Hepatitis C is an infectious disease of the liver caused by the blood-borne hepatitis C virus (HCV). Around 115 million people worldwide have been infected at some point in their life by HCV. Two-thirds of these are estimated to be chronically infected, over 5 million within the European Union. The infection is highly prevalent among people who inject drugs who can contract HCV through the sharing of needles, syringes and other injecting equipment. In a new report published today on World Hepatitis Day, the EU drugs agency (EMCDDA) looks at new opportunities for the effective prevention and treatment of the disease, including the use of new generations of medicines (1).
The new report — Hepatitis C among drug users in Europe: epidemiology, treatment and prevention — provides a state-of-the-art review of the epidemiology of HCV infection in Europe (2) and its estimated prevalence among people who inject drugs (3). HCV infection levels in this group range from 15% to 84%, with many studies showing 50% or more infected. There is also strong evidence of ongoing and, in some countries, high levels of transmission among young injectors, suggesting that infection can be acquired early in an individual’s injecting career. According to the report: ‘HCV prevention remains one of the major challenges for Europe’s public health responses to drug injecting’.
Initial infection with HCV is often asymptomatic and many people with an injection history are unaware that they are carrying the virus, leading to the disease being referred to as a ‘hidden epidemic’. If left unresolved, the infection can lead to chronic liver disease, cirrhosis, cancer and death.
EMCDDA Director Alexis Goosdeel says: ‘Failure to address HCV infection among people who inject drugs will mean considerable costs in the future, both to individuals and to health budgets. Our new report shows, however, that there are now grounds for greater optimism in preventing and treating the disease. This is thanks to the combination of opioid substitution treatment and needle- and syringe-exchange programmes with new pharmacological options for HCV and a growing confidence in how to deliver treatment to people who inject drugs in the community. I believe that we now have an opportunity in Europe to make real and sustained progress in this area. By combining treatment with adequate prevention and harm-reduction measures, we have the necessary tools to control this epidemic’.
New medications help lower barriers to treatment
Traditional treatment for HCV included the use of the drugs interferon and ribavirin. While these could be effective, they were often poorly tolerated, brought severe side effects and involved a lengthy treatment period (24–48 weeks). These factors often contributed to poor treatment uptake by drug users.
‘This situation is now changing however’, states the report, which provides an up-to-date overview of the new medicines currently available or in development. Following the appearance on the market of new antiviral drugs, it describes how these can be administered over a shorter period and with fewer side effects, improving chances of treatment retention.
‘The provision of HCV treatment has become less challenging’, states the report. The use of all-oral, interferon-free HCV treatment regimens makes them easier to administer, including in drug treatment and primary care settings. The report adds: ‘These developments now mean that, probably for the first time, a real opportunity exists to tackle the high prevalence of HCV infection at the level of injecting drug-user communities’.
Preventing further infections and improving screening
Health promotion activities encouraging people not to inject drugs, or to change risky injecting behaviour (e.g. needle-exchange programmes, opioid substitution treatment), remain key elements in current HCV prevention approaches. ‘However, coverage of both measures remains suboptimal in many countries and, therefore, requires strengthening’, states the report, which goes on to underline the need to extend services to the most disadvantaged and vulnerable but also to provide people who inject drugs with specific HCV diagnosis and care.
The report underlines the important role that treatment can play in preventing the spread of the virus: ‘Treatment as prevention now emerges as a real possibility in providing an effective response to the HCV epidemic among drug injectors in Europe’, it says.
The fact that many of those infected with HCV are unaware of their infection has consequences both for the continued transmission of the virus and for the long-term health of the individual concerned. This underlines the importance of raising public and professional awareness around the need for testing.
Offering testing to all drug users in treatment is regarded as good practice. This is supported by the recently agreed EU minimum quality standards for demand reduction (Council of the European Union, 2015), which recommend that ‘treatment services provide voluntary testing for blood-borne infectious diseases, counselling against risky behaviours and assistance to manage illness’ (4).
Scaling up treatment and supporting policies to eliminate hepatitis
Studies suggest that the combination of widespread hepatitis C treatment, supported by other primary prevention measures, has the potential to reduce HCV transmission. The report emphasises that experimental evidence is now needed to test model projections and show how scaling up HCV treatment with other interventions can reduce HCV transmission in the population. Scaling up treatment offer will also require the development of effective partnerships between specialist services working with drug users and those offering HCV treatment and care. According to the report: ‘The challenge is to develop a comprehensive approach to care in this area that ensures that both prevention activities and treatment access are adequately resourced and proactively delivered’.
The World Health Organization has declared as one of its global strategic objectives the elimination of viral hepatitis as a public health threat by 2030 (WHO, 2016)(5). The EMCDDA is committed to working with its international, European and national partners in this area to improve the evidence base and support the measures necessary to ensure that the ambitious public health goals established for the elimination of HCV infection are realised.