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Priorities for primary prevention of new hepatitis C infections
Matthew Hickman, Reader in Public Health and Epidemiology, Department of Social Medicine, University of Bristol

Abstract
In UK there are 120,000 to 300,000 people infected with HCV; 85% through injecting drug use. Public health surveillance data suggest that HCV prevalence in IDU is not declining and in some groups maybe increasing e.g. HCV prevalence has almost doubled in the last 10 years among recent injectors. Less than half of active IDU with HCV have been diagnosed. In some cities 1 in 2 injectors will be infected with HCV. The critical public health and policy question is what can be done to improve the primary prevention of HCV among injectors.

Evidence:
We assessed the review level evidence on the effectiveness of key interventions (principally needle and syringe programmes (NSP) and methadone and other opiate substitute treatment (OST). We found that the strength of direct evidence is weaker than we expected, and is weaker than often given credit for by many of the reviews in the literature. However, cost effectiveness models do suggest that increasing intervention coverage is likely to be cost effective and that the combination of interventions maybe the most effective and possibly cost saving given certain assumptions. There is emerging evidence from epidemiological studies that HCV incidence could be reduced by a 1/3 in people in full harm reduction (OST and regular NSP); but partial harm reduction may be ineffective in relation to HCV. Dried blood spots (DBS) offer a method of both increasing HCV diagnosis and epidemiological intelligence.

Implications for discussion:
Comprehensive/ combined interventions are required to reduce HCV transmission. Injecting cessation and reduction must be a goal of HCV prevention – as in some cities even small lapses in otherwise safe injecting behaviour can put people at considerable risk of acquiring HCV. HCV diagnosis and treatment needs to be increased, and may have a role (given certain assumptions) in primary prevention. How can more and better evaluation of interventions be undertaken to strengthen evidence base?

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