29 May 2023
Brendan Harney is a PhD student at Burnet Institute and Monash University, vice chair of INHSU’s Early-Mid-Career-Researchers committee, and a passionate advocate for hepatitis C and HIV treatment and care among people who use drugs. Brendan recently attended the Harm Reduction International Conference in Melbourne, and here, he shares his key takeaways from the hepatitis C and HIV focussed sessions.
Across the various conference sessions, key themes emerged, including how – even though direct-acting antivirals have increased the cure rate of individuals with hepatitis C – there is still much work to be done to ensure testing and treatment is equitable.
Indigenous communities remain underserved, there is a lack of data focussed on women, and low-middle-income countries do not have the same access, despite emerging examples of how innovative models of HCV care can reach even the most remote communities.
Meanwhile, in HIV, the need to integrate PrEP into harm reduction service delivery for people who inject drugs was a key theme, with multiple speakers presenting on its potential positive impact on the community globally.
Session 1: Towards the elimination of viral hepatitis C
In a session focused on hepatitis C elimination, conference attendees heard about some successes, and ongoing challenges, in the elimination of hepatitis C among people who inject drugs and people in prison, with data presented from Australia, Ireland and Kyrgyzstan.
Findings from Australia
Drawing on data from a long-running surveillance program at needle and syringe programs across Australia, Professor Lisa Maher from the Kirby Institute reported that the incidence of hepatitis C had declined by more than half since the availability of direct-acting antivirals to cure hepatitis C.
From 2012 to 2015, hepatitis C incidence was 13.6 per 100-person years; in contrast between 2016 and 2021, it was 5.4 per 100-person years.
However, Professor Maher also emphasized that these declines were not seen among certain subgroups of people, including Aboriginal and Torres Strait Islanders, highlighting that even though these people are attending services, there is a need to do more to provide equitable access to prevention, diagnosis, and treatment of hepatitis C.
We also heard from Tom Wright, who presented on hepatitis C re-treatment in a network of public prisons in New South Wales, Australia. For the benefit of the international audience, Mr Wright started his presentation by sharing data on the shameful and disproportionate incarceration of Australian and Torres Strait Islanders, who are 3% of the Australian population, yet are almost 30% of people in prison and 51% of young people in prison.
Across the prisons that Mr Wright’s team visits, there have been 1,100 retreatments for hepatitis C, with 70% identified as new infections following a previous cure. It was also highlighted that Aboriginal and Torres Strait Islander people are vastly over-represented in these data, accounting for about 60% of all re-treatments and noted that a lack of evidence-based harm reduction in prisons, inequitable access to harm reduction in the community, and the disproportionate incarceration of both people who inject drugs and Aboriginal and Torres Straight Islanders are ongoing challenges in hepatitis C elimination efforts.
Findings from Ireland
Dr Margaret Bourke, a general practitioner from Dublin, Ireland, reported on hepatitis C care provision among people entering opioid agonist therapy during the first year of COVID. Among 643 people starting OAT, 50% of whom were experiencing homelessness or were unstably housed, 40 people were HCV RNA positive.
Almost all (35) started treatment through the OAT service, all of whom were cured. As discussed by Dr Bourke, the clinic also provided care to refugees and asylum seekers from Georgia and Ukraine, including offering OAT, HIV, and hepatitis C services.
Despite successes, challenges remained, including language barriers, and some distrust of services perceived to be “state agencies”, highlighting that even when services are readily available, there are additional aspects to be considered.
Findings from Kyrgyzstan
Danil Nikitin from the Global Health Research Centre of Central Asia shared data from a hepatitis C self-testing project that is a partnership with the Foundation for Innovative New Diagnostics. Following on from formative evaluation work, people attending harm reduction services used a hepatitis C self-test, albeit under supervision, to determine antibodies to hepatitis C.
Of 39 people who tested positive for HCV antibodies, 27 had active hepatitis C based on confirmatory RNA testing; all started treatment, and all were cured. This work adds to a growing body of work showing hepatitis C self-testing among people who inject drugs is possible. However, work is needed to evaluate it outside of supervised settings.
Session 2: Twin epidemics: responding to HIV and Viral Hepatitis
In this session, HIV and hepatitis C testing and treatment, integrated care, and gender differences in hepatitis C care were all discussed with new data shared.
Global systematic review
Presenting a global systematic review, Associate Professor Behzad Hajarizadeh of Kirby Institute drew attention to substantial gaps in HIV and hepatitis C testing and treatment for people who inject drugs. Data on HIV testing was available from 67 countries globally, with only four countries having tested more than 75% of people who inject drugs in the past 12 months.
There was less data available for treatment, with only 18 countries having this data available. In addition, high treatment coverage was rare, with only two countries, Australia and Vietnam, having data showing treatment for at least 75% of people who inject drug living with HIV. More countries, 15, we found to have high levels of antibody testing for hepatitis C, however, as highlighted, these were almost all high-income countries.
Crucially, only three countries, Australia, the United States and Vietnam, had data on RNA testing, which is essential to confirm active hepatitis C infection. In the 23 countries with treatment data available, only one, Spain, had data indicating more than 75% of people who inject drugs had been treated for hepatitis C.
Testing and treatment in Myanmar
Integrating hepatitis C care into a harm reduction program in northern Myanmar was presented by Myo Thet Oo. At a Medical Action Myanmar clinic, and using outreach for people in living in remote villages, 300 people, 99% of whom were males, had both HIV and hepatitis C. Of these people, 90% completed treatment, and 211 (83%) were cured.
The settings and context of this program show that even in challenging situations, it is possible to test and treat people if properly resourced, and programs like this could be scaled up in other similar settings.
More gender-specific data is required
Closing the session, Dr Heather Valerio answered the call for more hepatitis C outcomes to be presented by gender. Drawing on data from a cohort study across Australia of 2,395 people eligible, 786 (33%) identified as women, of whom 352 (45%) had active hepatitis C and were eligible for hepatitis C treatment, compared to 56% of men.
Women were more likely to be Aboriginal or Torres Strait Islanders. However, they were less likely to have recently been incarcerated. Treatment uptake was lower among women at 64% compared to men at 71%. Women aged 45 or older were more likely to start treatment. However, this was not found for men. As highlighted by Dr Valerio, this may reflect previous work showing pregnancy and childbirth is associated with less treatment uptake. More efforts are needed to reach this group of women.
Session 3: Practice and potential of pre-exposure prophylaxis of HIV among people who use drugs and people in prisons
Opening this session, Annette Vester from the World Health Organization presented findings from a recently published review that aimed to map PrEP service delivery for people who inject drugs. The vast majority of published studies included, 20 of 22, were from the USA, and many highlighted a range of barriers to PrEP at both a personal and structural level.
To complement the ‘traditional’ review, WHO also worked with INPUD to identify PrEP service delivery for people who inject drugs which may not have any data published. Based on this, there was evidence that 27 countries had PrEP services, however, more than half of these, 15, were in high-income countries. Most of these were clinic based and did not offer any other harm-reduction services.
As discussed in the conclusion of the presentation, this highlights that PrEP for people who inject drugs should complement, but certainly not replace, evidence-based harm reduction services, including needle and syringe programs and opioid agonist therapy. In addition, there needs to be more work on community-based and peer-led models of PrEP for people who inject drugs globally.
Jitttaphon Chaejaew from Thailand’s Institute of HIV Research and Innovation presented data on integrating PrEP into existing harm reduction services. Working with Ozone Foundation in Bangkok, HIV testing was undertaken by people receiving other harm reduction services, and those who tested negative were offered PrEP if they were interested. Overall, 72 people commenced PrEP; the vast majority were men and crucially included both people who inject drugs, and people who use drugs via other means. As noted by Mr. Chaejaew and colleagues, this highlights that community-based PrEP is feasible, however many challenges remain include affordability outside of these specifically funded projects.
Continuing the theme of integrating PrEP into existing harm reduction services, Associate Professor Lyle Cooper of Meharry Medical College presented a pre-implementation study in rural Tennessee. Using a mixed methods approach, a range of both individual and structural barriers were identified and included the need for multiple appointments, stigma, a lack of stable housing and the over-policing of people who use and inject drugs. Facilitators included strong relationships with the community and a ‘one-stop shop model’ whereby people can get HIV testing and PrEP, as well as other harm reduction services in the one place; this was highlighted as being particularly important as there is essentially no public transport in this, and many other rural areas.