amfAR, The Foundation for AIDS Research

New Recommendations for Treating Hepatitis C Among People Who Inject Drugs

Published November 13, 2015

A patient is screened for HCV at the Thai Red Cross AIDS Research Centre in Bangkok. 
A patient is screened for HCV at the Thai Red Cross AIDS Research Centre in Bangkok.

Globally, 130–170 million people are infected with the hepatitis C virus (HCV), and in high-income countries up to 80% of those living with the virus are current or former injection drug users. In low- and middle-income countries, the burden of HCV among people who inject drugs (PWID) is growing, and is particularly high among HIV-positive PWID—an estimated 75–99% of whom are co-infected with HCV. However, very few people infected with hepatitis C who are currently injecting drugs have access to lifesaving treatment, not only compromising their own health, but also increasing the likelihood of further transmission of HCV.

In October, the International Network on Hepatitis in Substance Users (INHSU) released new recommendations that present data showing that treating PWID with newer direct-acting antiviral (DAA) medicines—which are easier to take and provide much higher cure rates than older HCV treatments—is both feasible and cost effective. The recommendations also offer guidelines for how to successfully scale up HCV screening, linkage to care, and treatment among PWID.

“Increasing access to DAAs to cure the seven million PWID who are [chronically] infected with HCV is a global public health priority,” says Jason Grebely, lead author of the recommendations and associate professor at The Kirby Institute at the University of New South Wales in Australia, a TREAT Asia Network partner. “The global burden of HCV-related liver disease among this population is increasing, but treatment uptake remains unacceptably low.”

The recommendations were released in the International Journal of Drug Policy as part of its October “Special Issue on Expanding Access to Prevention, Care and Treatment for Hepatitis C Virus Infection Among People Who Inject Drugs.” Until 2013, some international HCV guidelines excluded PWID, citing concerns regarding poor adherence, possible adverse events, and a high likelihood of reinfection. However, in the past five years multiple studies have challenged these assumptions, showing that adherence rates among PWID are similar to those among other groups and that the rate of HCV reinfection among them is very low, at only 1–5% per year.

Today, international guidelines from the American Association for the Study of Liver Disease/Infectious Disease Society of America, the European Association for the Study of the Liver, INHSU, and the World Health Organization all recommend treating HCV in PWID. The newly released recommendations enhance these guidelines by providing a more detailed blueprint for overcoming existing barriers, such as mistrust of healthcare workers, that can prevent PWID from accessing treatment. They also dispel misconceptions that can prevent enrolment of PWID in HCV treatment programs, such as the false assumption that heroin causes liver toxicity.

HCV progresses more quickly in individuals living with HIV, and improved treatment access is particularly critical for these patients. “In the Asia-Pacific region, the burden of HCV among PWID is very high, especially among those living with HIV.” says Giten Khwairakpam, TREAT Asia’s project manager for community and policy. “These recommendations demonstrate that treatment among PWID is feasible and underscore that it should be prioritized for co-infected patients, regardless of their stage of disease.”

The guidelines conclude by stressing that because people currently injecting drugs are often left out of clinical studies pertaining to HCV, further research that involves PWID is critical to developing optimal strategies for improving treatment uptake.