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‘Game-changing’ infection therapies plus harm reduction ‘flood’ would roll back hepatitis C epidemic

In 1993, an article in the UK’s magazine for the drug misuse field alerted Britain’s drug workers to an invisible “sleeping giant” – hepatitis C. The authors warned, “It may be wise to let sleeping dogs lie, but not sleeping giants”. Before a test was available to identify it, the virus had already infected a much larger proportion of drug injectors than HIV ever would. Since then it has been a case of playing catch-up. Hepatitis C has been hard to contain: high prevalence meant a high probability that anyone who passed you their used injecting equipment was infected, and the robustness and transmissibility of the virus meant a high probability (relative to HIV) of infection being transmitted.

More recent studies and simulations have suggested that the spread of the virus has been slowed down, but making a substantial impact will require a widespread and multi-pronged attack. As comprehensively detailed in a four-part Findings series, coverage is the key. Rather than a reluctantly funded trickle, a “flood” of harm reduction services is needed to bring the virus under greater control, supplemented by treatment of infection.

This hot topic describes the different components of hepatitis C control, including diagnosis, treatment and prevention. It reviews the place of harm reduction, which up to now has been the mainstay of hepatitis C control, and what could be game-changing additions to this armoury, in the form of new treatments for people already infected.

Half of people unaware they have the virus

Before treatment of infection can help stem the spread of hepatitis C, the infection first has to be tested for and diagnosed. But in the UK “half of those with hepatitis C remain unaware of their status”. This was a stark headline finding within a recent Public Health England report. The 50% figure includes people who have never been tested, as well as people who have become infected (or reinfected) since their last test. Good practice highlighted in the report involves adopting multiple strategies to raise uptake of testing. For example, employing a blood-borne virus nurse, distributing information about referral pathways to all staff in local drug and alcohol services, writing and re-writing to clients, and offering appointments on a flexible and drop-in basis.

Treatment needs to be scaled up...

In high income countries, hepatitis C is primarily transmitted through the sharing of contaminated injecting equipment, making drug users priority targets for intervention. In the UK, around 90% of diagnosed hepatitis C infections have been acquired through injecting drug use. In England and Wales around 50% of people who inject drugs are infected with hepatitis C, compared with 23% in Northern Ireland, and 57% in Scotland. Estimates from Public Health England suggest that 3 in 4 people infected with hepatitis C will develop chronic infection (a total of 214,000 in the UK), a primary cause of liver cancer and cirrhosis. Not only does treating hepatitis C saves individuals (already impacted by substance use) the adverse effects of chronic hepatitis, but by clearing the infection, it also helps prevents further spread of the virus among injectors. With this in mind, how much focus should we be placing on treating hepatitis C infection, and how can we maximise the preventive impact of treatment?

One study has mapped the current prevalence of chronic hepatitis C across seven sites in the UK, and projected what the prevalence would be in ten years’ time if we continued with the current approach to treatment versus a ‘scaled-up’ programme. The findings suggest that maintaining the status quo will not generate substantial reductions in hepatitis C. However, we could see a reduction of 15% after 10 years by increasing the rate of access to treatment, and using new medications. The authors estimate that treatment rates would need to be increased to more than 26 per 1000 people who inject drugs. These levels were already observed at two sites in the UK. A range of new oral drug treatments may be available in the UK from 2016, which according to clinical trials, promise to be more effective, more easily tolerated and more acceptable for patients than existing treatment options for hepatitis C, though perhaps unsurprisingly, also more expensive. The treatments are currently being evaluated by Britain’s National Institute for Health and Care Excellence (NICE). In the meantime, this interim policy statement indicates the treatments likely to be routinely commissioned for hepatitis C infection among patients who have already developed cirrhosis of the liver.

...and better targeted

Both the old and the new treatments offer a cure to people with hepatitis C. However, treatments do not prevent later reinfection. People who engage in high risk behaviours, such as sharing used injecting equipment, are more likely to become reinfected (and infectious). This has caused some reluctance to focus treatment on high-risk groups. The following studies indicate that, while it may seem counterintuitive to treat people who have a high risk of becoming reinfected, it might actually be the most effective strategy at a population level.

Researchers in Australia have calculated that for maximum impact, treatment for hepatitis C should be focused on people who are still actively injecting and not engaged in methadone treatment. This is to some extent conditional on the likelihood that individuals will comply with hepatitis C treatments. Where compliance levels are the same between people actively injecting and those in methadone maintenance therapy, the simulation model estimates that over 84% of hepatitis C virus treatment should be allocated to the active injectors. Focusing on methadone patients becomes preferential when (as it can do) being in a methadone programme increases compliance with hepatitis C virus therapy. Similarly, in a simulation study researchers compared the preventive impact of treating high-risk injectors who share injecting equipment very frequently, with the impact among injectors who share less frequently. They found that when more than half of all the shared syringes in a population of injecting drug users are contaminated with hepatitis C, the greatest preventive impact is gained by treating low-risk injecting drug users first. But below this threshold, it is most efficient to treat high-risk injecting drug users first.

The strategies described in the above two studies require information about the level of risk of injectors and the likelihood of compliance with treatment. Another study, based on injectors surveyed in the city of Melbourne in Australia, has suggested that information about the social networks of people who inject drugs should also be taken into account when planning treatment. Of those explored in this study, the most effective strategy was to ask an injector being treated for infection who they injected with, and then to offer treatment to those among their injecting circle who were also infected with the virus – helping to prevent the focal injector becoming reinfected.

Harm reduction remains the “cornerstone of hepatitis C infection control”

Infection with hepatitis C is one potential negative consequence among many for people who inject drugs, including other blood-borne viruses such as HIV and hepatitis B. Diagnosis and treatment is an important arm of hepatitis C control. Running alongside this is ‘harm reduction’, an approach that seeks to reduce the harms associated with drug use and to mitigate the impact of drug use on individuals and the rest of society.

Dr Mary Ramsay from the National Infection Service (Public Health England) describes harm reduction, including provisions for safer injecting and non-injecting practices, as the “cornerstone of hepatitis C infection control”. A Consensus Statement on Best Practice published by three leading organisations in harm reduction – the National Needle Exchange Forum, UK Harm Reduction Alliance and Exchange Supplies – details essential elements of harm reduction as the provision of sterile injecting equipment, facilities for the safe disposal of used equipment, and substitute prescribing. The Statement advises that together, these constituent parts of harm reduction can help to reduce the transmission of the hepatitis C virus, and reduce wider injecting-related harms.

Methadone maintenance therapy can have a strong protective effect on the spread of hepatitis C. For example, in an analysis of three Canadian surveys of drug users, the prevalence of hepatitis C was significantly lower among methadone maintenance patients (24%) than among other participants (76%). Furthermore, the analysis revealed that after two years, the chances that someone engaged in methadone maintenance treatment at the start of the study would become infected were half those of someone not engaged in treatment, and the longer participants had been in treatment during the two years, the less likely they were to have become infected with hepatitis C by the end of the study.

Safer injecting practices too can have a protective effect on hepatitis C. NICE advises that for needle and syringe exchange programmes to be most effective, services should strive for over 100% coverage, with a view to increasing the number of people who have more than one sterile needle and syringe available for every injection. The need for exchange services to achieve extensive coverage is further discussed in this in-depth Findings review. In the light of the national policy shift towards abstinence and recovery, NICE’s Public Health Advisory Committee caution that “a focus on recovery (that is, encouraging people to stop taking drugs completely) should not compromise the provision of needle and syringe programmes and any associated harm-reduction initiatives”.

Where people who inject drugs do not (or cannot) access needle and syringe exchange services, they may employ their own harm reduction techniques, including disinfecting used syringes and needles. The effectiveness of this procedure has been tested in a laboratory setting with readily available household products. Rinsing with bleach was found to be the most effective, eliminating hepatitis C in syringes with both fixed and detachable needles. Though promising, this practice is unlikely to safeguard all. Injectors may choose not to rinse their syringes with bleach for a number of reasons, including the fact that multiple rinses can damage the equipment.

Harm reduction is not a quick-fix. It is an approach which, according to the UK Harm Reduction Alliance, recognises that “for many, dependent drug use is a long term feature of their lives”, and in response to this, it “seeks to maximise the range of intervention options that are available”. In the context of reducing the harm to injecting drug users, this involves a combination of all of the strategies listed above. The next section identifies why the use of various harm reduction and treatment strategies is desirable when tackling hepatitis C.

It’s the combination of services that will make the biggest impact

Consistent participation in methadone maintenance treatment plus adequate access to fresh injecting equipment has prevented many hepatitis C infections. A synthesis of results from UK studies found that access to either type of service is associated with a halving in the risk of infection, and moreover that a combination of both could reduce risk by up to 80%. In Scotland, the combination of needle exchange, methadone maintenance and a shift away from injecting has meant that between 2008 and 2012, 1000 fewer injectors faced chronic infection. Treating the virus is also effective in reducing the overall prevalence of hepatitis C and reducing the risk of transmission. However according to an Australian study reported on above, resources must be allocated to harm reduction services as well as treatment in order to significantly reduce the risk of infection in the population. A synthesis of relevant studies by world-leading experts echoes that it is the combination of services and strategies which will make the biggest impact, and suggests that it has already substantially and significantly reduced transmission of hepatitis C by as much as 75% within populations of people who inject drugs.

A simulation model for the UK and other countries indicates that investment in methadone maintenance treatment and needle exchange services has been money well spent. Saving tens of thousands of lives from being blighted by infection. However, further substantial progress will require comprehensive hepatitis C control – pulling together strands of diagnosis, treatment and harm reduction – and a large degree of commitment on the part of both injectors and health service funders. For an idea of scale, the researchers estimate that cutting prevalence by a third over 10 years will require over 60% of injectors to be engaged in methadone maintenance and needle exchange services. Another simulation model found that getting to the point where under 1 in 10 injectors in London are infected with hepatitis C would need the average injector to cut their sharing of used syringes from 16 times a month to once or twice.

We can, but will we?

Harm reduction continues to be a pillar of hepatitis C control. However, according to NICE, further increasing the coverage of syringe distribution and substitute prescribing programmes will not substantially curb hepatitis C. This will require a multi-faceted programme, including early diagnosis and treatment of injectors already infected with hepatitis C, a strategy reflected in the Welsh Government’s hepatitis action plan.

Public Health England recommends regular review of population needs to feed into strategies for hepatitis C control. This attention to the characteristics of the population reflects studies examined above which found better results when levels of risk, levels of compliance and injecting networks were factored into population-level treatment interventions.

Achieving a dramatic impact will also require continuing investment. The Scottish study above revealed promising reductions in the prevalence of chronic hepatitis C, but the researchers stressed that these reductions may need to be sustained for over a decade before the virus is substantially less common across the injecting population.

Given funding constraints and the current policy emphasis on recovery from addiction and abstinence, it may be unrealistic to expect a further major contribution to stemming the hepatitis C epidemic from harm reduction services. What would help is if their workload could be reduced because (aided or not by treatment) drug users turn away from injecting. From population estimates and trends in the treatment caseload, it seems this may be happening, with an estimated 137,000 injecting drug users in England in 2004/05 falling to 117,000 in 2006/07, and an estimated 103,185 in 2009/10 falling to 93,401 in 2010/11.

Last revised 27 November 2015. First uploaded 01 November 2011

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