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