A combination of interventions to create opportunities for
stable housing, stigma reduction and changes in the delivery of health care
could play a critical role in improving uptake of hepatitis C treatment in
people who inject drugs, according to a review published this month in Harm Reduction Journal (full text
Modelling studies suggest that scaling up hepatitis C
treatment access for people who inject drugs would reduce the prevalence of
infection and act as a prevention measure. Moreover, guidelines in several
countries have been revised so that drug use is no longer a reason to exclude a
person from hepatitis C treatment, and there is evidence that drug users can have
comparable adherence and treatment outcomes to other populations.
Nonetheless, uptake of treatment by injecting drug users is
extremely low – around 2 to 4% of those eligible, according to estimates.
In order to better understand the barriers to and
facilitators of treatment access, Magdalena Harris and Tim Rhodes of the London
School of Hygiene & Tropical Medicine reviewed the available research on
hepatitis C in people who inject drugs, particularly studies describing social
factors that are linked to testing and treatment.
Although 165 relevant articles were identified, the authors
say that limited research has been done and that their review’s findings must
be seen as preliminary.
The review identified stigma and discrimination as barriers
to both testing and treatment of hepatitis C. Past experiences of breaches of
confidentiality or discriminatory treatment by healthcare providers (discrimination
related to either drug use or hepatitis infection) could act as a barrier to
use of health services. Problems were particularly reported by women, in prison
settings and in rural areas.
Unstable housing or homelessness was identified as a barrier
to treatment uptake, although few studies examined the issue in depth.
Individuals with housing problems often have high support needs, have
difficulties registering with health services, may not be able to store
pegylated interferon in a fridge and may find side-effects more difficult to
cope with. However, the authors note that some services have attempted to
address such problems, for example by providing outreach services to distribute
treatment, especially the weekly injections.
Transport difficulties and distance from healthcare
providers limited uptake of health services, both in rural and urban areas.
Qualitative studies suggested that competing demands (earning money, getting
hold of drugs, accessing needle exchange or opioid substitution therapy, caring for children)
could take precedence over hepatitis treatment services, especially if such
services were inconveniently located.
The review found that research on the links between the
criminalisation of drug use and hepatitis C treatment uptake was lacking, although
problems have been widely reported in relation to HIV treatment.
But there were clear data on difficulties accessing hepatitis
C treatment in prisons. Adherence challenges, limited access to diagnostic
tests, abstinence eligibility requirements, inconsistent medical support, treatment
interruptions due to prison transfers, limited understanding by prison staff,
and a lack of aftercare were reported.
The review found that the highly compartmentalised nature of
healthcare systems can create a barrier to comprehensive care for people who
inject drugs, who may have complex needs spanning multiple disciplines – drug
dependency treatment, psychiatry, hepatology, acute care of wounds and
infections. Navigating healthcare systems could be daunting and inflexible
hospital services were not ideally suited.
Several studies noted communication difficulties between
medical specialists and patients. Some patients felt that doctors had
down-played the severity and variety of treatment side-effects, did not
adequately respond to their concerns and did not have enough time for patient
While the authors say that not enough research has examined
the impact of gender on treatment access, they note that concerns about
confidentiality, stigma and side-effects are felt especially keenly by women. Moreover,
violence, sex work and childcare are likely to be relevant.
The authors also note limited attention to immigration
status, ethnicity and culture in the available literature.
“We have identified social stigma, housing, criminalisation,
health care systems, and gender as key domains in the conditionality of
hepatitis C treatment access, and thus also, as important targets for social
and structural change,” say the researchers. While a strong evidence base of
effective interventions is lacking, they recommend a combination intervention
approach which includes social, welfare and structural interventions and which
seeks to integrate care services at the point of delivery.