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

Ketevan Stvilia, MD; Philip R. Spradling, MD; Alexander Asatiani, MD; Maka Gogia, MD; Khatuna Kutateladze, MD; Maia Butsashvili, MD, PhD; Jaba Zarkua, MD; Tengiz Tsertsvadze, MD, PhD; Lali Sharvadze, MD, PhD; Maia Japaridze, MD; Tinatin Kuchuloria, MD, PhD; Lia Gvinjilia, MD, PhD; Irinka Tskhomelidze, MPH; Amiran Gamkrelidze, MD, PhD; Irma Khonelidze, MPA; David Sergeenko, MD, PhD; Shaun Shadaker, MPH; Francisco Averhoff, MD; Muazzam Nasrullah, MD, PhD


Morbidity and Mortality Weekly Report. 2019;68(29):637-641. 

In This Article

Abstract and Introduction


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 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 2006–2018, NSPs provided 118,943 HCV antibody tests to persons who inject drugs, 48,228 (40.5%) of which were positive (Figure 1). During the years preceding program implementation (2006–2014), 32,738 (average 3,638 per year) tests were conducted; nearly half (49.6%; 16,247) were positive. Following implementation of the elimination program (2015–2018), the average number of antibody tests performed each year among persons who inject drugs increased approximately 500%, to 21,551. Among the 86,205 HCV antibody tests provided during this period, 31,981 (37.1%) were positive. Males accounted for 96.1% of tests, and persons aged 30–39 years were the most frequently tested age group (33.7%). In 2018, the HCV antibody prevalence among persons aged 18–29 years was 5.5%, the lowest among all age groups during 2015–2018. HCV antibody positivity was 37.8% among males and 24.0% among females tested at NSPs during 2015–2018.

Figure 1.

Number of tests for hepatitis C virus (HCV) antibody conducted and positive test results among persons who inject drugs — Georgian Harm Reduction Network, Georgia, 2006–2018

During 2017–2018, among 12,163 HCV antibody-positive test results from 11,424 clients at NSPs, 2,780 (24.3%) persons were identified by their NIN in the national treatment database, 1,626 (58.5%) of whom received a follow-up diagnostic test for active HCV infection (Figure 2). Among those tested, 1,370 (84.3%) had active HCV infection. Of those with active infection, 1,029 (75.1%) initiated treatment, 892 (86.7%) of whom completed treatment and were eligible for sustained viral response testing. Of these, 494 (55.4%) returned for sustained viral response testing, 482 (97.6%) of whom achieved cure.

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, 2017–2018
* HCV RNA or HCV core antigen.

* 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.