Increasing access to HCV testing in drug services is the starting point for the EMCDDA initiative. The (diagnostic) process of identifying barriers and opportunities to HCV testing in drugs services involves:
The diagnostic process is described in a practical manual which will be published towards the end of 2019.
EMCDDA Elimination Barometer
An essential preparatory step for assessing barriers and facilitators to HCV testing in drugs services is mapping and understanding the current epidemiological context and response situation. This helps to obtain clarity about the context in which any further activities are taking place, is an important input to discussions with stakeholders and provides the basis for choosing the appropriate objectives. Knowing the size of the PWID target population and of the HCV epidemic, and being aware of the current infrastructure for HCV testing and treatment in your country is important background knowledge for identifying the need for and barriers to HCV testing, and to define or ‘diagnose’ whether there is a problem.
The EMCDDA elimination barometer is a new tool that can support this diagnosis. It is composed of indicators routinely reported to the agency which can assist the EU and Member States to assess progress towards the elimination of HBV and HCV infection, based on the WHO evaluation framework for viral hepatitis. It includes, for example, information about the size of the HCV epidemic among people who inject drugs, on the national policy context, and on the scale of prevention measures in place in a country. These indicators help to assess progress towards the elimination of HBV and HCV infection at national level and to identify data gaps. The five building blocks of the elimination barometer are presented in Figure 2 below. Each building block includes quantitative and/or qualitative indicators with a corresponding target. Showing the data at the start of the roundtable discussion/workshop (see section below) provides a basis to stimulate the discussion, helping to assess needs in the implementation of prevention and treatment responses as well as identifying data gaps. The full set of 30 country barometers is under preparation and will be launched in October 2019.
Figure 2. Elimination of viral hepatitis among PWID - EMCDDA indicators and related 2020 WHO elimination targets
The core element recommended for the diagnostic process is a structured roundtable discussion or workshop. This format is well suited for the purpose of bringing the different groups of stakeholders together with different perspectives, background and knowledge. The goal is to identify problems and possible solutions together.
The EMCDDA has piloted this approach in Luxembourg and Poland.
A manual to guide people through the process of conducting this type of diagnostic process, including the lessons learned from conducting the exercise in these countries will be launched towards the end of 2019. The manual will include the in-depth description of the preparatory process, resources needed, and also provide examples of the objectives for a roundtable discussion.
The first pilot roundtable discussion took place on 22 January in the Directorate of Health in Luxembourg. It was organised jointly by the staff of the national Reitox Focal Point and experts from the Luxembourg Institute of Health (LIH).
Why did they have this event?
In Luxembourg, hepatitis C antibodies are present among approximately 75% of all PWID, which may in the near future result in high morbidity and mortality due to hepatitis C. The National Action Plan against Hepatitis outlines a decrease of the prevalence rate as a priority for the country. The purpose of the roundtable was to bring together an interdisciplinary group of experts working in different areas related to HCV testing and access to care for PWID to discuss how to improve HCV testing and health care practices and to empower drug treatment centres to facilitate access to care. The goal was to achieve a common understanding, a consensus, about the main barriers to HCV screening and access to treatment among policy makers and service providers, taking the reality of the clients’ situation into account, and to propose a list of actions, reflecting the priorities and their feasibility.
Who was involved?
The roundtable gathered 21 national health professionals, as well as experts from the EMCDDA and the Robert Koch Institute. The participants were the representatives of the Department of Penitentiary Psychiatric Medicine, specialists from the National Service of Infectious Diseases, nurses, social workers, directors of drug treatment and harm reduction centres, social workers and educators, and other stakeholders.
What was achieved?
The initiative allowed fruitful discussions on the main perceived barriers as well as identifying priority areas for action regarding hepatitis C testing and access to treatment for PWID. The meeting resulted in a report which systematically documents the barriers to testing on policy-, provider- and client levels in Luxembourg as well as opportunities and possible solutions. The feasibility and prioritisation of the individual measures was discussed, linking them to Luxembourg’s Hepatitis Action Plan 2018-2022 which follows the global agenda to eliminate viral hepatitis as a public health threat by 2030.
Participants found the process useful and particularly appreciated the opportunity to work together with many different stakeholders sharing their experiences:
- ‘I can guide people better, because I know how the different services work.’
- ‘The same kind of meeting should be organized for other relevant problems in the drug scene: quality design in harm reduction; working together between the drug working organization and the police.'
- 'We all agree that we need national guidelines and political support.'
Roundtable participants appreciated the fact that core experts were gathered and that all stakeholders were working together, developing a network for the response to viral hepatitis. The meeting allowed them to get to know the other service providers, their actors and their functioning; to learn about other points of view and to share experiences. Key-messages from the evaluation survey indicated several key points, such as: the importance of working together, bringing the issue to the political level, the need for improvements in access to other health services and housing, the need to develop common guidelines, the importance of staff motivation in treatment centers to improve the situation and work in the same direction. Respondents also suggested inviting other experts as well as political representatives, the city of Luxembourg, and (former) drug users to any further meetings of this kind.
The second pilot discussion/workshop was organised by Polish National Bureau for Drug Prevention and the National Public Health Institute and supported by staff from the EMCDDA. It took place on 11th of June 2019 in Poland.
Why did they have this event?
A recent national seroprevalence study among PWID in Poland detected that more than half of the population had been infected with HCV. A national hepatitis policy document does not yet exist, but under the national Drug Prevention Bureau two initiatives (both in Warsaw) have recently been launched to improve HCV testing among PWID. The goals of the roundtable discussion were to improve the understanding of barriers and facilitators for HCV testing in Poland and to improve the access and availability of health care in the area of HCV.
Who was involved?
There were 25 participants with diverse backgrounds, such as medical doctors, representatives of National Bureau of Drug Prevention, EMCDDA, Health Ministry, Harm reduction workers, drug services workers, the representatives of Public Health Institute, Medical University, Association of Epidemiologists and Hepatologists, as well as local government representatives and other stakeholders.
What was achieved?
The participants worked together towards a consensus regarding main barriers for HCV testing and health care delivery. They created a list of possible actions to overcome or diminish these barriers and prioritised them in terms of feasibility.
The participants reported finding the debate very valuable, providing an opportunity to share information, knowledge, opinion and experiences between many different stakeholders:
- ‘Gathering all barriers and recommendations together and defining specific actions to implement these recommendations was very useful’
- ‘We should maintain the … Regularity of meetings for the assessment, evaluation and summary of progress of actions aimed at solving the problem’
- ‘The meeting had high professional level, a large dose of practical information, as well as many different approaches and solutions to identified problems’.
Participants found the roundtable very useful and well-organised. The meeting gave them the opportunity to deepen their understanding of the situation regarding Hepatitis situation in Poland and in other EU countries. In the evaluation survey they mentioned that the level of the presentations and discussion was very professional with a good dosage of high-quality data. They could discuss different point of views, exchange experiences and work together with national experts and health professionals. The key messages of the meeting were: the importance of establishing the common ground, the need of eliminating barriers in HCV testing, the collection of the recommendations for future action, the importance of facilitating the PWID in their access to treatment, and the plans for creation of the national standards of Harm Reduction and National Hepatitis Strategy. Respondents also suggested inviting other experts, such as representatives of National Health Fund, staff of opioid substitution programmes and staff of addiction treatment services. They mentioned that it is important to repeat these meetings regularly to follow up, monitor and evaluate the actions undertaken to solve the problem.
The report from the meeting is under preparation by National Bureau for Drug Prevention.