CommentaryTen priorities for expanding access to HCV treatment for people who inject drugs in low- and middle-income countries
Introduction
Of the estimated 130–150 million people who are chronically infected with hepatitis C virus, around 90% reside in low- and middle-income countries (Mohd Hanafiah, Groeger, Flaxman, & Wiersma, 2013). People who inject drugs are disproportionately affected by HCV, with a global estimated prevalence of 67%; world-wide over 10 million people who inject drugs are estimated to be infected with HCV (Aceijas and Rhodes, 2007, Nelson et al., 2011), compared to around 1.7 million with living HIV (UNODC, 2014); this number is far higher if individuals with HCV who have either temporarily or permanently ceased injecting drugs are included. Around half of the world's estimated 12.7 million (range 8.9–22.4 million) people who inject drugs live in low or middle income countries, including 1 million in Africa, 1.1 million in Latin America and the Caribbean, and 4.7 million in Asia (UNODC, 2014). In these countries, health budgets are generally limited, there is a lack of appropriate diagnostics and drugs, health insurance mechanisms are often inadequate and, as a consequence, out-of-pocket healthcare payments are common.
The World Health Organization (WHO) identifies people who inject drugs as a key target group for HCV screening, prevention and treatment (WHO, 2010). Considering that the majority of people with HCV who inject drugs reside in low- and middle-income settings, improving access to HCV diagnosis and treatment for this priority group will require ensuring access to affordable treatment delivered through models of care that are adapted to settings with limited health resources.
Until recently, the standard treatment for HCV comprised 6–12 months of pegylated-interferon and ribavirin, which is associated with frequent and sometimes severe side-effects and low rates of treatment success. The arrival of new direct acting antivirals (DAAs) is stimulating considerable efforts to scale up access to treatment. The DAAs are administered for a shorter time, have fewer side effects, and high rates of treatment success, allowing for effective public policy action to address the large burden of HIV in resource-limited settings (Ford et al., 2014).
In 2014 Member States of the WHO endorsed a resolution requesting WHO to examine the feasibility of and strategies needed for the elimination of HCV with a view to setting global targets for treatment and care (WHO, 2014c). Modeling studies have suggested that improved access to effective HCV treatment can reduce the prevalence of HCV among people who inject drugs (Durier et al., 2012, Martin et al., 2011). Modelling has also suggested that prioritizing people who inject drugs for treatment will substantially impact incident transmission as in many countries the majority of incident infections occur among people who inject drugs. In contrast, prioritizing people with moderate/advanced fibrosis has the greatest impact on severe liver mortality but is suboptimal in terms of averting incident infection (Innes, Goldberg, Dillon, & Hutchinson, 2014). However, while treatment efficacy, defined as sustained virological suppression (SVR), now exceeds 90%, treatment coverage is less than 10% in most countries (Grebely & Dore, 2014), and coverage for people who inject drugs is generally lower than for the general population (Mathers et al.), with some studies estimating that less than 2% of people who inject drugs are receiving treatment (Alavi et al., 2014, Iversen et al., 2014). According to one recent report, around 2 million people who inject drugs globally are estimated to need treatment for HCV, based on current clinical criteria (Medecins du Monde/International Network of People who use Drugs, 2014).
Drawing on lessons learnt from scaling up access to HIV treatment in low- and middle income countries, this article outlines ten key priorities for expanding access to HCV treatment for people who inject drugs.
Section snippets
Affordable access to direct acting antivirals
WHO guidelines make clear that people should not be excluded from HCV treatment programmes on the basis of injecting drug use, but such exclusion persists, either directly or because they are considered ineligible for health insurance (WHO, 2014a). Reasons cited for limiting access to treatment for people who inject drugs included concerns about poor adherence, increased susceptibility to side effects, risk of reinfection, and financial constraints. For people who inject drugs, fear of side
Increased awareness and testing
A recent study among people who inject drugs in India found that more than half of the study population had not heard of HCV despite infection rates of over 30% in this population; this low level of knowledge translated into low testing rates and consequently poor awareness of HCV status in those who were infected (Solomon et al., 2015). Low levels of awareness about HCV have been reported in other settings (Ti et al., 2013, Treloar et al., 2011).
WHO and other key United Nations agencies
Standardization of treatment
After decades of neglect, there is now a rich pipeline of novel therapies in development for HCV, with over 25 new drugs and combinations in development as of the end of 2014. While renewed innovation is welcome, the delivery of HCV treatment at scale in resource-limited settings will likely be facilitated by the prioritization of a limited number of key drugs to standardize treatment. In the case of HIV, global treatment guidelines have evolved over the last decade from recommending eight
Simplification of service delivery
Traditional models of HCV treatment delivery rely on specialist clinicians in secondary and tertiary centres, with interferon injections often administered as directly observed therapy. The numerous side effects of interferon and ribavirin, and high failure rates associated with certain genotypes has led to a reliance on multiple laboratory investigations including baseline genotyping, frequent viral load testing, and full blood chemistry measures to guide therapy and support decisions to stop
Integration of services
Many individuals with HCV are lost along the cascade of care from diagnosis to sustained virological suppression (Yehia, Schranz, Umscheid, & Re, 2014). Integration of services is an important way to increase access to HCV treatment and care, and can reduce the risk of loss to follow up by reducing the need to transfer between services to receive treatment and care. Successful models of integration of HCV care within different services have been documented, including opioid substitution
Peer support
The low uptake of HCV services has been partly explained by stigma, discrimination, criminalization of drug use, and lack of trust between patients and health workers. Peer support has been put forward as one way to overcome these barriers (Crawford & Bath, 2013).
Peer support is associated with improved uptake of and outcomes on treatment for a number of infectious and non-communicable diseases, including HIV/AIDS (Mills et al., 2014), drug-resistant tuberculosis (Horter, Stringer, Venis, & Du
Treatment within a framework of comprehensive prevention
Concern about HCV reinfection among people who inject drugs has been cited as a reason why treatment has been held back. Rates of reinfection have been found to be relatively low (Grady et al., 2013), with one recent meta-analysis estimating a reinfection rate of just over 2% a year over five years (Hill, Simmons, Saleem, & Cooke, 2015). Although reinfection rates in the setting of IFN-free therapy have been low, most of these studies were retrospective and included patients who were more
Tracking progress
In public health, what gets measured gets done (Chan, 2007). Global estimates of the number of people who inject drugs is limited, in particularly in the Caribbean and sub-Saharan Africa region, where only a minority of countries report data. Where data do exist, there are issues of inconsistency in definitions used in prevalence estimations that make between-country comparisons difficult (Mathers et al., 2008). Similarly, only a quarter of countries report prevalence estimates for HCV among
Increased funding to support scale up of treatment
The arrival of highly active antiretroviral therapy for HIV in 1996 changed the prognosis from a few additional life years to the management of HIV as a chronic disease. However, the initial cost of treatment was prohibitive, and cost effectiveness analyses concluded that funding should be directed at prevention rather than treatment (Marseille, Hofmann, & Kahn, 2002). As prices came down, donors began to support treatment – some later admitting to have delayed doing so for too long (Boseley,
Enabling policies
The DAAs will facilitate HCV treatment scale-up for people who inject drugs, but the benefits of these medications are limited by numerous structural barriers to health care for people who inject drugs, including stigma, poverty, homelessness, criminalization and mass incarceration. Unless tensions are resolved between the public health approach, which views drug dependence as a chronic, relapsing condition, and the public security agenda, which applies criminal and administrative penalties to
Conclusions
The scale up of HIV treatment over the last decade is viewed as one of the most successful programmes in global health. From this experience, a number of important lessons can be applied to rapidly expand access to effective screening, care and treatment of HCV and other epidemic infectious diseases in low- and middle-income countries. The DAAs offer significant potential to rapidly expand access to treatment for HCV. The first critical step will be to ensure access at an affordable price.
Acknowledgement
We would like to thank Nick Walsh for providing valuable comments on an earlier draft of this manuscript.
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