Elimination of hepatitis C among people who inject drugs in Europe will require simultaneous scale-up of direct-acting antiviral treatment, needle and syringe programmes and opioid substitution therapy, and a re-think of attitudes to drug policy and harm reduction in Central Europe, according to a modelling study led by researchers from the University of Bristol.
The study findings, published in advance online by the Journal of Hepatology, show that although increasing the number of people treated for hepatitis C may result in large reductions in prevalence in countries with low hepatitis C virus (HCV) prevalence, it will have little impact on new infections in most settings.
In the European Union, 3.6 million people were estimated to have chronic HCV infection in 2016. Estimates of the number of people with hepatitis C who inject drugs are difficult to arrive at, due to lack of surveillance systems, lack of information about possible sources of exposure and uncertainty about the size of the current injecting population in European countries.
The modelling study found that in most European settings, hepatitis C prevalence would fall by less than five per cent at current rates of treatment uptake among people who inject drugs. Treating five per cent of people who inject drugs each year would achieve a 99% reduction in prevalence in the Czech Republic and Slovenia, but a large reduction in prevalence would only come about in other countries if the coverage of opioid substitution therapy and needle and syringe programmes reached 80%.
To achieve greater treatment coverage among people who inject drugs, improvements in screening will be needed to identify people with hepatitis C. A systematic review also published this month shows that prevalence is high in many countries among people who inject drugs and among prisoners. Systematic screening for prisoners and engagement in care, and provision of hepatitis C screening and treatment in accessible places for people who inject drugs, are two of the ways in which screening might be improved, say the authors.
Several other innovative methods of harm reduction could have an impact on HCV transmission among people who inject drugs and in prisons.
In Canada, federal prison authorities are considering the introduction of a needle and syringe programme for prisons, and also the provision of safe tattooing facilities, to reduce hepatitis C transmission.
Needle and syringe programmes in prisons are still rare; Harm Reduction International found that only eight countries – including Germany, Spain and Switzerland – provided clean needles and syringes to inmates in 2016.
Several cities in North America are pioneering the introduction of safe injecting sites, where people who inject drugs can go to inject drugs using sterile injecting equipment, with overdose treatment close at hand. These facilities offer a good way of engaging people who inject drugs in other harm reduction services, such as opioid substitution therapy, and can offer screening for hepatitis C too.
One of the most important harm reduction interventions, opioid substitution therapy, is still not widely available in many countries and is strongly rejected as a harm reduction measure by governments and experts in some of the Eastern European countries with the highest prevalence of hepatitis C. Ukraine, however, is expanding its opioid substitution therapy programme and is now providing treatment to over 10,000 people. A recent Cochrane Collaboration systematic review found that opioid substitution therapy reduced the risk of HCV acquisition by 50% among people who inject drugs, while high coverage of opioid substitution therapy and needle and syringe programmes reduced the risk of HCV acquisition by 75%.
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