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Social, welfare and structural interventions needed to improve HCV treatment access for people who inject drugs

Roger Pebody
27 May 2013

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 freely available).

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 appointments.

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.


Harris M & Rhodes T Hepatitis C treatment access and uptake for people who inject drugs: a review mapping the role of social factors. Harm Reduction Journal 10:7, 2013. (Open-access article available here.)