Progress in Testing for and Treatment of Hepatitis C Virus Infection Among Persons Who Inject Drugs — Georgia, 2018

In April 2015, the country of Georgia, with a high prevalence of hepatitis C virus (HCV) infection (5.4% of the adult population, approximately 150,000 persons), embarked on the world's first national elimination program (1,2). Nearly 40% of these infections are attributed to injection drug use, and an estimated 2% of the adult population currently inject drugs, among the highest prevalence of injection drug use in the world (3,4). Since 2006, needle and syringe programs (NSPs) have been offering HCV antibody testing to persons who inject drugs and, since 2015, referring clients with positive test results to the national treatment program. This report summarizes the results of these efforts. Following implementation of the elimination program, the number of HCV antibody tests conducted at NSPs increased from an average of 3,638 per year during 2006-2014 to an average of 21,551 during 2015-2018. In 2017, to enable tracking of clinical outcomes among persons who inject drugs, NSPs began encouraging clients to voluntarily provide their national identification number (NIN), which all citizens must use to access health care treatment services. During 2017-2018, a total of 2,780 NSP clients with positive test results for HCV antibody were identified in the treatment database by their NIN. Of 494 who completed treatment and were tested for HCV RNA ≥12 weeks after completing treatment, 482 (97.6%) were cured of HCV infection. Following the launch of the elimination program, Georgia has made much progress in hepatitis C screening among persons who inject drugs; recent data demonstrate high cure rates achieved in this population. Testing at NSPs is an effective strategy for identifying persons with HCV infection. Tracking clients referred from NSPs through treatment completion allows for monitoring the effectiveness of linkage to care and treatment outcomes in this population at high risk, a key to achieving hepatitis C elimination in Georgia. The program in Georgia might serve as a model for other countries.

In April 2015, the country of Georgia, with a high prevalence of hepatitis C virus (HCV) infection (5.4% of the adult population, approximately 150,000 persons), embarked on the world's first national elimination program (1,2). Nearly 40% of these infections are attributed to injection drug use, and an estimated 2% of the adult population currently inject drugs, among the highest prevalence of injection drug use in the world (3,4). Since 2006, needle and syringe programs (NSPs) have been offering HCV antibody testing to persons who inject drugs and, since 2015, referring clients with positive test results to the national treatment program. This report summarizes the results of these efforts. Following implementation of the elimination program, the number of HCV antibody tests conducted at NSPs increased from an average of 3,638 per year during 2006-2014 to an average of 21,551 during 2015-2018. In 2017, to enable tracking of clinical outcomes among persons who inject drugs, NSPs began encouraging clients to voluntarily provide their national identification number (NIN), which all citizens must use to access health care treatment services. During 2017-2018, a total of 2,780 NSP clients with positive test results for HCV antibody were identified in the treatment database by their NIN. Of 494 who completed treatment and were tested for HCV RNA ≥12 weeks after completing treatment, 482 (97.6%) were cured of HCV infection. Following the launch of the elimination program, Georgia has made much progress in hepatitis C screening among persons who inject drugs; recent data demonstrate high cure rates achieved in this population. Testing at NSPs is an effective strategy for identifying persons with HCV infection. Tracking clients referred from NSPs through treatment completion allows for monitoring the effectiveness of linkage to care and treatment outcomes in this population at high risk, a key to achieving hepatitis C elimination in Georgia. The program in Georgia might serve as a model for other countries.
The Georgian Harm Reduction Network began operating and receiving hepatitis C testing data from NSPs in 2006. As of 2016, 16 NSPs were operating in 13 cities across Georgia. During 2017-2018, with additional resources provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria, two additional NSP centers and eight mobile NSP units became operational, increasing coverage to approximately 50 of 79 municipalities countrywide. The Georgian Harm Reduction Network also provides diverse services* to persons who inject drugs to improve their health outcomes (5).
Persons who inject drugs and who test positive with a rapid HCV antibody test at NSPs are offered case management support and referred to authorized treatment sites for testing to confirm active HCV infection. † Since 2017, those persons who agree to treatment referral are asked to provide their 11-digit NIN to the NSP so that further clinical management can be confirmed and documented in the national program treatment database. Once at the treatment center, those patients with confirmed infection are enrolled in the treatment program and, if eligible for treatment, prescribed a direct-acting antiviral regimen according to national treatment guidelines (6). Within 12-24 weeks of completing treatment, patients are instructed to return to the treatment site for HCV RNA testing to determine whether sustained viral response (i.e., virologic cure) was achieved. Demographics, diagnostics, and treatment outcomes are recorded in real-time in the national program treatment database.
For this analysis, program records from the Georgian Harm Reduction Network were reviewed to ascertain annual HCV * Services provided though the Georgian Harm Reduction Network include distribution of sterile injecting equipment, condoms, and naloxone; voluntary counselling and testing for hepatitis C, human immunodeficiency virus, hepatitis B, and syphilis; peer-to-peer education; raising prevention awareness among persons who inject drugs; and advocacy for increased access to NSPs. † Positive for HCV RNA or HCV core antigen. antibody screening and positivity frequencies at NSPs during January 2006-December 2018 among persons who inject drugs; age group and sex distribution data were available from NSPs for 2015-2018. NSPs entered testing and service provision data into a database, which were validated by data management specialists at the Georgian Harm Reduction Network. Deduplication of test results was not conducted during 2006-2013 because of insufficient resources; during 2014-2018, deduplication of results was performed for each calendar year. Data for HCV antibody-positive persons who inject drugs who provided their NIN to NSPs during January 1, 2017-December 31, 2018, were linked to the national program treatment database to ascertain the hepatitis C care cascade, which summarizes the sequential steps in care. Because this analysis constituted a program evaluation, institutional review board oversight was not indicated.
During   Fewer than one fourth of persons who inject drugs agreed to provide their NIN to NSPs for the purpose of tracking clinical outcomes. Stigma related to drug use and fear of adverse legal, social, and economic consequences might discourage persons from disclosing their NIN to NSPs before accessing hepatitis C care and treatment (6). To avoid revealing their injection drug use status in the national registry and treatment database, persons could opt to visit treatment sites without divulging their affiliation with NSP services. At present, no incentives are offered by NSPs to motivate persons to provide their NIN. Without the NIN, persons who inject drugs cannot be tracked throughout the cascade of hepatitis C care, and the degree to which elimination efforts are proceeding in this population is hard to ascertain. A study is currently underway to examine the feasibility and effectiveness of providing screening, care, and treatment services at NSPs.

FIGURE 2. Hepatitis C virus (HCV) testing* and treatment outcomes among persons who inject drugs referred by needle and syringe programs (NSPs) to the national hepatitis C treatment program, as identified by their national identification numbers -Georgia
The findings in this report are subject to at least three limitations. First, data from NSP screening and the treatment programs could not be independently verified and could be subject to data entry errors. Second, resources were unavailable to deduplicate NSP test records before 2014; thus, it is not known whether each HCV antibody test during 2006-2013 represented a single person screened. Finally, because only a small proportion of screening data from NSPs were linked to

Summary
What is already known about this topic? Georgia, with a high prevalence of hepatitis C virus (HCV) infection and a high prevalence of injection drug use, launched a hepatitis C elimination program in 2015. Since 2006, needle and syringe programs (NSPs) have offered HCV antibody testing for persons who inject drugs.
What is added by this report?
Following the launch of the hepatitis C elimination program, the number of HCV antibody tests performed at NSPs has increased fivefold, and the number of persons with positive test results has doubled.
What are the implications for public health practice?
Hepatitis C testing at NSPs is an effective strategy for identifying persons with HCV infection. The program in Georgia might serve as a model for other countries. treatment data, this analysis could not fully assess the effectiveness of linkage from NSP screening to the national care and treatment program.
Strategies to engage persons who inject drugs in hepatitis C prevention, care, and treatment are needed to ensure elimination in Georgia. Lessons from Georgia could inform other countries with a high prevalence and similar epidemiology of hepatitis C.