Commentary
The promise of treatment as prevention for hepatitis C: Meeting the needs of people who inject drugs?

https://doi.org/10.1016/j.drugpo.2015.05.005Get rights and content

Highlights

  • We critically appraise the promise of HCV treatment as prevention (TasP) for PWID.

  • TasP has potential to be a powerful HCV treatment access advocacy tool for PWID.

  • There is a need to be cognisant of and address PWID community concerns about TasP.

  • Enhanced OST and NSP are critical human rights and TasP interventions.

  • Community engagement and enabling interventions are pivotal for TasP success.

Abstract

Treatment as prevention (TasP) is a concept common to the HIV sector. In this commentary we draw on the literature addressing HIV and HCV TasP, alongside qualitative HCV research, to critically appraise the promise of TasP for HCV and assess the needs of PWID in the future of HCV care. With the advent of highly effective direct-acting antiviral HCV treatments, TasP is now under consideration for HCV. A growing body of literature documents numerous social structural barriers to HCV treatment access and uptake for PWID, among whom HCV is highly prevalent. Yet these barriers – and suggestions for surmounting them – are rarely included in emergent literature on HCV TasP. Although HCV TasP has important advocacy potential for increasing treatment access among PWID, critical reflection on its implications are warranted. We outline potential limitations of TasP for HCV and the conditions under which it might be optimised. We argue that HCV treatment as a prevention strategy can only be realisable in a context of enhanced harm reduction access, meaningful community engagement, and enabling environment interventions informed by the needs and perspectives of PWID.

Section snippets

The promise of treatment as prevention for HCV

We are in the midst of a changing HCV treatment landscape. Oral direct-acting antivirals (DAAs) have cured up to 100% of clinical trial participants from HCV, fuelling considerable optimism in the sector (Afdhal et al., 2014, Sulkowski et al., 2014). References to HCV eradication and elimination are now commonplace (Grebely and Dore, 2014, Ryder and Dillon, 2014). One key strategy in the HCV elimination toolbox is TasP. HCV TasP involves prioritisation and scale up of HCV treatment provision to

The limits of a population-based approach

TasP for HCV, as with HIV, has implications for clinical treatment decision-making and for the way health systems prioritise and target treatment provision. This has become a particularly fraught issue since the development and licencing of expensive DAAs. In the context of potential cost-justified rationing of DAAs in the UK, Innes, Goldberg, Dillon, and Hutchinson (2014) project that the prioritisation of treatment for PWID will optimally impact on transmission incidence (a TasP approach),

Needs of PWID in future HCV care

High HCV treatment interest and willingness has been evidenced among PWID, even in a context of interferon-based therapy provision (Canfield et al., 2010, Doab et al., 2005). International clinical guidelines increasingly recommend treatment assessment and access for people who are currently injecting (European Association for the Study of the Liver, 2014). Yet HCV treatment access and uptake is suboptimal worldwide – especailly for PWID (Martin, Vickerman, et al., 2013). Barriers to treatment

What can we learn from HIV?

The HIV field illustrates the multiple social structural barriers to ART treatment uptake and adherence for PWID (Milloy et al., 2012). There has been a dearth of prospective studies addressing the efficacy of TasP for PWID, despite findings by Wood et al. (2009) that community viral load, over and above condomless sex or syringe sharing, is predictive of HIV incidence. HIV TasP for PWID at best remains a concept – with ART access and uptake among this population woefully inadequate, at only 4%

Conclusion

It is well evidenced that PWID are interested in HCV treatment and have comparable adherence and SVR rates to other groups. Clinical guidelines are increasingly recommending HCV treatment assessment and access for PWID, yet provider reluctance to refer and treat is common. DAAs have revolutionised HCV treatment options, however these more efficacious drugs are unlikely to be available for all. In this context HCV TasP has the potential to be a powerful advocacy tool. Modelling work has

Conflict of interest

The authors have no conflicts of interest to declare.

Acknowledgements

Thank you to Jude Byrne, AIVL, for your input into ongoing TasP discussions. Thank you also to the three anonymous reviewers for your encouraging and helpful suggestions. This article builds on a brief discussion piece published in Lazarus et al., 2014 and draws on qualitative data from the NIHR funded Hepatitis C Treatment Journey Study. Magdalena Harris is funded by an National Institute of Health Research postdoctoral fellowship [NIHR-PDF-2011-04-031].

References (69)

  • C. Treloar et al.

    How to build trustworthy hepatitis C services in an opioid treatment clinic? A qualitative study of clients and health workers in a co-located setting

    International Journal of Drug Policy

    (2014)
  • C. Treloar et al.

    Factors associated with hepatitis C knowledge among a sample of treatment naive people who inject drugs

    Drug and Alcohol Dependence

    (2011)
  • D. Wolfe et al.

    Human rights and access to hepatitis C treatment for people who inject drugs

    Int J Drug Policy

    (2015)
  • B. Adam

    Epistemic fault lines in biomedical and social approaches to HIV prevention

    Journal of the International AIDS Society

    (2011)
  • N. Afdhal et al.

    Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection

    New England Journal of Medicine

    (2014)
  • M. Alavi et al.

    Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS Study

    Clinical Infectious Diseases

    (2013)
  • E.J. Aspinall et al.

    Treatment of hepatitis C virus infection among people who are actively injecting drugs: A systematic review and meta-analysis

    Clinical Infectious Diseases

    (2013)
  • D. Barr et al.

    Articulating a rights-based approach to HIV treatment and prevention interventions

    Current HIV Research

    (2011)
  • P. Bourgois et al.

    The everyday violence of hepatitis C among young women who inject drugs in San Francisco

    Human Organization

    (2004)
  • P. Bruggmann et al.

    Models of care for the management of hepatitis C virus among people who inject drugs: One size does not fit all

    Clinical Infectious Diseases

    (2013)
  • K. Canfield et al.

    Methadone maintenance patients’ knowledge, attitudes, beliefs, and experiences concerning treatment for hepatitis C virus infection

    Substance Use and Misuse

    (2010)
  • Centers for Disease Control and Prevention

    Estimated HIV incidence in the United States, 2007–2010

    HIV Surveillance Supplemental Report

    (2012)
  • Centers for Disease Control and Prevention

    CDC's new high-impact approach to HIV prevention funding for health departments

    (2014)
  • M.S. Cohen et al.

    Prevention of HIV-1 infection with early antiretroviral therapy

    New England Journal of Medicine

    (2011)
  • C. Cook et al.

    The funding crisis for harm reduction

    (2014)
  • S. Crawford et al.

    Peer support models for people with a history of injecting drug use undertaking assessment and treatment for hepatitis C virus infection

    Clinical Infectious Diseases

    (2013)
  • A. Doab et al.

    Knowledge and attitudes about treatment for hepatitis C virus infection and barriers to treatment among current injection drug users in Australia

    Clinical Infectious Diseases

    (2005)
  • C. Duff et al.

    Counterpublic health and the design of drug services for methamphetamine consumers in Melbourne

    Health

    (2015)
  • N. Durier et al.

    Treatment of hepatitis C as prevention: A modeling case study in Vietnam

    PLoS ONE

    (2012)
  • European Association for the Study of the Liver

    EASL recommendations on treatment of hepatitis C 2014

    (2014)
  • S. Fraser et al.

    Harm reduction and hepatitis C: On the ethics and politics of prevention and treatment

    Addiction Research & Theory

    (2011)
  • S. Friedman et al.

    Socially-integrated transdisciplinary HIV prevention

    AIDS and Behavior

    (2014)
  • M. Harris et al.

    Hepatitis C treatment access and uptake for people who inject drugs: A review mapping the role of social factors

    Harm Reduction Journal

    (2013)
  • M. Harris et al.

    The future of hepatitis C care: Taking PWID needs and perspectives into account

  • Cited by (24)

    • Socioeconomic stability is associated with lower injection frequency among people with distinct trajectories of injection drug use

      2021, International Journal of Drug Policy
      Citation Excerpt :

      For PWID unable or unwilling to completely stop, reducing the frequency of injection may be an achievable target, and is a favorable interim alternative because of the diminished risks of injection-related harms (Bruneau et al., 2011; Bruneau, Roy, Arruda, Zang, & Jutras-Aswad, 2012; Hope, Kimber, Vickerman, Hickman, & Ncube, 2008; Islam et al., 2019). At a time when the importance of creating enabling environments to minimize harms among PWID is increasingly emphasized (Harris, Albers & Swan, 2015; McNeil & Small, 2014; Rhodes, 2009; Strathdee et al., 2010), this study seeks to refine our understanding on the impact of these two modifiable factors on injection drug use. Our aims were (i) to characterize long-term trajectories of injection drug use in a sample of active PWID living in Montréal and (ii) to examine how housing and income stability relate to injection frequency among PWID with diverse longitudinal injection patterns.

    • Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

      2019, International Journal of Drug Policy
      Citation Excerpt :

      For simplicity of presentation, this process is not included in Table 1. However, we note its consistency with the findings of numerous studies of HCV care in PWID, which have tied widespread experiences of stigmatisation and discrimination in health services to the receipt of inadequate care (Brener et al., 2015; Harris, 2005; Harris, Albers, & Swan, 2015; Harris & Rhodes, 2013; Harris et al., 2013; Lang et al., 2013; Treloar & Rhodes, 2009; Zickmund et al., 2004). These experiences are internalised, shape expectations of future treatment, reinforce mistrust in health services, and can drive avoidance and delays in care seeking (Biancarelli et al., 2019, 2749).

    • Transitioning from interferon-based to direct antiviral treatment options: A potential shift in barriers and facilitators of treatment initiation among people who use drugs?

      2019, International Journal of Drug Policy
      Citation Excerpt :

      Nonetheless, an international study of clinicians found that only 15% were willing to prescribe these medications to active PWID, with willingness inversely related to injection frequency (Asher et al., 2016). Our findings suggest that current strategies continue to exclude individuals whose drug use is not medically stabilized, including stimulant users and those injecting with high frequency (Harris, Albers, & Swan, 2015). These are individuals with substantially elevated risk of HCV transmission (Bruneau et al., 2012) and innovative strategies, such as the integration of care systems within supervised injection sites (Høj, Minoyan, Artenie, Grebely, & Bruneau, 2018) or social network strategies to referral and treatment (Hellard et al., 2014) may be required.

    • Care, agency and criminality: Making sense of authorised extended distribution in the accounts of key stakeholders

      2019, International Journal of Drug Policy
      Citation Excerpt :

      In relation to HIV, the TasP strategy has attracted sustained criticism for its over-emphasis on biomedical responses the detriment of social and behavioural responses, and for its focus on HIV-positive over HIV-negative individuals (Adams, 2011; Kippax, 2012). Harris, Alber, and Swan (2015) draw convincing comparisons to hepatitis C and argue that the promise of DAA is a biomedical and population-health response that is more appealing to policy makers than human-rights responses, and that this biomedical emphasis and the costs associated with it threatens resources for primary prevention and harm reduction, including the introduction of NSP innovations such as extended distribution. Indeed, in a setting where biomedical solutions are seen to be achievable, there is much less enthusiasm for seeking the authorisation of extended distribution which would require difficult legislative changes.

    • Caring and curing: Considering the effects of hepatitis C pharmaceuticalisation in relation to non-clinical treatment outcomes

      2018, International Journal of Drug Policy
      Citation Excerpt :

      The image of DAAs as the pharmaceutical solution to the social problem of HCV acts to reposition those most-at-risk and most marginalised from care as critical to potentiating elimination impact at the population level. An elimination agenda rehabilitates PWID as a treatment priority population; but in relation to their potential as HCV ‘transmitters’, rather than as individuals deserving of care (Fraser & Moore, 2011; Harris, Albers, & Swan, 2015). Interferon-era research makes an alternative case for treatment access – illustrating the transformative potentials of HCV treatment for individuals, over and above population-based measures of morbidity, mortality and transmission reduction.

    View all citing articles on Scopus
    View full text