Elimination of HCV as a public health concern among people who inject drugs by 2030 – What will it take to get there?

Abstract

Introduction: Globally, there is a considerable burden of HCV and HIV infections among people who inject drugs (PWID) and transmission of both infections continues. Needle and syringe programme (NSP) and opioid substitution therapy (OST) coverage remains low, despite evidence demonstrating their prevention benefit. Direct-acting antiviral therapies (DAA) with HCV cure >95% among PWID provide an opportunity to reverse rising trends in HCV-related morbidity and mortality and reduce incidence. However, HCV testing, linkage to care, and treatment remain low due to health system, provider, societal, and patient barriers. Between 2015 and 2030, WHO targets include reducing new HCV infections by 80% and HCV deaths by 65%, and increasing HCV diagnoses from <5% to 90% and number of eligible persons receiving HCV treatment from <1% to 80%. This commentary discusses why PWID should be considered as a priority population in these efforts, reasons why this goal could be attainable among PWID, challenges that need to be overcome, and key recommendations for action.Discussion: Challenges to HCV elimination as a global health concern among PWID include poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low HCV testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. Key recommendations for action include reforming drug policies (decriminalization of drug use and/or possession, or providing alternatives to imprisonment for PWID; decriminalization of the use and provision of sterile needles-syringes; and legalization of OST for people who are opioid dependent), scaling up and improving funding for harm reduction services, making health services accessible for PWID, supporting community empowerment and community-based programmes, improving access to affordable diagnostics and medicines, and eliminating stigma, discrimination, and violence against PWID.Conclusions: The ambitious targets for HCV elimination set by WHO are achievable in many countries, but will require researchers, healthcare providers, policy makers, affected communities, advocates, the pharmaceutical and diagnostics industries, and governments around the world to work together to make this happen.

Real‐world outcomes of unrestricted direct‐acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience

“…Although community DAA initiation from general practitioners proportionally increased over the 12‐month period in our cohort, the absolute increase was small. Treating an estimated 8% of the current Australian PWID annually or 40 per 1000 PWID is projected to reduce HCV transmission by 90% within 12 years in order to achieve WHO elimination targets . In our cohort over twelve months, 62 confirmed current injecting drug users of an estimated 6700 users in South Australia were treated .…”

Research gaps in viral hepatitis

“…These estimates are considerably higher than the roughly 30% of HIV‐infected individuals unaware of their infection . Most undiagnosed cases of HBV and HCV in high‐income countries (HIC) belong to marginalized groups not covered by conventional screening programmes . Undiagnosed cases in low‐ to middle‐income countries (LMIC) are also found in these key populations, but the greater problem lies in limited centralized diagnostic facilities, cost of testing, lacking public education and awareness, and need for skilled health professionals .…”

Hep‐CORE: a cross‐sectional study of the viral hepatitis policy environment reported by patient groups in 25 European countries in 2016 and 2017

“…The presence of injecting drug use‐related restrictions on access to DAAs for the treatment of HCV in several study countries is also a matter of concern, and other research has similarly documented such restrictions . European and global experts concur that injecting drug use does not constitute a valid reason for withholding treatment – indeed, global HCV elimination strategies depend on the reductions in transmission that are expected to occur when large numbers of chronically HCV‐infected people who currently inject drugs are cured with DAAs .…”