Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs.
Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs.
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DOI：
10.1002/14651858.cd012021.pub2
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发表时间：
2017-09-18
期刊：
影响因子：
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通讯作者：
Hickman M
中科院分区：
文献类型：
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作者：
Platt L;Minozzi S;Reed J;Vickerman P;Hagan H;French C;Jordan A;Degenhardt L;Hope V;Hutchinson S;Maher L;Palmateer N;Taylor A;Bruneau J;Hickman M
预防注射吸毒者丙型肝炎传播的针头注射器规划和阿片类药物替代治疗是减少注射吸毒者丙型肝炎传播的主要干预措施。有很好的证据表明NSP和OST在减少注射风险行为方面的有效性，并有越来越多的证据表明OST和NSP在降低艾滋病毒感染风险方面的有效性，但关于NSP和OST在预防HCV感染方面的有效性的证据很弱。评估针头注射规划和阿片类药物替代治疗（单独或联合使用）在预防注射吸毒者获得丙型肝炎病毒方面的效果。截至2015年11月16日，我们检索了Cochrane药物和酒精登记处、CENTRAL、Cochrane系统评价数据库（CDSR）、效果评价摘要数据库（DARE）、卫生技术评估数据库（HTA）、NHS经济评估数据库（NHSEED）、MEDLINE、Embase、PsycINFO、Global Health、CINAHL和科学网。我们在2017年3月更新了这一搜索，但我们尚未将这些结果纳入综述。在观察性研究未报告任何结果测量的情况下，我们要求作者提供未发表的数据。我们检索了主要国际机构的出版物和会议摘要。我们查阅了所有纳入文章的参考文献列表和符合条件的论文的主题相关系统综述。我们纳入了前瞻性和回顾性队列研究、横断面调查、病例对照研究和随机对照试验，这些研究测量了NSP和/或OST暴露与不干预或减少暴露的对比，并报告了注射吸毒者中HCV发病率的结果。我们将干预措施定义为与不干预或减少接触相比，当前的OST（过去6个月内）、终生使用OST和高NSP覆盖率（定期到NSP就诊或所有注射都使用新针头/注射器）或低NSP覆盖率（不定期到NSP就诊或新针头/注射器的注射率低于100%）。我们遵循标准Cochrane方法学程序，纳入观察性研究偏倚风险分类的新方法。我们针对以下“偏倚风险”领域描述了研究方法：混淆、选择偏倚、干预措施的测量、偏离干预措施、缺失数据、结果的测量、报告结果的选择；我们为每个标准分配了一个判断（低，中等，严重，关键，不清楚）。我们确定了28项研究（21项已发表，7项未发表）：13项来自北美，5项来自英国，4项来自欧洲大陆，5项来自澳大利亚，1项来自中国，包括1817例HCV感染事件和8806.95人年的随访。在这些研究中，HCV的发病率从每100人年0.09例到42例不等。我们判断只有两项研究具有中等偏倚风险，而17项研究具有严重风险，7项研究具有严重风险；对于两个未发表的数据集，没有足够的信息来评估偏倚。由于没有任何干预效果是由RCT证据产生的，我们通常将质量归类为低。我们发现证据表明，目前的OST降低了50%的HCV感染风险（风险比（RR） 0.50, 95%可信区间（CI） 0.40 ~ 0.63, I2 = 0%，所有地区的12项研究，N = 6361），但证据质量较低。在排除未发表的数据集和被认为存在严重偏倚风险的论文的敏感性分析中，干预效果仍然显著。我们发现了样本中女性参与者比例差异影响的证据，但没有发现研究样本中研究的地理区域、主要药物使用或无家可归或监禁史。总的来说，我们发现非常低质量的证据表明，高NSP覆盖率并没有降低HCV感染的风险（RR 0.79, 95% CI 0.39至1.61），基于北美和欧洲的5项研究，涉及3530名参与者，异质性高（I2 = 77%）。在按地区分层后，欧洲高NSP覆盖率与HCV感染风险降低76%相关（RR 0.24, 95% CI 0.09至0.62），异质性较小（I2 =0%）。我们从涉及3241名参与者的三项研究中发现了低质量的证据，证明NSP和OST的高覆盖率联合使用的影响，导致HCV获得风险降低74% （RR 0.26, 95% CI 0.07至0.89）。OST与HCV感染风险的降低有关，这一点在评估OST和NSP联合使用的研究中得到了加强。研究之间存在较大的异质性，NSP对HCV感染的影响证据较弱。在欧洲的研究中，高NSP覆盖率与HCV感染风险的降低有关。减少注射吸毒者丙型肝炎感染的干预措施综述问题我们研究了针头注射规划（NSP）和阿片类药物替代治疗（OST）在降低丙型肝炎病毒感染风险方面的影响。全球约有1.149亿人患有丙型肝炎，每年有300万至400万人新感染。感染的主要风险是共用用过的针头/注射器。注射吸毒者中几乎有一半患有丙型肝炎。通过国家卫生服务提供者提供无菌注射设备减少了在制备和注射药物时共用设备的需要。口服口服避孕药可减少注射频率和不安全的注射做法。我们研究了单独或同时提供NSP和OST是否能有效减少注射吸毒者感染丙型肝炎的机会。证据截止到2015年11月。我们在欧洲、澳大利亚、北美和中国进行了28项研究。在这些研究中，平均每年每100人中有19.0人感染丙型肝炎。来自11,070名注射吸毒者的数据在研究开始时没有感染丙型肝炎。在样本中，32%是女性，50%注射阿片类药物，51%每天注射，40%无家可归。我们的研究是由国家卫生研究院（NIHR）公共卫生研究计划、干预措施评估健康保护研究单位和欧洲委员会药物预防和信息计划（DIPP）“欧洲的治疗即预防：模型预测”资助的。目前使用OST（定义为在调查时或过去6个月内使用）可使感染丙型肝炎的风险降低50%。我们不确定在全球所有研究中，高覆盖率的NSP（定义为定期参加NSP或所有注射都由新针头/注射器覆盖）是否降低了感染丙型肝炎的风险，但欧洲的一些研究表明，高覆盖率的NSP可能会将丙型肝炎感染的风险降低76%。高覆盖率NSP与OST联合使用可将丙型肝炎感染风险降低74%。证据质量由于没有一项研究采用随机对照试验的金标准设计，证据质量从中等到极低不等。
Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs Needle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak. To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs. We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic‐related systematic reviews for eligible papers. We included prospective and retrospective cohort studies, cross‐sectional surveys, case‐control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure. We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion. We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person‐years of follow‐up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person‐years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples. Overall, we found very low‐quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low‐quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89). OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe. Interventions for reducing hepatitis C infection in people who inject drugs Review question We examine research on the effect of needle syringe programmes (NSP) and opioid substitution treatment (OST) in reducing the risk of becoming infected with the hepatitis C virus. Background There are around 114.9 million people living with hepatitis C and 3 to 4 million people newly infected each year. The main risk for becoming infected is sharing used needles/syringes. Almost half the people who inject drugs have hepatitis C. The provision of sterile injecting equipment through NSPs reduces the need for sharing equipment when preparing and injecting drugs. OST is taken orally and reduces frequency of injection and unsafe injecting practices. We examined whether NSP and OST, provided alone or together, are effective in reducing the chances of becoming infected with hepatitis C in people who inject drugs. Search date The evidence is current to November 2015. Study characteristics We identified 28 research studies across Europe, Australia, North America and China. On average across the studies, the rate of new hepatitis C infections per year was 19.0 for every 100 people. Data from 11,070 people who inject drugs who were not infected with hepatitis C at the start of the study were combined in the analysis. Of the sample, 32% were female, 50% injected opioids, 51% injected daily, and 40% had been homeless. Our study was funded by the National Institute of Health Research's (NIHR) Public Health Research Programme, the Health Protection Research Unit in Evaluation of Interventions, and the European Commission Drug Prevention and Information Programme (DIPP), Treatment as Prevention in Europe: Model Projections. Key results Current use of OST (defined as use at the time of survey or within the previous six months) may reduce risk of acquiring hepatitis C by 50%. We are uncertain whether high coverage NSP (defined as regular attendance at an NSP or all injections being covered by a new needle/syringe) reduces the risk of becoming infected with hepatitis C across all studies globally, but there was some evidence from studies in Europe that high NSP coverage may reduce the risk of hepatitis C infection by 76%. The combined use of high coverage NSP with OST may reduce risk of hepatitis C infection by 74%. Quality of the evidence Quality of evidence ranged from moderate to very low because none of the studies used the gold standard design of randomised controlled trials.