Hepatitis C treatment and prevention failing to reach people most affected

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 are chronically infected 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. These included:

  • Widespread lack of needle and syringe programming and opioid substitution treatment, both proven to reduce the risk of hepatitis C transmission.
  • Lack of attention to people who inject drugs in national viral hepatitis elimination plans and lack of involvement of key populations including people who inject drugs.
  • Treatment guidelines still require abstinence from active drug use to obtain hepatitis C treatment despite evidence from clinical trials of high cure rates in active drug users.
  • Hepatitis C treatment out of reach of drug users due to lack of health insurance and high out-of-pocket costs of treatment.
  • Poor treatment uptake among people who inject drugs due to criminalisation of drug use, stigmatisation and lack of testing and treatment 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.

Increase in clean needle and syringe provision essential for hepatitis C elimination

Elimination of hepatitis C will not be achievable without substantial improvements in provision of sterile injecting equipment, Dr Magdalena Harris of the London School of Hygiene and Tropical Medicine told a conference on hepatitis C elimination in London last month.

Current estimates of 'high' coverage don’t reflect the realities of drug users’ lives and statistics on needle exchange services in London have not been updated since 2007, meaning that funders and policy makers have no idea whether services in London are providing adequate numbers of needles and syringes to people who inject drugs in the capital, she warned.

Needle and syringe programmes have been shown to reduce hepatitis C transmission among people who inject drugs. Provision of sterile injecting equipment through needle and syringe programmes is recommended as a core intervention for prevention of hepatitis C by the World Health Organization (WHO).

WHO has set a target for distribution of sterile injecting equipment to people who inject drugs. By 2020, every person who injects drugs should receive at least 200 needle and syringe sets per year, and this should rise to 300 sets per year by 2030. WHO estimated that on average, just 20 sets of needles and syringes reached each person who injected drugs in 2014.

But are these targets adequate? Dr Harris pointed out that 200 needles and syringes per year is the equivalent of 3.85 per week. According to Public Health England, only three in five people who injected drugs in England and Wales reported having sterile injecting equipment for each injection in 2018, and 80% in Scotland.

Dr Harris said there is a disconnect between policy on needle and syringe provision and the realities of drug users’ lives.

Half of people who inject drugs in Middle East have hepatitis C

Half of people who inject drugs in the Middle East and north Africa have been infected with hepatitis C, and researchers from Weill Cornell Medicine Qatar estimate that around 221,000 people who inject drugs in the region have chronic hepatitis C infection, a review published in the journal Addiction reports.

Hepatitis C infection is endemic in north Africa and the Middle East. One in five of the global population with hepatitis C live in the region, with Egypt severely affected. The region comprises 24 countries stretching from Pakistan to Morocco and includes some of the world’s major drug production sites and trafficking routes.

Several countries in the region are already engaged in ambitious efforts to eliminate hepatitis C but to achieve elimination, targeted testing and treatment will be needed, as well as enhanced prevention measures.

Prevalence among drug users ranged from 21% in Tunisia and 25% in Lebanon to 56% in Pakistan, 52% in Iran and 94% in Libya. Insufficient data were available to produce estimates for Algeria, Bahrain, Djibouti, Iraq, Jordan, Kuwait, Mauritania, Somalia, Sudan, United Arab Emirates or Yemen.

Across the region the average prevalence of hepatitis C was 49% and the investigators used this average and country-level estimates to calculate that 221,000 people who inject drugs in the region have chronic hepatitis C. The countries with the largest number of chronic infections are Algeria (14,220), Morocco (6718), Iran (68,526) and Pakistan (46,444). The much lower numbers in many other countries is an opportunity for affordable elimination.

Lack of harm reduction services in the region means that hepatitis C will continue to spread among people who inject drugs. Non-governmental organisations in Morocco, Iran and Lebanon have developed harm reduction services but these services need to be scaled up and backed by national policies on harm reduction provision. Testing and treatment also need to be scaled up, especially in prisons, say the investigators.

90% of injection drug users miss opportunities for HIV or HCV testing

Around 90% of people who inject drugs in the United States missed opportunities for HIV or hepatitis C virus (HCV) testing between 2010 and 2017, a review of more than 840,000 healthcare visits shows. Men in rural America seeking care for skin infections or endocarditis were most likely to miss out on testing.

The study looked at commercial health insurance databases to identify people with probable markers of injecting drug use including overdose, endocarditis, skin infections or abscesses, substance use or prescription of opioid substitutes, naltrexone or naloxone. They calculated the likelihood of testing for hepatitis C according to demographic factors.

Only 8% had been tested for HIV and a similar proportion had been tested for hepatitis C. Testing for either virus was more likely to have occurred at medical visits to specialist services such as substance use treatment and less likely to occur in general medical practice visits.

People outside the north-eastern United States were less likely to have been tested and people living in rural areas were less likely to have been tested for hepatitis C despite the fact that approximately one in three acute hepatitis C infections are estimated to occur in rural counties in the United States.

In an accompanying editorial in the Journal of Infectious Diseases, Benjamin Linas of Boston University School of Medicine proposes that venue-based testing might be an effective way of increasing the proportion of people who inject drugs who are tested for hepatitis C and HIV.

Routine testing of everyone who attends an addiction treatment clinic, a needle and syringe programme or a residential drug detoxification clinic would increase the number of people tested and would be more effective than risk-based testing in the United States, he argues. “Risk-based targeted testing does not work. Many times, providers do not identify the risk behavior.” What’s more, routine one-time testing does not address the needs of people at ongoing risk of infection.

“One thing is clear—we cannot end any epidemic among PWID [people who inject drugs] unless we take concrete steps to address underperformance in identifying and treating new infections. It is time for a new approach to HIV and HCV testing among PWID,” Dr Linas concludes.

Hepatitis B treatment suboptimal in people with HIV in Africa

Testing for chronic hepatitis B infection was very low in people living with HIV in Cameroon, a country with a high burden of hepatitis B, and suppression of hepatitis B virus was suboptimal in people with HIV on antiretroviral therapy, Cameroonian and French researchers report in BMC Infectious Diseases.

Medicines Patent Pool and Mylan sign agreement to scale up access to first generic version of hepatitis C treatment glecaprevir/pibrentasvir

The Medicines Patent Pool announced last week that it signed a sublicence agreement and partnered with Mylan, a global pharmaceutical company, to develop, manufacture and supply the first generic version of glecaprevir/pibrentasvir – a World Health Organization (WHO)-recommended treatment for hepatitis C virus (HCV) infections.

Glecaprevir/pibrentasvir is the only all oral, once-daily pangenotypic combination regimen recommended by WHO that is currently not available as a generic medicine. The two organisations have entered an agreement to undertake glecaprevir/pibrentasvir manufacturing henceforth and boost the supply to make it accessible to people with hepatitis C.

“We are pleased that, thanks to this sublicence agreement, Mylan will soon be able to increase access to the first generic version of G/P [glecaprevir/pibrentasvir] in developing countries, and supply affordable, quality-assured versions of this key treatment for treating HCV,” said Charles Gore, Medicines Patent Pool Executive Director.

In November 2018, Medicines Patent Pool signed a royalty-free licence agreement with patent holder AbbVie to enable quality-assured manufacturers to develop and sell generic medicines containing glecaprevir/pibrentasvir in 96 low- and middle-income countries and territories at affordable prices.

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