H, Dore GJ, Ward JW. Estimates on HCV disease burden worldwide - filling the gaps. J Viral Hepat. 2015;22 Suppl 1:1–5.View ArticleGoogle Scholar
- Pimenov N, Chulanov V, Komarova S, Karandashova I, Neverov A. Hepatitis C in Russia: current epidemiology and approaches to improving diagnosis and surveillance. Epidemiol Infect Dis. 2012;4:4–10.Google Scholar
- Mukomolov S, Trifonova G, Levakova I, Bolsun D, Krivanogova E. Hepatitis C in the Russian Federation: challenges and future directions. Hepat Med. 2016;8:51–60.PubMedPubMed CentralGoogle Scholar
- Linas BP, Barter DM, Leff JA, Assoumou SA, Salomon JA, Weinstein MC, et al. The hepatitis C cascade of care: identifying priorities to improve clinical outcomes. PLoS One. 2014;9:e97317.View ArticlePubMedPubMed CentralGoogle Scholar
- Yehia BR, Schranz AJ, Umscheid CA, Lo Re 3rd V. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9:e101554.View ArticlePubMedPubMed CentralGoogle Scholar
- Mehta SH, Genberg BL, Astemborski J, Kavasery R, Kirk GD, Vlahov D, et al. Limited uptake of hepatitis C treatment among injection drug users. J Community Health. 2008;33:126–33.View ArticlePubMedPubMed CentralGoogle Scholar
- Socias ME, Shannon K, Montaner JS, Guillemi S, Dobrer S, Nguyen P, et al. Gaps in the hepatitis C continuum of care among sex workers in Vancouver, British Columbia: Implications for voluntary hepatitis C virus testing, treatment and care. Can J Gastroenterol Hepatol. 2015;29:411–6.View ArticlePubMedPubMed CentralGoogle Scholar
- Hajarizadeh B, Grebely J, McManus H, Estes C., Razavi H, Gray RT, et al. Chronic hepatitis C burden and care cascade in Australia in the era of interferon-based treatment. J Gastroenterol Hepatol. 2016. doi:10.1111/jgh.13453
- Solomon SS, Mehta SH, Srikrishnan AK, Solomon S, McFall AM, Laeyendecker O, et al. Burden of hepatitis C virus disease and access to hepatitis C virus services in people who inject drugs in India: a cross-sectional study. Lancet Infect Dis. 2015;15:36–45.View ArticlePubMedGoogle Scholar
- Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372:1733–45.View ArticlePubMedGoogle Scholar
- Gnatienko N, Han SC, Krupitsky E, Blokhina E, Bridden C, Chaisson CE, et al. Linking Infectious and Narcology Care (LINC) in Russia: design, intervention and implementation protocol. Addict Sci Clin Pract. 2016;11:10.View ArticlePubMedPubMed CentralGoogle Scholar
- So-Armah KA, Edelman EJ, Cheng DM, Doyle MF, Patts GJ, Gnatienko N, et al. Effects of heavy drinking on T-cell phenotypes consistent with immunosenescence in untreated HIV infection. Alcohol Clin Exp Res. 2016;40:1737–43.View ArticlePubMedGoogle Scholar
- National Institute on Drug Abuse: Seek, Test, Treat and Retain Initiative. HIV/HCV/STI testing status and organizational testing practices questionnaire. 2013. Available at: http://www.drugabuse.gov/researchers/research-resources/data-harmonization-projects/seek-test-treat-retain/addressing-hiv-among-vulnerable-populations (accessed 06 Oct 2015).
- Needle R, Fisher DG, Weatherby N, Chitwood D, Brown B, Cesari H, et al. Reliability of self-reported HIV risk behaviors of drug users. Psychol Addict Behav. 1995;9:242–50.View ArticleGoogle Scholar
- Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59 Suppl 20:22–33.PubMedGoogle Scholar
- Weatherby N, Needle R, Cesar H, Booth R, McCoy C, Watters J, et al. Validity of self-reported drug use among injection drug users and crack smokers recruited through street outreach. Eval Program Plann. 1994;17:347–55.View ArticleGoogle Scholar
- McLellan AT, Luborsky L, Cacciola J, Griffith J, Evans F, Barr HL, et al. New data from the Addiction Severity Index. Reliability and validity in three centers. J Nerv Ment Dis. 1985;173:412–23.View ArticlePubMedGoogle Scholar
- Broome K, Knight K, Joe G, Simpson D. Evaluating the drug-abusing probationer: clinical interview versus self-administered assessment. Crim Justice Behav. 1996;23:593–606.View ArticleGoogle Scholar
- Knight K, Simpson D, Morey J. Evaluation of the TCU Drug Screen. National Criminal Justice Reference Service. 2002. Report No.: 196682.Google Scholar
- European Association for Study of Liver. EASL recommendations on treatment of hepatitis C 2015. J Hepatol. 2015;63:199–236.View ArticleGoogle Scholar
- Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, et al. Recommendations for the management of hepatitis C virus infection among people who inject drugs. Int J Drug Policy. 2015;26:1028–38.View ArticlePubMedGoogle Scholar
- Platt L, Easterbrook P, Gower E, McDonald B, Sabin K, McGowan C, et al. Prevalence and burden of HCV co-infection in people living with HIV: a global systematic review and meta-analysis. Lancet Infect Dis. 2016;16:797–808.View ArticlePubMedGoogle Scholar
- Thomas DL, Leoutsakas D, Zabransky T, Kumar MS. Hepatitis C in HIV-infected individuals: cure and control, right now. J Int AIDS Soc. 2011;14:22.View ArticlePubMedPubMed CentralGoogle Scholar
- Vickerman P, Hickman M, May M, Kretzschmar M, Wiessing L. Can hepatitis C virus prevalence be used as a measure of injection-related human immunodeficiency virus risk in populations of injecting drug users? An ecological analysis. Addiction. 2010;105:311–8.View ArticlePubMedGoogle Scholar
- Ocheret D, Bikmukhametov D, Sultangaziev A, Matuizaite E. Current situation regarding access to hepatitis C treatment in Eastern Europe and Central Asia. Eurasian Harm Reduction Network (EHRN). 2013. Available at: https://www.harm-reduction.org/library/current-situation-regarding-access-hepatitis-c-treatment-eastern-europe-and-central-asia-0. Archived by WebCite® at http://www.webcitation.org/6c5CV08LL. (Accessed 6 Oct 2015).
- Denniston MM, Jiles RB, Drobeniuc J, Klevens RM, Ward JW, McQuillan GM, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med. 2014;160:293–300.View ArticlePubMedPubMed CentralGoogle Scholar
- Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology. 2012;55:1652–61.View ArticlePubMedPubMed CentralGoogle Scholar
- Kwiatkowski CF, Fortuin CK, Booth RE. The association between knowledge of hepatitis C virus status and risk behaviors in injection drug users. Addiction. 2002;97:1289–94.View ArticlePubMedGoogle Scholar
- Bouscaillou J, Champagnat J, Luhmann N, Avril E, Inaridze I, Miollany V, et al. Hepatitis C among people who inject drugs in Tbilisi, Georgia: an urgent need for prevention and treatment. Int J Drug Policy. 2014;25:871–8.View ArticlePubMedGoogle Scholar
- Bowring AL, Luhmann N, Pont S, Debaulieu C, Derozier S, Asouab F, et al. An urgent need to scale-up injecting drug harm reduction services in Tanzania: prevalence of blood-borne viruses among drug users in Temeke District, Dar-es-Salaam, 2011. Int J Drug Policy. 2013;24:78–81.View ArticlePubMedGoogle Scholar
- Cachay ER, Hill L, Wyles D, Colwell B, Ballard C, Torriani F, et al. The hepatitis C cascade of care among HIV infected patients: a call to address ongoing barriers to care. PLoS One. 2014;9:e102883.View ArticlePubMedPubMed CentralGoogle Scholar
- Tsui JI, Saitz R, Cheng DM, Nunes D, Libman H, Alperen JK, et al. Awareness of hepatitis C diagnosis is associated with less alcohol use among persons co-infected with HIV. J Gen Intern Med. 2007;22:822–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Tsui JI, Vittinghoff E, Hahn JA, Evans JL, Davidson PJ, Page K. Risk behaviors after hepatitis C virus seroconversion in young injection drug users in San Francisco. Drug Alcohol Depend. 2009;105:160–3.View ArticlePubMedPubMed CentralGoogle Scholar
- World Health Organization. Draft global health sector strategies: viral hepatitis, 2016–2021. 2016. Report No.: A69/32.Google Scholar
- Kirk GD, Mehta SH, Astemborski J, Galai N, Washington J, Higgins Y, et al. HIV, age, and the severity of hepatitis C virus-related liver disease: a cohort study. Ann Intern Med. 2013;158:658–66.View ArticlePubMedPubMed CentralGoogle Scholar
- Weber R, Sabin CA, Friis-Moller N, Reiss P, El-Sadr WM, Kirk O, et al. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med. 2006;166:1632–41.View ArticlePubMedGoogle Scholar
- de Ledinghen V, Barreiro P, Foucher J, Labarga P, Castera L, Vispo ME, et al. Liver fibrosis on account of chronic hepatitis C is more severe in HIV-positive than HIV-negative patients despite antiretroviral therapy. J Viral Hepat. 2008;15:427–33.View ArticlePubMedGoogle Scholar
- Martin NK, Vickerman P, Grebely J, Hellard M, Hutchinson SJ, Lima VD, et al. Hepatitis C virus treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct-acting antivirals. Hepatology. 2013;58:1598–609.View ArticlePubMedPubMed CentralGoogle Scholar
- Grebely J, Matthews GV, Lloyd AR, Dore GJ. Elimination of hepatitis C virus infection among people who inject drugs through treatment as prevention: feasibility and future requirements. Clin Infect Dis. 2013;57:1014–20.View ArticlePubMedGoogle Scholar