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Global health experts are today are calling for the removal of restrictions preventing people who use drugs from accessing new hepatitis C cures. So long as these restrictions exist, the goal of disease elimination will remain out of reach, they say.
They are gathered in Oslo for the 5th International Symposium on Hepatitis Care in Substance Users, where new research continues to highlight not just the pivotal role treatment for people who use drugs plays in reducing hepatitis C transmission, but also how it can be rolled out to achieve best results.
“The science is clear. We now need to focus on overcoming barriers to access, and harness latest research to implement programs that work,” said President of the International Network of Hepatitis C in Substance Users (INHSU), Associate Professor Jason Grebely, the Kirby Institute, UNSW Australia.
“To delay further is unethical and undermines public health,” he added.
Hepatitis C – which if left untreated can lead to cirrhosis and liver cancer – affects approximately 64-103 million people around the world, resulting in around 700 000 deaths per year. In countries such as the US and Australia, hepatitis C now kills more people than HIV. In the UK, the number of annual deaths due to hepatitis C has quadrupled since 1996.
New, highly effective curative treatments have sparked hope of a world free of hepatitis C. The World Health Organisation (WHO) has set ambitious elimination targets of 90% diagnosed, 80% treated and a 65% reduction in hepatitis C-related mortality by 2030. In most high income countries, the vast majority (80%) of new infections are in people who inject drugs, but this group has faced widespread exclusion from the new therapies.
Reasons given for this exclusion include the price of new medications, fears of poor adherence, fears of reinfection and concerns over efficacy. However, international research debunks these myths.
The world’s largest study of new hepatitis c curative therapies – the C-EDGE CO-STAR Clinical Trial – has now found that illicit drug use prior to and during hepatitis C therapy had no impact on the effectiveness of the therapy, and that reinfection is low, at 4%. The results also showed excellent treatment adherence. Cure rates were comparable to results in hepatitis C populations that exclude people who use drugs.
Further, mathematical modelling suggests that even moderate levels of treatment uptake in people who use drugs could offer considerable prevention benefits.
One study looking at settings in Scotland, Australia and Canada indicated a 3-5 fold increase in treatment uptake among people who inject drugs could halve hepatitis C prevalence in 15 years.
Other studies modelled on people who inject drugs in the UK and France concluded realistic treatment scale-up could achieve 15-50% reduction in chronic hepatitis C prevalence in a decade.
To add to the benefits, treating people who use drugs with moderate or mild hepatitis C with new therapies is cost-effective in most settings compared to delaying until cirrhosis.
Several countries have introduced hepatitis C elimination programs, with Australia, France and Iceland offering unrestricted access. All eyes are now turned on Australia, where over 20 000 people (10% of the chronic HCV population) have initiated treatment in the first four months since subsidised treatment has become available.
“Countries such as Australia and France have taken the lead in adopting evidence-based policies that will save lives. Now it’s time for other countries, including the US and Norway, to follow their lead and allow all patients with chronic hepatitis C to be treated with the new drugs,” said Professor Olav Dalgard, Chair of the INSHU 2016 Symposium.
“We strongly recommend that all restrictions on access to new hepatitis C treatments based on drug or alcohol use or opioid substitution treatment be removed. There is no good ethical or health based evidence for such discriminations. Nor do the restrictions make clinical, public health or health economic sense,” he said.
“Providing treatment to people who inject drugs, integrated with harm reduction programs and linkage to care, is the key to hepatitis C program success. And our experience in Copenhagen shows this can work. Such efforts need to be initiated and scaled up globally,” added Professor Jeffrey Lazarus, Centre for Health and Infectious Disease Research, Rigshospitalet, University of Copenhagen, Denmark, who is presenting at the Symposium.
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ABOUT THE INTERNATIONAL SYMPOSIUM ON HEPATITIS CARE IN SUBSTANCE USERS
This symposium is the leading International conference focused on the management of hepatitis among substance users. It is organized by the International Network for Hepatitis in Substance Users (INHSU). The symposium is held biennially and was first held in Zurich, Switzerland, in 2009, Brussels, Belgium, in 2011, Munich, Germany, in 2013 and Sydney, Australia, in 2015.
DEBUNKING THE MYTHS: Why treatment works
Adherence and Efficacy: Emerging data suggests that people who use drugs and people receiving opioid substitution therapy have high rates of adherence and response to new hepatitis C curative treatments (interferon-free DAA HCV therapy) – comparable to people without a history of drug use.
Reinfection: While HCV reinfection can occur, data suggests that the rate of reinfection among people who inject drugs is low and should not be a reason for withholding hepatitis C therapy. The expansion of programs for enhancing drug user health (including opioid substitution therapy and needle and syringe programs) will be essential to ensure that HCV reinfection risk is minimized.
Cost: It has been demonstrated that treatment of people who inject drugs is cost-effective, given the potential for preventing onward transmission.
INHSU 2016: NEW RESEARCH SUPPORTING THE TREATMENT OF PEOPLE WHO INJECT DRUGS WITH HEPATITIS C
The research below is being presented at INHSU 2016 and provides further evidence that treating people who inject drugs (PWID) is effective.
HIGH RATES OF SUSTAINED VIROLOGICAL RESPONSE IN PEOPLE WHO INJECT DRUGS TREATED WITH ALL-ORAL DIRECT ACTING ANTIVIRAL REGIMENS
This study demonstrates that all PWID completed therapy with high rates of viral cure despite significant rates of drug use. This data demonstrates support for the treatment of PWID. Read the abstract.
REAL WORLD OUTCOMES OF DIRECT ACTING ANTIVIRAL (DAA) THERAPY FOR HEPATITIS C (HCV) AMONGST PERSONS WHO INJECT DRUGS TREATED IN AN INNER-CITY HEPATITIS C TREATMENT PROGRAM, VANCOUVER, CANADA
Outcomes attained using DAA therapies are high in a real world setting. Strategies to improve retention in care post therapy will be important to ensure appropriate monitoring for treatment failure and re-infection. Read the abstract.
CHANGES IN RISK BEHAVIOURS DURING AND FOLLOWING TREATMENT FOR HEPATITIS C VIRUS INFECTION AMONG PEOPLE WHO INJECT DRUGS: THE ACTIVATE STUDY
Recent injecting drug use and hazardous alcohol use decreased, while OST increased during and following HCV treatment among participants with on-going injecting drug use. These findings support further expansion of HCV care among PWID. Read the abstract.
OPTIMAL ADHERENCE DURING HCV TREATMENT AMONGST ACTIVE DRUG USERS AT A COMMUNITY BASED PROGRAM IN TORONTO, CANADA
This study provides insight into the adherence patterns of marginalized people living with HCV and demonstrates that despite high rates of substance use, a community- based model of HCV treatment can support positive HCV treatment outcomes. Read the abstract.
CC-EDGE CO-STAR: RISK OF REINFECTION FOLLOWING SUCCESSFUL THERAPY WITH ELBASVIR (EBR) AND GRAZOPREVIR (GZR) IN PERSONS WHO INJECT DRUGS (PWID) RECEIVING OPIOID AGONIST THERAPY (OAT)
Data on HCV reinfection rates after successful treatment are limited. This study is the largest on reinfection post-interferon-free therapy to date. Several HCV reinfection cases were detected among PWID on OAT following successful EBR/GZR therapy. Further follow-up is required to determine the natural course of HCV reinfection in the setting of interferon-free HCV treatment and the impact of viral persistence following reinfection on long-term response rates in this population. Read the abstract.
COMBINING THE EXPANSION OF MEDICATED ASSISTED THERAPIES AND HCV TREATMENT AMONG PWID IN UKRAINE: INSIGHTS FROM NETWORK MODELING
Combining antiviral HCV treatment with continued OST expansion are crucial for the reduction of HCV prevalence in the longer run. Substantial scale up of HCV treatment is a necessary condition for effective treatment in the context of high HCV prevalence and complex networks structures among PWID. Read the abstract.