Elimination of HCV as a public health concern among people who inject drugs by 2030 - What will it take to get there?

Abstract

Introduction: Globally, there is a considerable burden of HCV and HIV infections among people who inject drugs (PWID) and transmission of both infections continues. Needle and syringe programme (NSP) and opioid substitution therapy (OST) coverage remains low, despite evidence demonstrating their prevention benefit. Direct-acting antiviral therapies (DAA) with HCV cure >95% among PWID provide an opportunity to reverse rising trends in HCV-related morbidity and mortality and reduce incidence. However, HCV testing, linkage to care, and treatment remain low due to health system, provider, societal, and patient barriers. Between 2015 and 2030, WHO targets include reducing new HCV infections by 80% and HCV deaths by 65%, and increasing HCV diagnoses from <5% to 90% and number of eligible persons receiving HCV treatment from <1% to 80%. This commentary discusses why PWID should be considered as a priority population in these efforts, reasons why this goal could be attainable among PWID, challenges that need to be overcome, and key recommendations for action.

Discussion: Challenges to HCV elimination as a global health concern among PWID include poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low HCV testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. Key recommendations for action include reforming drug policies (decriminalization of drug use and/or possession, or providing alternatives to imprisonment for PWID; decriminalization of the use and provision of sterile needles-syringes; and legalization of OST for people who are opioid dependent), scaling up and improving funding for harm reduction services, making health services accessible for PWID, supporting community empowerment and community-based programmes, improving access to affordable diagnostics and medicines, and eliminating stigma, discrimination, and violence against PWID.

Conclusions: The ambitious targets for HCV elimination set by WHO are achievable in many countries, but will require researchers, healthcare providers, policy makers, affected communities, advocates, the pharmaceutical and diagnostics industries, and governments around the world to work together to make this happen.

Keywords: HCV; HIV; NSP; OST; control; drug users; elimination; hepatitis C.

Figure 1.

Combinations of annual treatment rates per 1000 injectors and coverage of opioid substitution therapy (OST) and high-coverage NSP (HCNSP) required to reduce prevalence by 50% within 10 years. Results shown for 3 baseline chronic prevalence settings (20%, 40%, and 60%). Assumes no intervention coverage at baseline with OST and HCNSP scale-up to 0%, 20%, 40%, or 60% of each and using direct-acting antivirals (90% SVR). The box-plots signify the uncertainty (middle line is the median, limits of the boxes are 25% and 75% percentiles and whiskers are 2.5% and 97.5% percentiles) in the impact projections due to uncertainty in the intervention effect estimates. Reproduced with permission from [68].