Research paper
Access to hepatitis C treatment for people who inject drugs in low and middle income settings: Evidence from 5 countries in Eastern Europe and Asia

https://doi.org/10.1016/j.drugpo.2015.07.016Get rights and content

Highlights

  • Study documents evidence regarding HCV treatment access in Eastern Europe and Asia.

  • PWID carry a significant relative HCV burden of disease, ranging from 2.7% to 40.4%.

  • Yearly treatment uptake was below 1% for the general population and PWID.

  • National policy plans did not include specific and relevant strategies regarding PWID.

  • Study shows an urgent need for improvement of HCV treatment access in LMICs.

Abstract

Background

People who inject drugs (PWID) are disproportionately affected by the hepatitis C (HCV) epidemic. Of the estimated 16 million PWID worldwide, approximately 8 million live with chronic HCV, and around 26% and 23% of the global HCV infections among PWID occur in East/Southeast Asia and Eastern Europe respectively. Globally, few PWID have access to treatment for HCV.

Methods

We conducted a systematic literature review and internet survey in 2014 to document the burden of disease, access to diagnosis and treatment and the existence of national policy and treatment guidelines for HCV. We included Georgia, Russia, Ukraine, Myanmar and Indonesia as countries with injection drug use epidemics.

Findings

HCV antibody prevalence among the general population ranged from 0.80% in Indonesia to 5% in Georgia, and among PWID from 48.1% in Myanmar to 92% in Georgia. PWID carried a significant burden of disease, ranging from 2.7% in Indonesia to 40.4% in Russia. Yearly treatment uptake was under 1% for the general population and PWID in all countries. Diagnostic tools and disease staging investigations as well as pegylated interferon/ribavirin treatment were available at a range of prices. Despite policy and treatment protocols for HCV in the majority of countries, strategies focusing on PWID were largely absent.

Conclusion

PWID are a priority group for treatment, and access to treatment should be based on sound national policy, accessible public treatment programmes and functional surveillance systems.

Introduction

Estimates suggest that between 80 and 150 million people are chronically infected with viral hepatitis C (HCV) worldwide, (Gower et al., 2014, WHO, 2014c) resulting in 499,000 deaths annually (Lozano et al., 2012). Central- and Southeast-Asia and Eastern Europe are among the regions with the highest infection rates, with 3.8%, 2% and 2.9% of the general population infected respectively (Hanafiah, Groeger, Flaxman, & Wiersma, 2013). Chronic HCV infection is associated with substantial morbidity and mortality (Thomas, Strathdee, & Vlahov, 2000) but as it is typically symptom free for decades, most infected individuals are unaware of their infection status.

People who inject drugs (PWID) are disproportionately affected by the HCV epidemic, with prevalence rates of 50–90% in the majority of countries (Aceijas & Rhodes, 2007). Globally there are an estimated 16 million PWID (Mathers et al., 2007), of whom around 8 million live with chronic hepatitis (Grebely & Dore, 2014). Approximately 26% and 23% of the global HCV infections among PWID occur in East/Southeast Asia and Eastern Europe respectively; these regions are home to almost half of hepatitis C infected PWID (Nelson et al., 2011). Furthermore, PWID are at high risk of onward transmission. In high-income countries (HIC), an estimated 80% of new cases of HCV infection occur among PWID (Grebely & Dore, 2014). Incidence data for low and middle income countries (LMICs) are scarce.

In the general population, 10% of HIV-infected persons are co-infected with HCV, however, among PWID infected with HIV, HCV co-infection rates range from 50% to over 90% (Walsh & Maher, 2012). Dual infection alters the natural history of both diseases. HIV can accelerate the course of HCV disease, including more rapid progression to cirrhosis, liver failure, hepatocellular carcinoma, and increased HCV-related mortality (Taylor, Swan, & Matthews, 2013).

Although drug-related mortality is high among PWID, the ageing cohorts of PWID mean that liver disease-related mortality is increasing (Deans et al., 2013, Grebely and Dore, 2011). Treatment access to dual therapy with pegylated interferon and ribavirin (pegINF/RBV) among PWID has always been low. This is because of the complex, toxic and lengthy treatment requirements of pegINF/RBV as well as provider and policy related barriers to treatment. Even in HIC, treatment uptake among PWID is less than 2% (20 per 1000 infected) (Grebely & Dore, 2014). This is despite a willingness among PWID to receive treatment for HCV under current treatment scenarios, reported to be between 53–86% of those surveyed (Alavi et al., 2013, Doab et al., 2005, Grebely and Tyndall, 2011). In addition, the high price of pegINF/RBV based treatment courses in LMICs (Momenghalibaf, 2014) has put HCV treatment out of the reach of many PWID. Finally, international donors have not supported HCV treatment, with the exception of some very small pilot programmes, mainly in the area of HIV co-infection (Global Fund, 2014, UNITAID, 2014).

Over recent years, strong advocacy from civil society groups, resolutions by the World Health Assembly adopted in 2010 and 2014 (WHO, 2010, WHO, 2014a) and the publication of HCV treatment guidelines (WHO, 2014b) have helped to bring HCV onto the international public health agenda. Additionally, the development of simple, tolerable and highly effective directly acting antiviral (DAA) therapies may improve access to HCV treatment for PWID, including in LMICs.

We collected data from a sample of countries in Asia and Eastern Europe with injecting drug use epidemics, and with different socio-economic profiles and health care systems, in order to document current access to HCV treatment. This included structural barriers to diagnosis or treatment as well as the existence of national policies and treatment guidelines for PWID.

Section snippets

Methods

We conducted a systematic literature review and an internet based survey between September and December 2014. We had planned to focus on eight countries but were only able to gather data for five, namely Georgia, Russia, Ukraine, Myanmar and Indonesia. For the purpose of this survey, PWID were those who injected psychotropic substances for non-medical purposes in the past six months, and former injectors who were still active non-injection drug users and/or on opioid substitution therapy.

Epidemiology and burden of disease

HCV antibody prevalence ranged between 0.80% in Indonesia and 5% in Georgia in the general population and between 48.1% in Myanmar and 92% in Georgia among PWID. HCV prevalence among PWID was found to be 18 to 63 fold higher than in the general population. Data from our systematic review showed a high percentage of HCV/HIV co-infection among PWID (defined as being concurrently infected by both), with the highest prevalence rates in Russia and Myanmar (Table 1).

In terms of absolute burden of

Discussion

This study shows the high burden of HCV disease among PWID in a sample of five countries from the Eastern European and Asian region. Adult antibody prevalence among PWID was found to be 18–63 fold higher than in the general population. Based on data from a systematic review and available population size estimates, we found that PWID are carrying a relative disease burden of 21.5–40.4% of the overall HCV burden in the three Eastern European countries. In the Asian countries this was lower but

Acknowledgement

Médecins du Monde France was the funding source of this work.

Conflict of interest: The authors declare to have no conflict of interest.

References (43)

  • M. Butsashvili et al.

    Occupational exposure to body fluids among health care workers in Georgia

    Occupational Medicine (London)

    (2012)
  • G.D. Deans et al.

    Mortality in a large community-based cohort of inner-city residents in Vancouver, Canada

    Canadian Medical Association Journal

    (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)
  • K.V. Dumchev et al.

    HIV and hepatitis C virus infections among hanka injection drug users in central Ukraine: A cross-sectional survey

    Harm Reduction Journal

    (2009)
  • Global Fund to Fight AIDS TB and Malaria

    Global fund financing of hepatitis C treatment. GF/B32/DPO7

    (2014)
  • J. Grebely et al.

    What is killing people with hepatitis C virus infection?

    Seminars in Liver Disease

    (2011)
  • J. Grebely et al.

    Management of HCV and HIV infections among people who inject drugs

    Current Opinion in HIV and AIDS

    (2011)
  • K.M. Hanafiah et al.

    Global epidemiology of hepatitis C virus infection: New estimates of age-specific antibody to HCV seroprevalence

    Hepatology

    (2013)
  • R. Heimer et al.

    Hepatitis C virus seroprevalence among people who inject drugs and factors associated with infection in eight Russian cities

    BMC Infectious Diseases

    (2014)
  • M.N. Kamel Boulos et al.

    Crowdsourcing, citizen sensing and sensor web technologies for public and environmental health surveillance and crisis management: Trends, OGC standards and application examples

    International Journal of Health Geographics

    (2011)
  • A.E. Kim et al.

    Crowdsourcing data collection of the retail tobacco environment: Case study comparing data from crowdsourced workers to trained data collectors

    Tobacco Control

    (2014)
  • Cited by (0)

    View full text