Hepatitis C elimination in people who inject drugs needs a health system strategy, says expert review

Achieving the elimination of hepatitis C in people who inject drugs will require a comprehensive health system-wide strategy that addresses stigma, barriers to care, financing, the involvement of people who inject drugs and devolution of treatment services to community level, according to an expert review published this month in Liver International.

The expert review identified a range of actions which need to be taken at health system level to improve access to treatment and prevention for people who inject drugs. The actions are not just the provision of services, but also changes in the way that services are designed and delivered. These changes need to be promoted from the top in the health system and form part of planning and monitoring.

The authors identified actions relating to each of the World Health Organization’s six health system building blocks and highlighted actions relating to communication and participation as essential to the hepatitis C response.

Half of all hepatitis C infections in people who inject drugs are found in four countries: Brazil, China, the Russian Federation and the United States.

Evidence from clinical trials and observational studies shows that needle and syringe programme and opioid substitution therapy reduce the risk of hepatitis C virus acquisition in people who inject drugs. Direct-acting antiviral treatment is highly effective in curing hepatitis C in drug users.

However, making these interventions available, and diagnosing drug users with hepatitis C and linking them to care require changes in the health system to be made available at a large scale. The expert review identified a range of actions that can be taken to improve access to treatment and prevention services for people who inject drugs.

Improved communication with people who inject drugs is essential to improve health literacy and raise awareness of the benefits of treatment. Peer-led hepatitis C health promotion delivered through organisations of drug users, together with patient involvement in the development of communications strategies, will be essential for building trust and making information and messages relevant to drug users. Healthcare workers will benefit from training that addresses stigmatising language/terminology, attitudes, practices and policies. People who use drugs should be involved in the design and delivery of hepatitis C services and should also be represented on national bodies that plan viral hepatitis elimination strategies.

Increasing the access points for diagnosis and treatment will enable more people who use drugs to be cured of hepatitis C. Blood-based testing may present a barrier for drug users, whether because of veins damaged by injecting or because of wish to avoid needles in former drug users, and restrictions on who can draw blood may also restrict access to testing in community settings. Finger-stick or saliva testing methodologies should be supported as an alternative route into care. Task-shifting, or the devolution of aspects of treatment and care to non-physicians, should be promoted to expand the healthcare workforce capable of diagnosing hepatitis C and initiating people on treatment.

Following on from the recommendation of task-shifting, the panel also recommends that national strategies should aim to develop and expand the peer workforce. Peer-based models of care are highly acceptable to people who use drugs and help to build trust between services and their users. Education for healthcare workers on hepatitis C needs to be expanded too, so as to build capacity and provide non-stigmatising care.

Health information systems can be used to support hepatitis C elimination in people who use drugs by encouraging testing and by monitoring the uptake of testing and linkage to care. Electronic health record alerts can enable testing in the previously untested or in people who require ongoing risk-based testing. Robust policies to communicate how data will be used and how privacy will be protected need to be in place. A hepatitis C treatment registry that can capture treatment outcomes in community settings is also essential and needs to be flexible enough for use in a variety of community settings, especially as services evolve. Information systems should also monitor the impact of treatment on the long-term health of people who use drugs.

Procurement policies can enable greater access to testing by speeding up the certification of diagnostics, especially those that do not require a venous blood draw, including saliva tests.

Hepatitis C elimination in people who use drugs can be supported by developing the financial case for elimination. Identifying and sharing models of successful elimination that are appropriate for different epidemic settings and health systems will support implementation and aid in the development of investment cases that explore budget impact, cost-effectiveness and resource allocations strategies.

Hepatitis C elimination in people who use drugs will require leadership to ensure that people who use drugs are meaningfully involved in the development and implementation of national elimination strategies and included in national treatment guidelines. Leadership is also needed to ensure financial commitment from national and local government to treatment and to the scale-up of harm reduction interventions to a level that will maximise the impact of hepatitis C treatment as prevention.