Low rates of hepatitis C testing among people who inject drugs in Thailand: implications for peer-based interventions

Investigating the sociodemographic and behavioural factors associated with hepatitis C virus testing amongst people who inject drugs in England, Wales and Northern Ireland: A quantitative cross-sectional analysis

BACKGROUND

Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year).

METHODS

We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression.

RESULTS

Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67).

CONCLUSION

Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

The cost of community outreach HIV interventions: a case study in Thailand

BACKGROUND

There was an estimated 440,000 people living with HIV in Thailand in 2018. New cases are declining rapidly thanks to successful prevention programs and scaling up of anti-retroviral therapy (ART). Thailand aims to achieve its commitment to end the HIV epidemic by 2030 and implemented a cascade of HIV interventions through the Reach-Recruit-Test-Treat-Retain (RRTTR) program.

METHODS

This study focused on community outreach HIV interventions implemented by Non-Governmental Organizations (NGOs) under the RRTTR program in 27 provinces. We calculated unit cost per person reached for HIV interventions targeted at key-affected populations (KAPs) including men who have sex with men/ transgender (MSM/TG), male sex workers (MSW), female sex workers (FSW), people who inject drugs (PWID) and migrants (MW). We studied program key outputs, costs, and unit costs in variations across different HIV interventions and geographic locations in Thailand. We used these estimates to determine costs of HIV interventions and evaluate economies of scale.

RESULTS

The interventions for migrants in Samut Sakhon was the least costly with a unit cost of 21.6 USD per person to receive services, followed by interventions for migrants in Samut Prakan 23.2 USD per person reached, MSM/TG in Pratum Thani 26.5USD per person reached, MSM/TG in Nonthaburi 26.6 USD per person reached and, MSM/TG in Chon Buri with 26.7 USD per person. The interventions yielded higher efficiency in large metropolitan and surrounding provinces. Harm reduction programs were the costliest compare with other interventions. There was association between unit cost and scale of among interventions indicating the presence of economies scale. Implementing HIV and TB interventions jointly increased efficiency for both cases.

CONCLUSION

This study suggested that unit cost of community outreach HIV and TB interventions led by CSOs will decrease as they are scaled up. Further studies are suggested to follow up with these ongoing interventions for identifying potential contextual factors to improve efficiency of HIV prevention services in Thailand.

Knowledge, attitude, and behaviors toward liver health and viral hepatitis-related liver diseases in Thailand

This study aimed to quantify and evaluate the knowledge and awareness toward liver health and diseases as well as explore the attitudes and knowledge toward screening, diagnosis, and treatment of liver disease among the Thai population.This is a cross-sectional, self-reported and web-based questionnaire study. Awareness, perceptions and attitudes toward liver-related health and diseases as well as screening, diagnosis and treatment of liver diseases were assessed among 500 Thai adults.Respondents were mostly ≥35 years (62.0%) and females (52.0%). While there was an overall awareness regarding viral hepatitis as the main etiology of liver failure/cancer, respondents expressed misperceptions that hint at social stigmatization or discrimination toward infected individuals. A significant proportion lacked knowledge of liver screening tests and relevant diagnostic tests for viral hepatitis-related liver diseases. Screening or treatment costs and perception of being healthy were among reasons for not seeking medical consultation when exposed to risk factors or diagnosed. Treatment practices of hepatitis included prescription medication (59.1%), functional foods (51.8%) and traditional treatment (28.2%). Multivariate analysis identified income, recent health screening status and being diagnosed with liver disease(s) as significant predictors of the knowledge, attitude, and behaviors of the Thai population toward liver diseases.This study highlighted a degree of misperception and lack of in-depth understanding toward hepatitis-related liver diseases including poor attitudes and knowledge toward screening, diagnosis, and treatment of liver diseases. Factors identified suggest an unmet need to encourage proactive health-seeking behaviors to reduce transmission risks of hepatitis-related liver diseases within the community.

Improving access to the treatment of hepatitis C in low- and middle-income countries: evaluation of a patient assistance programme

Background Modern antiviral treatments have high cure rates against the hepatitis C virus however, the high cost associated with branded medicines and diagnostic tests, have resulted in poor access for many low-income patients residing in low-and-middle-income countries. Objective This study aimed to evaluate the role of a patient assistance programme and generic medicines in improving access to treatment of low-income hepatitis C patients in a low-and-middle-income country. Setting A major teaching public hospital in Islamabad, Pakistan. Methods Hepatitis C patients who presented and enrolled for the patient assistance programme during 12 months (1st July 2015 and 30th June 2016) were included. Demography, prescription characteristics, the total costs of Hepatitis C treatment, medicine cost supported by the programme, out-of-pocket cost borne by the patient and average cost effectiveness ratio per sustained virologic response were calculated and compared for different generic and branded regimens. Main outcome measure cost contribution of patient assistance programme. Results A total of 349 patients initiated the treatment through the programme and of those 334 (95.7%) completed the prescribed treatment. There were 294 (88.02%) patients who achieved sustained virologic response. Patient assistance programme contributed medicines cost averaging 60.28-86.26% of the total cost of treatment ($1634.6) per patient. The mean (SE) cost per patient for generic option (Sofosbuvir/Ribavirin) was the lowest [$658.36 (22.3) per patient, average cost effectiveness ratio = $720.1/SVR] than branded option (Sovaldi/Ribavirin) [$2218.66 (37.6) per patient, average cost effectiveness ratio = $2361.8/SVR] of the three available treatment regimens. From patients' perspectives, the mean (SE) out-of-pocket cost was $296.9 (6.7) which primarily included diagnostic cost (69.9%) of the total cost. Conclusions Patient assistance programme, combined with generic brands of newer hepatitis C treatment offered a significant reduction in cost and widens access to hepatitis C treatment in low-and middle-income countries. However, substantial out-of-pocket costs of the treatment presents an important barrier for service access. There is a scope to widen such financial assistance programme to offer other costs attributed to patients, specifically for diagnosis, to widen service use in low-and-middle-income countries.

Association Between Opioid Agonist Therapy and Testing, Treatment Uptake, and Treatment Outcomes for Hepatitis C Infection Among People Who Inject Drugs: A Systematic Review and Meta-analysis

BACKGROUND

People who inject drugs (PWID) experience barriers to accessing testing and treatment for hepatitis C virus (HCV) infection. Opioid agonist therapy (OAT) may provide an opportunity to improve access to HCV care. This systematic review assessed the association of OAT and HCV testing, treatment, and treatment outcomes among PWID.

METHODS

Bibliographic databases and conference presentations were searched for studies that assessed the association between OAT and HCV testing, treatment, and treatment outcomes (direct-acting antiviral [DAA] therapy only) among PWID (in the past year). Meta-analysis was used to pool estimates.

RESULTS

Of 9877 articles identified, 22 studies conducted in Australia, Europe, North America, and Thailand were eligible and included. Risk of bias was serious in 21 studies and moderate in 1 study. Current/recent OAT was associated with an increased odds of recent HCV antibody testing (4 studies; odds ratio (OR), 1.80; 95% confidence interval [CI], 1.36-2.39), HCV RNA testing among those who were HCV antibody-positive (2 studies; OR, 1.83; 95% CI, 1.27-2.62), and DAA treatment uptake among those who were HCV RNA-positive (7 studies; OR, 1.53; 95% CI, 1.07-2.20). There was insufficient evidence of an association between OAT and treatment completion (9 studies) or sustained virologic response following DAA therapy (9 studies).

CONCLUSIONS

OAT can increase linkage to HCV care, including uptake of HCV testing and treatment among PWID. This supports the scale-up of OAT as part of strategies to enhance HCV treatment to further HCV elimination efforts.

Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries

Introduction

Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic.

Methods

Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts.

Results

Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as ‘bridge’ and ‘role model’ processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and ‘bridge’ mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O).

Conclusion

Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.

Reported Low Uptake of HCV Testing among People Who Inject Drugs in Urban Vietnam

Background

HCV testing is an important first step for treatment and prevention, particularly for those who are highly vulnerable to HCV infection such as people who inject drugs (PWID). In settings where direct-acting antiretroviral medicines are becoming more available, limited information exists about who and where to target to increase the prevalence of HCV testing among PWID. This study is aimed at understanding the prevalence of HCV testing uptake and its determinants of medical services and risk behaviors.

Methods

From February 2016 to April 2017, a sample of 509 PWID was interviewed using a structured questionnaire on their history of HCV testing, confirmation, services using in the previous year as well as HCV-related knowledge, and risk behaviors. Multiple logistic regression identified factors associated with ever being tested for HCV before enrollment in the program.

Results

Approximately 33% reported ever testing for HCV. Most cited sources of testing are public hospitals and general clinics (68.9%) and outpatient clinics (18.9%). Having ever tested for HCV was positively associated with accessing health services within the prior 12 months (aOR = 2.25; 95% CI 1.11-4.58), being currently enrolled in a methadone treatment program (aOR = 2.35; 95% CI 1.34-4.08), and/or on ART treatment (aOR = 2.30; 95% CI 1.30-4.08). Those who ever delayed in seeking healthcare services for any reason were less likely to get tested for HCV (aOR = 0.54; 95% CI 0.35-0.84).

Conclusion

HCV testing prevalence is low among PWID in Hanoi despite a very high prevalence of HCV infection. To improve the cascade of HCV testing, it is critical that intervention programs scale up linkages among methadone, outpatient clinics, and HCV services, take steps to reduce stigma and discrimination in both community and, especially, in health care settings, and increase awareness of HCV for PWID by integrating HCV into routine counseling at health care services.

Risky injection practices and HCV awareness in Chiang Mai Province, Thailand: a respondent-driven sampling study of people who inject drugs

Background

People who inject drugs (PWID) are the most exposed to hepatitis C virus (HCV). In Thailand, drug use is highly criminalized, and harm reduction services are scarce. This study estimates risky injection practices and assesses the proportion of HCV awareness and screening in the PWID population in Northern Thailand.

Methods

We used respondent-driven sampling (RDS) to recruit PWID in Chiang Mai Province. Social and behavioural data were collected through face-to-face interviews at an addiction treatment facility. Weighted population estimates were calculated to limit biases related to the non-random sampling method. Univariate and multivariate analyses were performed to study factors associated with HCV awareness and screening.

Results

One hundred seventy-one PWID were recruited between April 2016 and January 2017. Median age was 33 (Interquartile range: 26–40) years, 12.2% were women, and 49.4% belonged to a minority ethnic group. Among participants, 76.8% injected heroin, 20.7% methadone, and 20.7% methamphetamine. We estimate that 22.1% [95% CI: 15.7–28.6] of the population had shared needles in the last 6 months and that 32.0% [95% CI: 23.6–40.4] had shared injection material. Only 26.6% [95% CI: 17.6–35.6] had heard of HCV. Factors independently associated with knowledge of HCV included belonging to a harm reduction organization (adjusted odds ratio (aOR) = 5.5 [95% CI: 2.0–15.3]) and voluntary participation in a drug rehabilitation programme (aOR = 4.3 [95% CI: 1.3–13.9]), while Lahu ethnicity was negatively associated (aOR = 0.3 [95% CI: 0.1–0.9]). We estimate that 5% of the PWID population were screened for HCV; the only factor independently associated with being screened was membership of a harm reduction organization (aOR = 5.7 [95% CI: 1.6–19.9]).

Conclusion

Our study reveals that the PWID population is poorly informed and rarely screened for HCV, despite widespread risky injection practices. A public health approach aimed at reducing the incidence of HCV should target the PWID population and combine harm reduction measures with information and destigmatization campaigns. Civil society organizations working with PWID are a major asset for the success of such an approach, based on their current positive interventions promoting awareness of and screening for HCV.

Prevalence and high risk behaviours associated with HCV testing among people who inject drugs: a systematic review and Meta-analysis

BACKGROUND

Hepatitis C diagnosis could be a gateway to behavioral change and subsequent decline in transmission among people who inject drugs (PWIDs). We assessed the association between the social determinants of PWID, their risk behaviors and hepatitis C testing.

METHODS

We searched for studies in English published before May 1, 2020, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with hepatitis C virus (HCV) testing among PWID. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. i) population: individuals who report injecting drugs; ii) intervention: HCV testing in the past year; iii) comparator: PWIDs who did not have an HCV test; iv) outcome: HCV testing among PWIDs and v) study type: cross-sectional, cohort, and case-control studies. Two independent reviewers (author BA and AB) chose the references in a two-phased monitoring process. The authors gathered data from selected papers, including the surname of the first author, publication date, participant demographic data (age, sex, and level of education) and other characteristics like previous HCV testing, past treatment attempts, duration of injecting drug use and condomless sex. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR), and 95% confidence intervals. The data were analyzed using Stata 12.0 software.

RESULTS

After a detailed assessment of over 12,000 articles, a total of 16 studies containing 38,952 participants met the eligibility criteria. Our findings showed a pooled prevalence rate of 61.01% (95% CI, 34.65-84.32%) for recent HCV testing among PWIDs. Being female (OR = 1.69, 95%CI = 1.13, 2.26), aged > 30 years, (OR = 2.61, 95%CI = 1.66-3.56) having past treatment attempt (OR = 2.24, 95%CI = 1.80-2.68), and reporting a previous test (OR = 2.03, 95%CI = 1.23-2.82). were significantly associated with having a recent HCV test.,,. Finding of present study was that unprotected sex had a negative association with HCV testing. Those PWIDs who had unprotected sex were 0.56 times less likely to have completed HCV testing during last year (OR = 0.56, 95%CI = 0.33-0.78).

CONCLUSION

Prevention programs that address age > 30 years, being female, past treatment attempt, previous testing of safe sexual practices, are strongly recommended to prioritize HCV risk reduction strategies.

Factors associated with HCV test uptake in heroin users entering substitution treatment in Greece

OBJECTIVES

People who inject drugs (PWID) represent the main risk group for hepatitis C virus (HCV) infection in most middle and high-income countries. Testing PWID is considered as an important prevention measure. Identification of PWID characteristics associated with HCV testing may contribute to strategies targeting the containment of the HCV and HIV epidemics in Greece.

METHODS

Anonymous behavioural data from 2747 heroin users were collected upon entry in 38 opioid substitution treatment (OST) clinics in Greece during the period 2013-2015. HCV test uptake was the dependent variable while covariates included sociodemographic and addiction-related variables, mostly derived from the EMCDDA treatment demand indicator protocol.

RESULTS

Among 2299 cases with complete data on HCV testing, 83.5% reported any HCV testing uptake, with 61.2% reporting a recent test (< 12 months). In the multivariate analyses, any previous HCV testing uptake was associated with age ≥ 25 years, past drug treatment attempt, injecting or sniffing the primary substance, injection history ≥ 5 years, and syringe sharing earlier than the past 12 months. Past HCV test uptake was higher among those reporting full-time employment and 2-4 years injecting histories, and lower among residents of Athens. Recent testing was positively associated with female gender and polysubstance use.

CONCLUSION

Any previous HCV testing uptake is high among PWID entering OST in Greece and is associated with older age, longer injecting histories and past drug-related treatment attempts. Efforts to prevent and mitigate the ongoing HCV test epidemic among PWID in Greece should combine treatment with scaling up of screening, targeting especially those younger than 25 years and at the beginning of their hazardous use.

Hepatitis C virus status awareness and test results confirmation among people who inject drugs in Ukraine

BACKGROUND

Among the estimated 340,000 people who inject drugs (PWID) in Ukraine, HCV prevalence is approximately 70%. As HCV treatment availability increases, an assessment of the HCV treatment cascade is needed to guide HCV prevention and treatment strategies.

METHODS

Opioid dependent PWID were interviewed and tested for HIV and HCV in five Ukrainian cities from January 2014 to March 2015. Logistic regression was used to examine the independent correlates of two cascade steps: a) anti-HCV positive status awareness; b) chronic HCV confirmation; and of c) annual HCV testing for PWID.

RESULTS

Among 1613 PWID, 1002 (62.1%) had anti-HCV positive test result, of which 568 (56.7%) were aware of it before the study and 346 (34.5%) reported previous confirmatory testing for chronic HCV. Independent correlates of being aware they had anti-HCV positivity included: current [AOR: 3.08; 95%CI: 2.16-4.40] or prior [AOR: 1.85; 95%CI: 1.27-2.68] opioid agonistic treatment (OAT) experience, relative to no prior OAT, living in Lviv [AOR: 0.50; 95%CI: 0.31-0.81] or Odesa [AOR: 2.73; 95%CI: 1.51-4.93] relative to Kyiv and being aware of having HIV [AOR: 4.10; 95%CI: 2.99-5.62]. Independent correlates of confirming HCV infection among those who were aware of their anti-HCV positive status included: current OAT [AOR: 2.00; 95%CI: 1.24-3.23], relative to prior OAT, the middle income category [AOR: 1.74, 95%CI: 1.15-2.63], relative to the lowest, and receiving ART [AOR: 4.54; 95%CI: 2.85-7.23]. Among 1613 PWID, 918 (56.9%) were either HCV negative or not aware of their HCV positive status, of which 198 (21.6%) reported recent anti-HCV test (during last 12 month). Recent anti-HCV test in this group was associated with current [AOR: 7.17; 95%CI: 4.63-11.13] or prior [AOR: 2.24; 95%CI: 1.32-3.81] OAT experience, relative to no prior OAT.

CONCLUSION

Encouraging PWID to participate in OAT may be an effective strategy to diagnose and link PWID who are HCV positive to care. Among HIV negative participants, regular HCV testing may be ensured by participation in OAT. More studies are needed to assess HCV treatment utilization among PWID in Ukraine and OAT as a possible way to retain them in treatment.

Pilot Study: Combining Formal and Peer Education with FibroScan to Increase HCV Screening and Treatment in Persons who use Drugs

BACKGROUND

Treatment uptake for hepatitis C virus (HCV) infection remains low in persons who inject drugs (PWID), due to lack of knowledge and low perceived need for treatment. Therefore, we conducted a pilot study to assess the influence on knowledge and willingness for HCV screening and treatment among persons who use drugs (PWUD) by combining formal and peer education with FibroScan measurement.

METHODS

Clients of the Center for Alcohol and other Drug problems (CAD) in Limburg (Belgium) were randomized into a control group, which received the standard of care, and an intervention group, which received an innovative combination of formal and peer education followed by FibroScan. Knowledge of HCV infection and willingness for screening and treatment were evaluated at baseline, after intervention and 1 and 3months after intervention by means of questionnaires.

RESULTS

Baseline knowledge was similar for the control (n=27) and the intervention group (n=25) (58 vs. 59%; p=0.67). Immediately after the information session, knowledge increased to 86% (p<0.001) in the intervention group. After 3months, knowledge decreased significantly (69%; p=0.01). No significant changes in knowledge were found in the control group. Baseline willingness for treatment was 81% in both the control and intervention groups, but after 1 month decreased in the control group (44%) and remained stable in the intervention group (75%). Differences in actual screening uptake between the control and intervention group were not significant (7% vs. 20%). Four percent of the intervention group and no one in the control group started treatment.

CONCLUSION

The small number of subjects should be considered when interpreting the results of this study. In brief, the single information session significantly improved HCV knowledge among PWUD, but did not result in a higher uptake for screening and treatment. This could signify that there are other important reasons, besides lack of knowledge, not to undergo screening or start treatment. The fact that knowledge decreased after 3months indicates that it would be beneficial to repeat the information session regularly.

Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives

BACKGROUND

People who inject drugs have been central to the development of harm reduction initiatives. Referred to as peer workers, peer helpers, or natural helpers, people with lived experience of drug use leverage their personal knowledge and skills to deliver harm reduction services. Addressing a gap in the literature, this systematic review focuses on the roles of people who inject drugs in harm reduction initiatives, how programs are organized, and obstacles and facilitators to engaging people with lived experience in harm reduction programs, in order to inform practice and future research.

METHODS

This systematic review included searches for both peer reviewed and gray literature. All titles and abstracts were screened by two reviewers. A structured data extraction tool was developed and utilized to systematically code information concerning peer roles and participation, program characteristics, obstacles, and facilitators.

RESULTS

On the basis of specific inclusion criteria 164 documents were selected, with 127 peer-reviewed and 37 gray literature references. Data extraction identified key harm reduction program characteristics and forms of participation including 36 peer roles grouped into five categories, as well as obstacles and facilitators at systemic, organizational, and individual levels.

CONCLUSIONS

Research on harm reduction programs that involve people with lived experience can help us better understand these approaches and demonstrate their value. Current evidence provides good descriptive content but the field lacks agreed-upon approaches to documenting the ways peer workers contribute to harm reduction initiatives. Implications and ten strategies to better support peer involvement in harm reduction programs are identified.

Ten priorities for expanding access to HCV treatment for people who inject drugs in low- and middle-income countries

Of the estimated 130-150 million people who are chronically infected with hepatitis C virus, around 90% reside in low- and middle-income countries. People who inject drugs are disproportionately affected by HCV, with a global estimated prevalence (based on serological reports of HCV antibodies) of 67%; world-wide over 10 million people who inject drugs are infected with HCV. Treatment for HCV has improved dramatically in recent years with the arrival of new direct acting antivirals (DAAs) and this is stimulating considerable efforts to scale up access to treatment. However, treatment coverage among the general population is less than 10% in most countries, and coverage for people who inject drugs is generally much lower. It is estimated that globally around 2 million people who inject drugs need treatment for HCV. The DAAs offer significant potential to rapidly expand access to treatment for HCV. While the ideal combination therapy remains to be established, key characteristics include high efficacy, tolerability, pan-genotypic activity, short treatment duration, oral therapy, affordability, limited drug-drug interactions, and availability as fixed-dose combinations and once daily treatments. This paper outlines 10 key priorities for improving access to HCV treatment for people who inject drugs: (1) affordable access to direct acting antivirals; (2) increased awareness and testing; (3) standardization of treatment; (4) simplification of service delivery; (5) integration of services; (6) peer support; (7) treatment within a framework of comprehensive prevention; (8) tracking progress; (9) dedicated funding; and (10) enabling policies.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection

In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.