The World Health Organization (WHO) has released a new policy brief detailing the current landscape of hepatitis C virus (HCV) care in people who inject drugs (PWID), as well as people in prison. According to the report, there exists a need for greater awareness around HCV testing and prevention in these populations, and they believe that the introduction of new policies and legislation may be helpful for improving access to care for these and many other marginalized groups.
A review of national and regional hepatitis policies in 194 countries and territories, as well as interviews with stakeholders and key informants in 7 high-burden countries, was used as the basis of this review. Interviews with stakeholders and key informants focused on the challenges associated with increasing HCV services access among PWID, as well as people in prison. Elements that initiate care for testing and treatment were also explored. National plans that adopted recommendations for the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 for PWID and people in prisons that included factors, such as harm reduction, HCV testing, and treatment were reviewed.
HCV Care in PWID and People in Prison: Current Statistics
According to the review, a total of 124 countries have national hepatitis plans in place, a stark contrast to the 17 countries who had developed plans in 2012. After the second WHO resolution in 2014 and the World Hepatitis Summit in 2015, the number of plans exponentially increased. At this time, only 6% of these countries located in the WHO African Region (Algeria, Mauritania, and Senegal) have plans in place. Approximately 63% of plans detailed interventions for PWID, including HCV testing and treatment and access to sterile injecting instruments and effective drug dependence treatment.
For people in prisons, the interventions for HCV remain uneven. Approximately 35% of national plans reference HCV testing, treatment or prevention for prisoners, and only 28% of these plans outlined interventions that were comprehensive. The WHO panel members suggested that HCV testing and prevention plans were not prioritized for this population.
Factors Affecting HCV Care Access
Ongoing stigma and discrimination against PWID and people in prisons were suggested to be important barriers to care access. The high costs of treatment, particularly in middle- and high-income countries, may be another challenge that needs to be addressed. In the United States, for instance, the cost of a 12-week course of direct-acting antivirals (DAAs) ranges from $15,000 to $94,000. In contrast, the cost of generic DAAs for a 12-week course in the Ukraine is less than $100.
In the Fourth National Hepatitis Strategy (2014-2017), the Australian government highlights goals and guidelines for the potential elimination of the hepatitis virus by 2030. The strategy document spotlights HCV testing and treatment for PWID and individuals in custodial settings and also emphasizes the need for facilitating policy and legislation that addresses criminalization, stigma, and discrimination. In the Fifth National Hepatitis Strategy (2018-2022), Australia seeks to reduce the number of newly acquired HCV infections by 60%, and to raise the cumulative proportion of patients who begin DAA therapy to 65%. Populations included in the strategy are individuals with previous injection history, those who currently inject, Aboriginal and Torres Strait Islander people, and individuals in custodial settings.
Steps to Improve Access to HCV Services
The WHO suggests that a greater number of countries require greater political involvement to improve access to HCV treatment in marginalized population groups. Structural barriers, including criminalization of behaviors, as well as discrimination and stigma, may be helpful strategies to investigate.
Countries may also need to identify effective delivery and access points for HCV screening and treatment. Services focused on harm reduction in the community, such as needle and syringe program locations, drop-in centers, drug dependence treatment, outreach services, and opioid substitution therapy sites, may be helpful.
Cost reduction of DAAs represents another important target area because it may allow the scaling up of HCV treatment coverage for key populations, including PWID and people in prisons. The improvement of HCV services in prison settings should also be prioritized.
“The global commitment to universal health coverage aspires to serve the vulnerable and leave no one behind,” the authors of the policy brief wrote. “As we aim for hepatitis elimination, universal health coverage is an important platform on which to include harm reduction and HCV testing and treatment services for PWID and people in prisons. Countries are strongly encouraged to include these interventions in their national health packages.”
Access to hepatitis C testing and treatment for people who inject drugs and people in prisons — a global perspective: Policy brief. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/312116/WHO-CDS-HIV-19.6-eng.pdf?ua=1. Updated April 2019. Accessed May 15, 2019.