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Editorial| Volume 85, P141-142, August 2019

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Macro-efforts for the micro-elimination of hepatitis C targeting people who inject drugs

  • Shui-Shan Lee
    Correspondence
    Corresponding author at: Stanley Ho Centre for Emerging Infectious Diseases, Postgraduate Education Centre, Prince of Wales Hospital, Shatin, Hong Kong.
    Affiliations
    Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong
    Search for articles by this author
  • Nick Crofts
    Affiliations
    School of Population and Global Health, University of Melbourne, Australia
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  • Chien-Ching Hung
    Affiliations
    Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

    Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
    Search for articles by this author
Open AccessPublished:June 11, 2019DOI:https://doi.org/10.1016/j.ijid.2019.06.003
Macro-efforts for the micro-elimination of hepatitis C targeting people who inject drugs
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      The World Health Organization (WHO) has set a target of a 90% reduction of hepatitis C virus (HCV) incidence by 2030, by which time 80% of eligible persons with chronic HCV infection should have been treated (
      • World Health Organization
      Global health sector strategy on viral hepatitis 2016-2021.
      WHO, Geneva2016
      https://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/
      ). With the increased availability of curative pan-genotypic direct-acting antivirals (DAAs), the target appears to be achievable, more so than that for the elimination of hepatitis B virus (HBV) infection, which is reliant on life-long suppressive therapy and universal vaccination. Policy-wise, there is consensus in the application of micro-elimination for achieving HCV eradication worldwide (
      • Lazarus J.V.
      • Safreed-Harmon K.
      • Thursz M.R.
      • Dillon J.F.
      • El-Sayed M.H.
      • Elsharkawy A.M.
      • et al.
      The micro-elimination approach to eliminating hepatitis C: strategic and operational considerations.
      Semin Liver Dis. 2018; 38: 181-192https://doi.org/10.1055/s-0038-1666841
      ). By breaking down the HCV population into multiple sub-population segments each for different means of targeting, micro-elimination is considered a pragmatic approach for achieving total elimination (
      • Lazarus J.V.
      • Wiktor S.
      • Colombo M.
      • Thursz M.
      • EASL International Liver Foundation
      Micro-elimination—a path to global elimination of hepatitis C.
      J Hepatol. 2017; 67: 665-666https://doi.org/10.1016/j.jhep.2017.06.033
      ). As we enter the 10th year since World Hepatitis Day was first observed in 2010, rethinking about micro-elimination strategies is needed as we are still very far from the goal. Specifically, have we given adequate attention to people who inject drugs (PWID)?
      Globally, PWID constitute a disproportionally large population group hardest hit by the HCV epidemic. There are an estimated 15.6 million PWID around the world, about half of whom are HCV antibody positive (
      • Degenhardt L.
      • Peacock A.
      • Colledge S.
      • Leung J.
      • Grebely J.
      • Vickerman P.
      • et al.
      Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.
      Lancet Glob Health. 2017; 5: e1192-207https://doi.org/10.1016/S2214-109X(17)30375-3
      ). A systematic review further estimated that globally 8.5% of all HCV infections occur among PWID who recently began injecting drugs (
      • Grebley J.
      • Larney S.
      • Peacock A.
      • Colledge S.
      • Leung J.
      • Hickman M.
      • et al.
      Global, regional, and country-level estimates of hepatitis C infection among people who have recently injected drugs.
      Addiction. 2019; 114: 150-166https://doi.org/10.1111/add.14393
      ). Despite WHO’s advocacy for HCV elimination, treatment coverage of HCV-infected PWID continues to be low. Recent studies in some western countries found that only one-fifth or less of PWID in the United States (US) (
      • Falade-Nwulia O.
      • Irvin R.
      • Merkow A.
      • Sulkowski M.
      • Niculescu A.
      • Olsen Y.
      • et al.
      Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore.
      J Subst Abuse Treat. 2019; 100: 45-51https://doi.org/10.1016/j.jsat.2019.01.021
      ,
      • Radwan D.
      • Cachay E.
      • Falade-Nwulia O.
      • Moore R.D.
      • Westergaard R.
      • Mathews W.C.
      HCV screening and treatment uptake among patients in HIV care during 2014-2015.
      J Acquir Immune Defic Syndr. 2019; 80: 559-567https://doi.org/10.1097/QAI.0000000000001949
      ), Canada (
      • Socías M.E.
      • Ti L.
      • Wood E.
      • Nosova E.
      • Hull M.
      • Hayashi K.
      • et al.
      Disparities in uptake of direct-acting antiviral therapy for hepatitis C among people who inject drugs in a Canadian setting.
      Liver Int. 2019; ([Epub 17 January 2019])https://doi.org/10.1111/liv.14043
      ), and European countries (
      • Murtagh R.
      • Swan D.
      • O’Connor E.
      • McCombe G.
      • Lambert J.S.
      • Avramovic G.
      • et al.
      Hepatitis C prevalence and management among patients receiving opioid substitution treatment in general practice in Ireland: baseline data from a feasibility Study.
      Interact J Med Res. 2018; 7e10313https://doi.org/10.2196/10313
      ,
      • Bourgeois S.
      • Mulkay J.P.
      • Lasser L.
      • Robaeys G.
      • Bastens B.
      • Delwaide J.
      • et al.
      A multicentre, observational study on demographic and disease characteristics of patients seeking care for chronic hepatitis C in Belgium in 2016.
      Acta Gastroenterol Belg. 2019; 82: 43-52
      ) had been on HCV treatment, the regimens of which included but were not limited to DAAs. The proportion of DAA-treated PWID would be expected to be even lower. Treatment coverage data from developing countries are scarce. In Malaysia, less than 2% of all HCV-infected patients had been treated (
      • Hiebert L.
      • Hecht R.
      • Soe-Lin S.
      • Mohamed R.
      • Shabaruddin F.H.
      • Syed Mansor S.M.
      • et al.
      A stepwise approach to a national hepatitis C screening strategy in Malaysia to meet the WHO 2030 targets: proposed strategy, coverage, and costs.
      Value Health Reg Issues. 2019; 18: 112-120
      ), while HCV transmission continues. In Europe PWID have accounted for 80% of all new HCV infections (
      • Dillon J.F.
      • Lazarus J.V.
      • Razavi H.A.
      Urgent action to fight hepatitis C in people who inject drugs in Europe.
      Hepatol Med Policy. 2016; 1: 2https://doi.org/10.1186/s41124-016-0011-y
      ). In the presence of active virus transmission, HCV micro-elimination initiatives are racing against time. The dynamicity of HCV transmission among PWID contrasts with that in other HCV-affected sub-populations, for example those linked with ineffective infection control. Slow implementation of elimination efforts targeting PWID would be overwhelmed by continuous transmission, canceling out progress made by isolated micro-elimination projects.
      Why has progress with HCV elimination been slow? Internationally the WHO targets for viral hepatitis elimination are extremely broad, perhaps too broad, covering not just HCV but HBV infections, and not just PWID but other at-risk populations. While the strategy of viral hepatitis elimination has been adopted by national governments, effective prioritisation of PWID is not universal. Belonging to the category of PWID was not uncommonly associated with lower likelihood of access to DAAs (
      • Rivero-Juarez A.
      • Tellez F.
      • Castaño-Carracedo M.
      • Merino D.
      • Espinosa N.
      • Santos J.
      Parenteral drug use as the main barrier to hepatitis C treatment uptake in HIV-infected patients.
      HIV Med. 2019; ([Epub ahead of print 22 April 2019])https://doi.org/10.1111/hiv.12715
      ). Physicians delivering opioid agonist treatment experienced barriers in providing HCV testing and management in Australia, Canada, Europe and US (
      • Litwin A.H.
      • Drolet M.
      • Nwankwo C.
      • Torrens M.
      • Kastelic A.
      • Walcher S.
      • et al.
      Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: the C-SCOPE Study.
      J Viral Hepat. 2019; ([Epub 9 May 2019])https://doi.org/10.1111/jvh.13119
      ). Strategies focusing on PWID were largely absent in developing countries, as reported in a study covering Eastern Europe and Asia (
      • Luhmann N.
      • Champagnat J.
      • Golovin S.
      • Maistat L.
      • Agustian E.
      • Inaridze I.
      • et al.
      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.
      Int J Drug Policy. 2015; 26: 1081-1087https://doi.org/10.1016/j.drugpo.2015.07.016
      ). In Hong Kong, for example, while an extensive methadone treatment programme has been in place for decades (
      • Lee K.C.K.
      • Lim W.L.
      • Lee S.S.
      High prevalence of HCV in a cohort of injectors on methadone substitution treatment.
      J Clin Virol. 2008; 41: 297-300
      ), access to HCV treatment has been restricted to ex-PWID (
      • Wong G.L.
      • Chan H.L.
      • Loo C.K.
      • Hui Y.T.
      • Fung J.Y.
      • Cheung D.
      • et al.
      Change in treatment paradigm in people who previously injected drugs with chronic hepatitis C in the era of direct-acting antiviral therapy.
      J Gastroenterol Hepatol. 2019; ([Epub 1 February])https://doi.org/10.1111/jgh.14622
      ). The International Network for Hepatitis in Substance Users highlighted poor access to health services and various forms of restrictions and punitive drug policies as the main obstacles for HCV elimination in PWID (
      • Day E.
      • Broder T.
      • Bruneau J.
      • Cruse S.
      • Dickie M.
      • Fish S.
      • et al.
      Priorities and recommended actions for how researchers, practitioners, policy makers, and the affected community can work together to improve access to hepatitis C care for people who use drugs.
      Int J Drug Policy. 2019; 66: 87-93https://doi.org/10.1016/j.drugpo.2019.01.012
      ).
      It is important to note that a targeted approach can make a difference. In Australia, DAAs became approved for use through the Pharmaceutical Benefits Scheme, which increased significantly the treatment uptake in marginalised communities such as PWID (
      • Butler K.
      • Larney S.
      • Day C.A.
      • Burns L.
      Uptake of direct acting antiviral therapies for the treatment of hepatitis C virus among people who inject drugs in a universal health-care system.
      Drug Alcohol Rev. 2019; 38: 264-269https://doi.org/10.1111/dar.12883
      ). In Iceland, a territory-wide universal HCV treatment programme, coupled with enhanced additional screening of PWID, could prepare the country for achieving HCV elimination targets (
      • Scott N.
      • Ólafsson S.
      • Gottfreðsson M.
      • Tyrfingsson T.
      • Rúnarsdóttir V.
      • Hansdottir I.
      • et al.
      Modelling the elimination of hepatitis C as a public health threat in Iceland: a goal attainable by 2020.
      J Hepatol. 2018; 68: 932-939https://doi.org/10.1016/j.jhep.2017.12.013
      ). In countries with established harm reduction services, these are the same platforms which could be adapted for introducing HCV elimination efforts (
      • Pericàs J.M.
      • Bromberg D.J.
      • Ocampo D.
      • Schatz E.
      • Wawer I.
      • Wysocki P.
      • et al.
      Hepatitis C services at harm reduction centres in the European Union: a 28-country survey.
      Harm Reduct J. 2019; 16: 20https://doi.org/10.1186/s12954-019-0290-x
      ). The conventional means of implementing HCV treatment through hospital specialists on referral basis is unlikely to make profound public health impact. Micro-elimination of HCV in PWID importantly involves expanding harm reduction services to incorporate HCV screening and treatment. This would mean not a micro- but a macro-effort in terms of the breadth and dimensions of the intervention targeting PWID. The principle of “treatment as prevention” can only be effective if the critical proportion of PWID screened for HCV and accessing DAAs is large. Small, uncoordinated and non-targeting micro-elimination projects will not lead us anywhere near the target of a 90% reduction of HCV incidence by 2030, which is just 10 years away. Indeed, global elimination of HCV is unachievable without proactively targeting PWID in expanded macro-efforts founded on a harm reduction principle.

      Conflicts of interest

      The authors declare no conflict of interest.

      Acknowledgements

      The support of Li Ka Shing Institute of Health Sciences and Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, are acknowledged.

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      Article info

      Publication history

      Published online: June 11, 2019
      Corresponding Editor: Eskild Petersen, Aarhus, Denmark

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      DOI: https://doi.org/10.1016/j.ijid.2019.06.003

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      © 2019 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

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