By Sébastien Morin, International AIDS Society, Eliot Ross Albers, Independent (formerly at the International Network of People Who Use Drugs), and Jürgen Rockstroh, University of Bonn
“For 2030, the first-ever global hepatitis targets are the reduction of hepatitis B and C infections by 90% and mortality by 65%, through universal coverage with prevention, testing and treatment services.”
– Gottfried Hirnschall, World Health Organization
The first-ever global targets on viral hepatitis were adopted at the 69th World Health Assembly last week. These targets include:
- Reduce new cases of chronic hepatitis by 30% (2020) and 90% (2030) (baseline 2015). Reduce from 6-10 million new cases in 2015 to < 1 million in 2030
- Reduce hepatitis B (HBV) and hepatitis C (HCV) mortality by 10% (2020) and 90% (2030) (baseline 2015). Reduce from 1.4 million deaths in 2015 to < 500,000 deaths in 2030
Why are these targets important?
HCV has historically been under-estimated, under-prioritized and under-resourced in comparison to the significant impact it has on millions of people around the world. However, with the adoption of the global hepatitis targets this is changing and an HCV-free generation, where the disease is no longer a great public health concern, is on the horizon.
Co-infection with HIV remains a major issue with 2.3 million people living with HIV (PLHIV) also living with HCV. Although co-infected people are only a fraction of the total number of people living with HCV (PLHCV, approximately 5%), the intersection with HIV represents an opportunity for integration and scaling up a still very limited response to the HCV epidemic.
People who inject drugs (PWID), one of the HIV key populations, in particular continue to be disproportionately affected by HIV and HCV because of limited investments in and hugely restricted access to proven interventions. Even when effective prevention services are available, the combination of punitive laws and experiences of stigma – both within healthcare settings and in the broader community – create barriers to their use.
It will be critical to ensure that the ambitious targets towards HCV elimination by 2030 are accompanied by predictable and focussed funding for testing, prevention and treatment, especially for middle-income countries, which suffer from the highest burden of HCV infections. In addition, placing the most at risk populations, in particular PWID, at the centre of the response will be essential. Despite dramatic advances in science with new medicines able to cure nearly all PLHCV, including people co-infected with HIV and the emergence of promising policies, the question of access to care by the communities most in need remains.
How can access be improved if the targets are to be met?
“Despite the global burden, only about 2% of the world’s population infected with HCV receives treatment or is cured from therapy each year – we have an enormous goal to achieve.”
– Marina Klein, McGill University, IAS Governing Council member
A substantial proportion of PLHCV remains undiagnosed, as a result of a combination of the infection being asymptomatic for up to 20 years and a lack of systematic and at-scale screening. For PWID, who are the least diagnosed among PLHCV, other factors such as profound criminalization, stigma and discrimination, police harassment and the real risk of government persecution for presenting for testing that exists in many countries, often in the form of government registries, constitute additional obstacles.
In spite of the significant breakthroughs made in the treatment of HCV, its access remains massively inadequate, uneven and inequitable. The new medicines remain inaccessible to the vast majority of people diagnosed with HCV infection as a result of the prohibitively high costs of originator drugs, as well as the restrictive terms of the licences for generic production, which exclude millions of PLHCV, in particular in middle-income countries. Providing treatment to PWID also offers a set of unique social, legal and political challenges. Community-based implementation of screening guidelines with the utilization of rapid testing, ideally using newly available point-of-care technologies, can help simplify and expand HCV testing in order to reach PWID and scale up treatment. Open door policies for accessible, peer-led harm reduction services – which include opioid substitution therapy (OST) and needle/syringe programmes (NSP) – are also essential for diagnosis and entry into care.
Community involvement is where the change can begin. There is a role for the PWID community to drive the movement through their strong engagement. This is increasingly becoming a living reality with several groups – through a range of civil society and constituency-led networks – leading the movement, often on access to generic drugs and intellectual property issues. Since PWID are best placed to reach members of their own community and often best understand their needs for harm reduction and HIV/HCV prevention, this is also an opportunity to foster and support peer-driven interventions as should be emphasized by the upcoming Injection Drug Users Implementation Tool (IDUIT) planned for release in 2016, which will highlight the importance of building community organizational and advocacy capacity, while promoting a human-rights framework.
What needs to be done?
In order to achieve these targets, the following must be carried out:
Address structural and legal factors that impede access to services
Structural barriers, including detention in the name of rehabilitation, imprisonment for drug use or possession, addition of names of PWID to government registries and stigma from health care providers, as highlighted in the recent Lancet publication Public health and international drug policy are addressed.
Increase access to and availability of integrated harm reduction services
Proven harm reduction strategies, including OST, NSP and the prevention and treatment of HIV, HCV, tuberculosis and STIs, are increased substantially and reach PWID beyond HIV mono- and co-infection prevention programmes. These should rely on community empowerment-based and peer-driven approaches that are scaled up and support strong constituency-led advocacy.
Support community advocacy for equitable access to affordable diagnostics and drugs
Advocacy efforts are supported – both at the global and the local levels – and result in affordable diagnostics and drugs becoming accessible to people who need them, in particular PWID, while effective actions – including patent oppositions and the use of Trade Related Aspects of Intellectual Property Rights (TRIPS) flexibilities – are taken when equity is not respected.
Join us at the upcoming 3rd International HIV/Viral Hepatitis Co-Infection Meeting taking place at the 21st International AIDS Conference (AIDS 2016) to continue the conversation.
This blog follows from a roundtable organized by the IAS’s Industry Liaison Forum during IAS 2015 in Vancouver, Canada.
The IAS statement on the WHO Global Health Sector Strategies, delivered at the 69th World Health Assembly is available online.