Major gaps in harm
reduction and treatment provision for people who inject drugs jeopardise the
achievement of global targets for hepatitis C elimination by 2030, a review of
hepatitis C treatment and care has found.
The review is published by the hepCoalition’s mapCrowd
platform, which is intended to gather the most up-to-date global data on
hepatitis C by crowd-sourcing through local experts and advocates.
The new report, Access to
hepatitis C treatment and care among people who inject drugs: failing people
most disproportionately affected, combines crowd-sourced data with data collected
by the World Health Organization and Harm Reduction International’s State of
Global Harm Reduction report, and finds:
- Globally,
the hepatitis C virus (HCV) antibody prevalence among people who inject drugs is estimated to be
52.3%
- Out of the estimated 15.6 million people (3.2 million are women) who inject drugs globally, 6.1 million of them have chronic infection with HCV (or have a 39.2% viremic prevalence)
- One in three HCV deaths are attributable to injecting drug use.
- Nearly a quarter of the world’s new HCV infections occur among people
who inject drugs.
- Four countries (Brazil, China, Russia,
and the United States) have the most people with recent injecting drug use who
are living with HCV. Together these countries make over half (51%) of all
people with recent injecting drug use living with HCV worldwide.
However, the survey found numerous gaps in global
programming and services for people who inject drugs, calling into question the
possibility of achieving targets for elimination of hepatitis C by 2030.
Lack of adequate harm reduction services
The survey found that only a third of lower middle-income
and low-income countries had operational needle and syringe programmes (NSPs). In 40%
of cases it was not possible to confirm that they existed. Twenty-seven per
cent of countries had no NSPs and the same proportion
had no opioid substitution programmes. Only 25% of countries had confirmed
opioid substitution programmes. Even where NSPs exist, services are often
inadequate. NSPs in six out of 30 European countries do not offer testing for
hepatitis C.
National plans on viral hepatitis C ignore people who
inject drugs
By September 2019, only 32 out of 119 country plans for
viral hepatitis (29%) mentioned key populations including people who inject
drugs.
Abstinence-based treatment restrictions
Forty-four countries have treatment guidelines for viral
hepatitis. Nine countries including Malaysia, the Russian Federation, and
Croatia exclude active drug users from hepatitis C treatment even though numerous
studies have demonstrated high cure rates among active drug users, especially
where opioid substitution therapy is also available.
HCV treatment out of reach due to cost and lack of health
insurance
Many people who use drugs are not covered by health insurance
and cannot afford the out-of-pocket costs of treatment, especially in countries
where generic versions of direct-acting antivirals are not available.
Treatment restrictions based on liver disease stage or
specialist prescribing
One-third of countries surveyed (70 with available data)
reported that hepatitis C treatment was restricted to people with F2 fibrosis
or above, delaying treatment for those with less advanced liver disease. Early
treatment prevents the development of fibrosis, reduces health system costs
associated with fibrosis and reduces the risk of hepatitis C transmission.
Restriction of treatment prescribing to liver specialists
limits treatment uptake. Only 20 countries surveyed permit primary care
practitioners to prescribe direct-acting antivirals.
Criminalising people who use drugs contributes to poor
treatment uptake
Treatment uptake among people who inject drugs is low due to
criminalisation and stigmatisation. A sample of six countries with hepatitis C
elimination plans (including Ukraine, Malaysia and Indonesia) shows that less
than 2% of people with drugs and chronic hepatitis C have started treatment.
People who inject drugs who are incarcerated are at especially high risk of
acquiring hepatitis C due to the low level of harm reduction services in
prisons. In 2018 the survey found that only ten countries provided NSPs in at least one prison and 54 countries provided opioid
substitution therapy in prisons.
Advocacy
The report makes a series of recommendations for advocacy
including:
- Reliable access to pangenotypic treatment and
introduction of generic versions of direct-acting antivirals to simplify
treatment and reduce costs.
- Allow non-specialists to prescribe
direct-acting antivirals.
- Train health professionals in harm reduction and
community-friendly healthcare approaches that destigmatise drug use and sex
work.
- Expand needle and syringe programmes and
increase coverage (number of needles and syringes distributed to drug users).
- Decentralise and simplify diagnostics for hepatitis
C.
- Train, remunerate and integrate peer workers
into the hepatitis C care cascade.
- Involve people who inject drugs in national
elimination planning.
- Reform drug policy to decriminalise drug use.
- Involve Ministries of Justice in hepatitis
elimination planning.
- Obtain political and funding commitments from
Ministries of Health and Justice to achieve elimination in drug users.