Hepatitis C treatment and prevention failing to reach people most affected

Keith Alcorn
25 February 2020

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.


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.