While epidemiologists and public health experts are excited
by the potential of new hepatitis C drugs to limit onward transmission of the
virus among people who inject drugs, the strategies ignore profound barriers to
drug users engaging with healthcare and their broader needs. For ‘treatment as
prevention’ to be ethical and acceptable to people who inject drugs, enabling
treatment and policy environments need to be created, the 24th International Harm Reduction Conference in
Kuala Lumpur, Malaysia, heard last week.
But there is also an opportunity: “Treatment as prevention
has the potential to be a powerful advocacy tool for enhancing treatment access
for people who inject drugs,” Magdalena Harris of the London School of Hygiene
and Tropical Medicine told the conference. Her analysis was co-authored with
Eliot Albers of the International Network of People Who Use Drugs and Tracy
Swan of Treatment Action Group.
Borrowed from the HIV field, the
concept of ‘treatment as prevention’ is now being applied to hepatitis C. Modelling
studies suggest significantly increasing the number of injecting drug users
whose hepatitis C is treated and cured could help prevent onward transmission
of the virus.
Modern hepatitis C treatment has fewer side-effects and is
more effective than treatment based on pegylated interferon injections. Studies
show that people who inject drugs can achieve good levels of adherence and
that the treatment is effective in this population. Recently, guidelines
were developed in order to encourage doctors to offer treatment to
people who inject drugs.
However at the moment, the provision of hepatitis C
treatment is frequently prioritised for those who have advanced liver disease. Typically,
drug users who receive treatment are no longer injecting, may be receiving
opioid substitution therapy and may have been assessed as having a sufficiently
‘stable’ lifestyle. In contrast, a treatment as prevention strategy would
prioritise those who are most likely to transmit the virus – people who
currently inject and do so frequently.
Public health rhetoric advocating the targeting, testing and
treatment of specific populations can raise fears in already alienated and marginalised
population, Magdalena Harris suggested. The language used is often stigmatising
(for example calling
for a focus on “the core transmitters of incident HCV infections”).
With the priority given to the benefits for the whole population and for public health, the needs, fears and desires of
the person taking the treatment slip out of focus.
She noted the many barriers which discourage people who use
drugs from receiving hepatitis C treatment. These barriers include those to do
with the individual (for example, mistrust of healthcare professionals, limited
knowledge and concern about treatment side-effects) and barriers at the level
of the healthcare provider (for example, perceptions of the patients’ readiness
or eligibility for treatment or concerns about ongoing substance use). The
availability of interferon-free hepatitis C treatments can help remove some of
these barriers, and others can be worked on, she suggested.
However the social and structural barriers are deeply
entrenched and are rarely mentioned by proponents of hepatitis C treatment as
prevention. These barriers include homelessness, poverty, stigma,
marginalisation, criminalisation, limited social support, problems with health
insurance or coverage, and alienating and confusing health care systems.
Magdalena Harris said that an enabling treatment environment
would be needed. Her numerous qualitative studies with people who inject drugs
suggested the potential of bringing hepatitis C treatment into community
settings, with peer support as part of a holistic package. Services need to be
trusted, familiar, accessible and convenient.
Services characterised by surveillance, punishment and
social control do not generate trust and would be inappropriate settings for
treatment as prevention. As well as prisons, this includes methadone clinics
which patients must attend every day and be observed taking their treatment.
An enabling policy environment would include the
availability of other harm reduction interventions. However Harris said that
many discussions of treatment as prevention strategies have ignored the
existence of other prevention methods, or the potential of scaling them up to
an adequate level of coverage. Globally only 8% of all people who inject drugs
are estimated to have access to harm reduction programmes of any sort, and on
average each injector only receives two needles and syringes per month.
“In this context, providing a treatment as prevention
strategy is frankly laughable,” she said. “Treatment as prevention can only be
effective and ethical in a context of scale-up of prevention as prevention.”
An enabling policy environment would also encompass
far-reaching progress on human rights and reform of drug policy, she argued. The
criminalisation of drug use creates far-reaching social stigma, discourages
people from identifying their needs at health services, and is often the cause
of treatment interruptions.
In terms of policy, the excessive cost of the newer,
interferon-free hepatitis C treatments also make massive provision of the drugs
hard to imagine. Advocacy and activism to improve access is required. (In fact,
just a few minutes after Harris’ presentation, protestors at the conference
called for compulsory licensing and affordable generic versions of hepatitis C
drugs in middle-income countries such as Malaysia.)
'Treatment as
prevention' could be used as an advocacy tool in order to achieve
universal access to hepatitis C drugs, regardless of injecting status or
disease progression.
“We need more community engagement and advocacy in order for
treatment as prevention to become a reality and to be acceptable and ethical
for the affected community,” she concluded.