We Need a Comprehensive Hepatitis C Package of Services for People Who Use and Inject Drugs!

Achieving hepatitis C virus (HCV) elimination by 2030 depends on how countries fund prevention, testing, treatment, and care and how they include HCV in efforts for universal health coverage. Investing in elimination requires national programs to provide services for key populations, particularly people who use and inject drugs who are disproportionately affected by the virus. Harm reduction, based on unconditional access to health and human rights, is a prerequisite for reaching people who use and inject drugs and connecting them to care.

This fact sheet helps advocates to demand from their governments a comprehensive hepatitis C package of services for people who use and inject drugs. Noting the political realities that certain provisions may not be available in some countries, we strive to see all these services, based on decades of public health evidence, implemented together.

Destigmatizing, accurate information about hepatitis C tailored for people who use drugs

• Provide information, education, and communication materials to people who use drugs and their sexual partners, via community health workers and peers with lived experience and across settings, through awareness sessions, trainings, and other events

Comprehensive prevention & sexual health services as part of general health package for people who use drugs

• Make pre- and post-exposure prophylaxis (PrEP/PEP) for HIV, internal/external condoms, and lubricants available and affordable for people who use drugs and their sexual partners
• Offer or refer to comprehensive sexual and reproductive services, including access to contraception

Sufficient number of syringes & access to opioid substitution therapy (OST)

• The World Health Organization (WHO) recommends [1] 300 sterile needles and syringes per person per year. However, higher coverage of syringes to have a measurable impact on hepatitis C. We need to strive so that people have access to sterile syringes for every single injection. The number of times a person injects depends on a person’s individual needs
• Access to safe injecting equipment should include low dead space syringes, which keeps only a small amount of fluid in the syringe and needle once the plunger is completely pressed. Evidence [2] suggests that low dead space syringes can reduce the risk of HIV/HCV transmission
• Ensure access to sterile injecting and smoking equipment and materials and trainings on safer injecting practices
• The combination of OST with needle and syringe programs (NSP), in which people can access both services at the same time, may reduce the risk of hepatitis C by over 70%. [3] The WHO Essential Medicines List includes methadone and buprenorphine and national health insurance should cover these medications. These services combined link people to essential services and also helps people decrease the frequency of their injections

Overdose prevention & management

• Expand harm reduction services to include trainings and access to free naloxone in a range of community settings and to offer peer-to-peer naloxone programs. Naloxone is a medication to block the effects of opioids and save lives when a person overdoses
• Provide training on rescue breathing for unconscious people, including oxygen therapy and bag valve masks in overdose prevention sites to prevent brain damage [4]
• Include drug checking to test safe supply of drugs
  

TESTING

Decentralized, simple, high quality & affordable hepatitis C testing for people who use drugs

• Make simple point-of-care testing available in harm reduction sites. Hepatitis C testing and treatment, especially for people without advanced liver disease or other complicated health issues, should be offered wherever people are receiving services
• We need to invest in more research and development in diagnostics that are simpler, faster, high quality, and used at the community/point-of-care (PoC) level. While we wait for the “ideal test,” we can use existing technologies according to a country’s epidemiology, such as confirming diagnosis on RNA platforms using fingerstick blood draws or dried blood spots at PoC. Governments need to validate and approve these tests
• Cover antibody and confirmatory (RNA or core antigen) testing in national insurance plans
• Governments should follow the WHO Guidelines [5] and simplify national diagnostics pathways. This incudes removing viral load monitoring. Countries with access to treatment regimens that treat all genotypes, should also remove genotype testing, except for people with advanced cirrhosis or who have not achieved curative rates on previous medications
• Antibody tests have less invasive procedures for obtaining oral or blood samples, but they are registered for healthcare professionals. Antibody tests should be validated and registered for hepatitis C self-testing, if appropriate telehealth and counseling supports are in place, as another option for diagnosing and linking stigmatized and marginalized communities to treatment and care
• Develop and validate dried blood spot testing protocols which can be a less painful, easier method for obtaining a sample from people who inject drugs who may have poor vein access
• Provide quality trainings and shift testing tasks to allied health professionals and community health workers, including those with lived experience
• Integrate hepatitis C tests on open diagnostics platforms that can test for multiple diseases at once; this can lower overall costs by purchasing items in bulk
• Demand transparent pricing on diagnostics products from companies, governments, and procurement agencies, and compare with neighboring countries to negotiate lower prices
• Ensure that an increased number of people who use drugs are screened and tested. Other ways to reduce diagnostics costs include bundling the procurement of tests, enabling competition among suppliers, and allowing diverse options among distributors

Affordable, universally accessible treatment for people who use drugs

• Break market monopolies (including among branded and generic manufacturers) that lead to artificially high prices
• Prioritize regimens that treat all HCV genotypes
• Expand direct-acting antivirals (DAAs) registration in your country
• Ensure the availability and affordability of sofosbuvir, as a backbone of most treatment combinations
• Lift all treatment restrictions, including those requiring abstinence before starting DAAs. Evidence indicates that people who use drugs achieve similar adherence and sustained virological response rates as people who do not use drugs
• Shift prescriber status of DAAs to non-specialists to reduce delays in starting treatment
• Demand transparent pricing on DAAs from companies, governments, and procurement agencies, and compare with neighboring countries to negotiate lower prices

POST-TREATMENT MONITORING

Testing & treating for reinfection

• Hepatitis C reinfections will occur but comprehensive prevention and harm reduction services can reduce them. Governments need to plan universal testing and treatment for everyone who needs it, including for people who become reinfected.
• Offer accurate, quality information on prevention methods alongside periodic confirmation testing for people at risk of hepatitis C reinfection, and access to affordable treatment, at no cost. It is essential to keep patients, who are at risk of reinfection, connected to care

Liver damage & liver cancer screening

• In follow up visits, or at least every 6 months, provide non-invasive screening, at no cost, for people with more advanced stages of liver damage. Monitor for early signs of liver cancer

High quality services

• People with lived experience must be included in strategies to shift tasks within hepatitis C-related services, which can achieve higher quality services and health outcomes. Improving the quality of services and health outcomes requires intersectional approaches to address the social determinants of health that affect people who use drugs
• Often women and gender non-conforming people do not have access to harm reduction services that are responsive to their particular needs. Hepatitis C services should be designed and led by trained women and gender non-conforming people who use drugs to ensure welcoming, destigmatizing, non-discriminatory, and gender-sensitive care. This may ensure that services for pregnant women who use drugs are provided
• Healthcare and related services, which are adapted to the needs of local communities who use drugs, need to be monitored by civil society, community advisory boards, and community members

Fair living wage of community health workers with lived experience

• People with lived experience and history of substance use provide valuable roles to support their peers, assist with community-based testing, ensure patients complete DAA treatment, and help patients navigate services so they are retained in care
• Remunerate, respect and protect the dignity of people who use drugs, community health workers, and peer educators!

Integrated services for other infectious diseases

• Prevent, diagnose, and treat HIV, TB and sexually transmitted infections with high quality, affordable tests and medicines
• Offer free hepatitis A and B vaccines

HCV/harm reduction sites provide referral services

• Services that could be offered on-site or referred to other community-friendly sites include transportation assistance, psychosocial/counseling, non-abstinence-based housing, employment, financial, legal, and other social services

Decriminalize drug use, possession, and low-level drug sales & end mass incarceration of people who use drugs

• Substance use requires a public health approach that increases funding and expands access to harm reduction services, not prisons! Drug policy reform reduces stigma, discrimination, and violence against people who use drugs. Decriminalization creates an enabling environment for people who use drugs to seek essential healthcare and other services

Fully fund hepatitis C & harm reduction services in national budgets

• Only 8% of the funding for viral hepatitis needed in low- and middle-income countries has been made available. [6] Budgeting for this package of services must include the healthcare training, storage/transportation of testing samples, required lab equipment, reporting systems upgrades, and the cost of tests, medicines, and harm reduction supplies