23 October 2015
Treatment for hepatitis C among people who use drugs is feasible and cost-effective and hepatitis C screening, linkage to care and treatment need to be scaled up, according to new recommendations for the management of hepatitis C released by the International Network on Hepatitis Care in Substance Users (INHSU).
The recommendations are being released as part of a Special Issue on Expanding Access to Prevention, Care and Treatment for Hepatitis C Virus Infection Among People Who Inject Drugs published in the October issue of the International Journal of Drug Policy.
"Increasing access to direct acting antivirals to cure the seven million people who inject drugs who are infected with hepatitis C is a global public health priority,'' said Jason Grebely, Associate Professor, The Kirby Institute, UNSW Australia and lead author of the recommendations. "The global burden of HCV-related liver disease among this population is increasing, but treatment uptake remains unacceptably low. Introducing evidence-based strategies to enhance hepatitis C treatment access for this vulnerable group is absolutely essential,'' he said.
An estimated 130–170 million people are living with chronic hepatitis C around the world, and over 350,000 die each year of HCV-related conditions, including cirrhosis and liver cancer. In many countries, people who inject drugs are the population most affected by hepatitis C.
New interferon-free therapies can cure more than 90 per cent of patients but are associated with high costs. Poor tolerability of older drugs, misconceptions around adherence and reinfection, and a belief that treatment outcomes may be poor, have led some countries such as the United States to exclude people who have recently used illicit drugs, injecting drugs or alcohol from access to these treatments.
However, new studies underpinning the recommendations demonstrate similar levels of adherence and responses to therapy among people who have and have never injected drugs. Further, rates of HCV reinfection following successful therapy are low (1-5 per cent per year).
They also show that curing hepatitis C among people who inject drugs, even with new expensive HCV therapies, is more cost-effective than delaying treatment until infection progresses to more advanced liver disease.
"Treating hepatitis C in people who use drugs will save lives, reduce the future potential disease burden and reduce costs to our healthcare system. It is also an important first step towards elimination of HCV. We need to step up treatment access for this group and these recommendations provide an essential evidence base to guide the management of hepatitis C among people who inject drugs ," said Jude Byrne, formerly a chair member of the International Network for People who Use Drugs (INPUD) and co-author of the recommendations .
ABOUT THE RECOMMENDATIONS
The Recommendations for the Management of Hepatitis C Virus Infection Among People who Inject Drugs have been developed by the International Network on Hepatitis Care in Substance Users (INHSU), who hosted a conference in Sydney, Australia, in October to address the growing global burden of hepatitis C in people who inject drugs (PWID).
INHSU established an expert panel to develop recommendations to enhance HCV assessment, management and treatment among PWID, with the first recommendations published in 2013 (Robaeys et al., 2013). These recommendations have been updated to reflect the rapidly changing landscape of HCV therapy and to be in line with the methodologies used by international guidelines from AASLD and IDSA (AASLD/IDSA, 2015)
RESEARCH SUPPORTING THE GUIDELINES
The following studies, published by Elsevier as part of special issues published in the October and November issues of the International Journal of Drug Policy are of particular importance to the recommendations.
Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum
Authors: Meyer JP, Moghimi Y, Marcus R, Lim JK, Litwin AH, Altice FL
Findings: Evidence-based interventions should be strategically incorporated into HCV treatment implementation efforts to propel the HCV cascade of care and maximise dissemination of effective treatments.
Quote: "Integration of healthcare delivery services, including treatment for underlying substance use disorders, is key to promoting HCV treatment uptake and completion in people who use drugs, allowing them to achieve parity with non-drug users in terms of clinical outcomes. Treatment outcomes are thus optimised when evidence-based interventions are implemented to target one or multiple steps of the HCV care cascade.'' Dr Jaime Meyer, Yale University, United States.
Injecting risk behaviours following treatment for hepatitis C virus infection among people who inject drugs: The Australian Trial in Acute Hepatitis C
Authors: Alavi M, Spelman T, Matthews GV, Haber PS, Day C, van Beek I, Walsh N, Yeung B, Bruneau J, Petoumenos K, Dolan K, Kaldor JM, Dore GJ, Hellard M, Grebely J; ATAHC Study Group
Findings: There is a concern that HCV treatment may increase injecting risk behaviours however this study showed that HCV treatment was not associated with injecting drug use or used needle and syringe borrowing. It found HCV treatment was associated with decreased ancillary injecting equipment sharing.
Quote: "These data clearly demonstrate that interferon-based HCV treatment does not lead to increases in injecting risk behaviour, and this should not be used as a reason for withholding HCV therapy among people who use drugs." Associate Professor Jason Grebely, The Kirby Institute, UNSW Australia.
Expansion of HCV treatment access to people who have injected drugs through effective translation of research into public health policy: Scotland's experience
Authors: Hutchinson SJ, Dillon JF, Fox R, McDonald SA, Innes HA, Weir A, McLeod A, Aspinall EJ, Palmateer NE, Taylor A, Munro A, Valerio H, Brown G, Goldberg DJ
Findings: The research on the impact of Scotland's HCV Action Plan has demonstrated that an evidence-based, Government-backed and invested approach can transform services and rapidly improve the lives of thousands.
Quote: "The INHSU recommendations provide an important spotlight on the management of hepatitis C among people who inject drugs, the group accounting for the vast majority of existing and new infection in many countries and thus crucial to targets if we are to stem the rising burden of hepatitis C-related liver disease worldwide." Professor Sharon Hutchinson, Glasgow Caledonian University, Scotland.
Ten priorities for expanding access to HCV treatment for people who inject drugs in low- and middle-income countries
Authors: Ford N, Wiktor S, Kaplan K, Andrieux-Meyer I, Hill A, Radhakrishnan P, Londeix P, Forette C, Momenghalibaf A, Verster A, Swan T
Drawing on the successful lessons learnt in improving access to HIV treatment, this article summarises ten priorities, including reducing the price of medicines, simplifying and standardising testing and treatment, and dedicated funding.
Quote: ''The HIV experience can pave the way towards HCV treatment access for millions of people who inject drugs.'' Tracy Swan, Treatment Action Group, United States.
Laurie Legere, The Kirby Institute, UNSW Australia
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