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Meta-Analysis
. 2025 Apr;10(4):315-331.
doi: 10.1016/S2468-1253(24)00442-4. Epub 2025 Feb 21.

Global, regional, and national estimates of hepatitis C virus (HCV) infection incidence among people who inject drugs and number of new annual HCV infections attributable to injecting drug use: a multi-stage analysis

Adelina Artenie  1 , Adam Trickey  2 , Katharine J Looker  2 , Jack Stone  2 , Aaron G Lim  2 , Hannah Fraser  2 , Louisa Degenhardt  3 , Gregory J Dore  4 , Jason Grebely  4 , Evan B Cunningham  4 , Behzad Hazarizadeh  4 , Daniel Low-Beer  5 , Niklas Luhmann  5 , Paige Webb  3 , Matthew Hickman  6 , Peter Vickerman  2
Affiliations
Meta-Analysis

Global, regional, and national estimates of hepatitis C virus (HCV) infection incidence among people who inject drugs and number of new annual HCV infections attributable to injecting drug use: a multi-stage analysis

Adelina Artenie et al. Lancet Gastroenterol Hepatol. 2025 Apr.

Abstract

Background: Measuring progress towards the WHO 2030 target for hepatitis C virus (HCV) elimination among people who inject drugs (PWID)-an incidence of two or fewer infections per 100 person-years-has been challenging due to insufficient data. We aimed to estimate HCV incidence among PWID before and since 2015, progress towards the 2030 target, and the number of new annual HCV infections attributable to injecting drug use since 2015.

Methods: Four sequential steps were taken to estimate country-specific HCV incidence. First, we estimated HCV incidence from HCV antibody prevalence by duration of injecting using force-of-infection (FOI) modelling. Second, using Bayesian random-effects meta-analysis, we pooled FOI-derived estimates with any direct HCV incidence estimates from a published global meta-analysis, by country. Third, for countries with no FOI-derived or direct HCV incidence data, we applied incidence estimates from a published multi-country dynamic mathematical model. Fourth, for countries for which incidence could not be estimated using any of the aforementioned methods but that had data on overall HCV antibody prevalence (ie, not stratified by duration of injecting), we used a regression model to predict incidence based on prevalence and average duration of injecting. WHO regional and global HCV incidence, incidence rate ratios (IRRs) for 2015-21 versus pre-2015, and relative decline needed to achieve the 2030 WHO target were derived and weighted by the country-specific number of PWID at risk (ie, those who were HCV RNA-negative), provided that data from at least five countries were available within a WHO region. New annual HCV infections attributable to injecting drug use were estimated by multiplying country-specific HCV incidence for the 2015-21 period by the number of HCV RNA-negative PWID; for countries with no HCV incidence data but with evidence of an existing PWID population, incidence was imputed using the corresponding WHO regional incidence.

Findings: For the pre-2015 period, 146 HCV incidence estimates from 81 countries were included: 52 (36%) direct, 61 (42%) FOI-derived, and 33 (23%) regression-based estimates. For 2015-21, 114 estimates from 97 countries were included: 20 (18%) direct, 18 (16%) FOI-derived, 68 (60%) dynamic model-derived, and eight (7%) regression-based. Globally, pooled HCV incidence was 13·9 per 100 person-years (95% uncertainty interval [UI] 11·9-16·4) for pre-2015 and 8·6 per 100 person-years (7·1-10·7) for 2015-21. Based on a subset of countries with data for both periods, incidence was lower in the Western Pacific (IRR 0·32 [95% UI 0·23-0·50]), Eastern Mediterranean (0·67 [0·50-0·89]), and European (0·79 [0·63-1·02]) regions in 2015-21 versus pre-2015, but no difference was observed in the Americas. Insufficient data prevented comparisons over time for the African and South-East Asia regions and globally. Based on 2015-21 HCV incidence, the global decline needed to meet the 2030 WHO target is 76·7% (95% UI 71·8-81·3), while the global number of new annual HCV infections attributable to injecting drug use was 833 760 (95% UI 493 716-1 544 395) among the 187 countries with documented evidence of a population of PWID.

Interpretation: A substantial increase in HCV treatment and prevention is needed globally to achieve the WHO 2030 HCV elimination target for incidence among PWID.

Funding: WHO and the Wellcome Trust.

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Conflict of interest statement

Declaration of interests AA, KJL, and PV declare support from WHO for the present manuscript. AGL declares support for attending meetings or travel through the Viral Hepatitis Prevention Board and the European Association for the Study of the Liver–Lancet Commission meeting. HF declares support for the present manuscript through the National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation. GJD declares having received clinical trial grants from Gilead Sciences and AbbVie; and participation on an advisory board (National Institutes of Health R01 grant). JG declares grants or contracts from AbbVie, bioLytical, Cepheid, Gilead, and Hologic; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AbbVie, Abbott, Cepheid, Gilead, and Roche. EBC declares an investigator grant from the Australian National Health and Medical Research Council (NHMRC). DL-B and NL declare support for the present manuscript, grants, or contracts through Unitaid and the United States Agency for International Development. MH declares being a trustee (unpaid) of the Society for the Study of Addiction. PV declares an unrestricted research grant from Gilead for modelling HCV in Georgia; and funds from GSK for attending an expert meeting on HSV-2 vaccines, unrelated to this work. All other authors declare no competing interests.

Figures

Figure 1:
Figure 1:
Data flow for estimating country/regional/global HCV incidence among people who inject drugs and the number of new annual HCV infections attributed to injecting drug use Please see separate file, as requested * If a study had data for multiple countries or for separate regions within a country, we extracted these as separate records. Sources: 1Artenie A, Stone J, Fraser H, et al. Lancet Gastroenterol Hepatol 2023; 2Trickey A, Fraser H, Lim AG, et al. Lancet Gastroenterol Hepatol 2019; 4(6): 435–44; 3Degenhardt L, Webb P, Colledge-Frisby S, et al. Lancet Glob Health 2023; 11(5): e659-e72; 4UNODC. Vienna, Austria, 2023. †Regional and global HCV incidence were estimated based only on countries with HCV incidence data (informed by one of the four estimation methods). Regional and global estimates of the number of new annual HCV infections attributed to injecting drug use were derived after imputing HCV incidence data for countries where this was absent. Note: The numbers within circles indicate how the different types of HCV incidence were derived or where they were sourced from.
Figure 2:
Figure 2:
Estimates of HCV incidence among people who inject drugs for (A) pre-2015 (n=146) and (B) 2015–2021 (n=114), by country and method of estimation Please see separate file, as requested Note: Circles represent point estimates of HCV incidence, and vertical whiskers indicate 95% uncertainty intervals.
Figure 2:
Figure 2:
Estimates of HCV incidence among people who inject drugs for (A) pre-2015 (n=146) and (B) 2015–2021 (n=114), by country and method of estimation Please see separate file, as requested Note: Circles represent point estimates of HCV incidence, and vertical whiskers indicate 95% uncertainty intervals.
Figure 3:
Figure 3:
Country-level estimates of HCV incidence ( /100py) among people who inject drugs for (A) the pre-2015 period and (B) the 2015–2021 period Please see separate file, as requested
Figure 3:
Figure 3:
Country-level estimates of HCV incidence ( /100py) among people who inject drugs for (A) the pre-2015 period and (B) the 2015–2021 period Please see separate file, as requested
Figure 4:
Figure 4:
Number of new HCV infections attributed to injection drug use annually for the 20 countries with the highest values Please see separate file, as requested Note: Estimates are based on 2015–2021 HCV incidence data. Circles represent point estimates of the number of new HCV infections attributed to injecting drug use, and vertical whiskers indicate 95% uncertainty intervals. The numbers shown above the error bars represent the proportion of global infections attributed to each country, based on their median values.
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