Beyond the Average: Modeling Individual-Specific Preferences for Ulcerative Colitis Surgery.

Globally, an estimated 14 million adults (aged 15–64) injected drugs, of whom approximately 1.7 million (12%) were living with HIV, 6.9 million (49%) had HCV infection, and roughly 1.5 million people who inject drugs (PWID) were living with HIV–HCV co-infections in 2023 [–]. In Myanmar, a major producer of opium, there are an estimated 116,000 PWID, among whom 19.0% are infected with HIV, 47.7% with HCV, and 20.1% are co-infected [, ]. While the introduction of effective antiretroviral therapy (ART) has improved survival among HIV-infected individuals, HCV-associated mortality remains high in HIV-HCV co-infected patients [, ]. The World Health Organization (WHO) has recommended direct-acting antiviral agents (DAAs) for HCV treatment since 2018 []. A systematic review of randomized controlled trials involving adults with chronic HCV infection treated with at least 8 weeks of two DAAs found that DAAs can achieve a sustained viral response, defined as undetectable HCV-RNA at 12 weeks after the completion of HCV treatment (SVR12), in more than 90% of patients with chronic HCV infection, although rates are slightly lower, ranging from 78 to 87%, in those with advanced cirrhosis []. Although a review of clinical trials showed SVR12 rates of 95–100% with DAAs among HIV-HCV co-infected general populations, the number of studies among HIV-HCV co-infected PWID remains very limited []. Regarding reinfection after SVR12, a meta-analysis has shown that the overall rate of HCV reinfection was 5.9 per 100 person-years (95% CI: 4.1–8.5) among people with recent drug use (injecting or non-injecting) []. Evidence has shown that HCV-associated liver disease, including fibrosis, cirrhosis, and end-stage liver disease (ESLD), progresses more rapidly in HIV-HCV co-infected individuals []. Moreover, given the high transmission risk among PWID, ensuring access to treatment for both infections is a critical public health concern. Still, there is limited access to HCV treatment among PWID globally. Stigma surrounding HIV and HCV co-infection and injecting drug use delays HCV diagnosis and treatment, increases mortality, and drives higher transmission rates [, ]. There is an urgent need for strategies that reduce stigma and enhance the acceptability of healthcare delivery to improve access to HCV care among PWID []. A multi-country survey covering countries across six WHO regions, with respondents originating mainly from Nigeria (23%), the United States (20%), Australia (7%), and the United Kingdom (7%), highlighted that integrating HCV services, such as simplified testing and treatment initiation, into community-based harm reduction centres improved access to HCV care among PWID []. In Myanmar, PWID have been a priority population for HCV elimination since 2017 []. Nevertheless, treatment access remains limited in Myanmar, particularly in remote areas, with a yearly treatment uptake of less than 1% among HCV-positive PWID [, , ]. Murdock et al. recommend a novel approach in which HCV treatment is integrated with other harm reduction services, including, prevention and care for HIV, other sexually transmitted infections (STI), and tuberculosis (TB), needle and syringe exchange programs (NSP), and opiate agonist therapy (OAT) []. Similarly, Medical Action Myanmar (MAM), a non-governmental organization (NGO) working in Myanmar, initiated an innovative HCV treatment program for HIV-HCV co-infected PWID, providing HCV diagnosis and treatment alongside other services, including HIV, STI, and TB care, guided remotely by specialists through telemonitoring in a remote community-based HIV clinic. The program, managed by general practitioners (GPs), supported by community health workers (CHWs) and peer educators (PEs), and guided through online case discussions with specialists (telemonitoring), represents a comprehensive and promising strategy for addressing HCV among HIV-HCV co-infected PWID. The MAM model of integrated service delivery, encompassing HIV and HCV testing and treatment, needle and syringe exchange, and community-based overdose prevention through naloxone distribution, has demonstrated significant improvements in health outcomes among PWID in a remote and challenging setting [].