There are few diseases in the world that we have the chance to totally eliminate, but hepatitis C (HCV) is one of them. This blood-borne virus, often transmitted through the sharing of needles, disproportionately affects people who inject drugs. A staggering 39.4 percent of the global population of 11 million injecting drug users are living with HCV.
Left unchecked, HCV can lead to severe health conditions, including liver cirrhosis and cancer, and, ultimately, death. It doesn’t need to be this way.
In 2013, new direct-acting-antiviral drugs (DAA) were released, with a 95 percent cure rate. This makes HCV—along with smallpox and polio—one of a handful of viruses the world could feasibly eradicate.
Yet over a decade after the release of these revolutionary drugs, and despite clear elimination targets set by the World Health Organization (WHO) for 2030, HCV remains a pressing global concern, with 1.5 million new transmissions and 290,000 deaths each year.
“There remains a high cost to the treatment in most countries, which has led to a disparate rollout globally.”
The financial cost of HCV is also high. In the United States alone, the total economic burden from the virus is estimated to exceed $10 billion annually.
Although some countries, such as Australia and the United Kingdom, have embarked on impressive elimination journeys, a new study, published in the Lancet Gastroenterology and Hepatology journal, reveals the stark reality: Nearly 90 percent of the 57 million individuals living with HCV reside in low- and middle-income countries. And only half of these countries offer access to curative DAA drugs.
“Current direct-acting antiviral treatments cure HCV in more than 95 percent of people, revolutionizing the way we manage this condition,” Dr. Alison Marshall, who led the research at the Kirby Institute, at the University of New South Wales in Sydney, Australia, told Filter. “But there remains a high cost to the treatment in most countries, which has led to a disparate rollout globally.”
The lack of funding for HCV treatment in low- and middle-income countries (LMIC) is deeply concerning, but there are glimmers of hope. In late 2023, Egypt became the first country to achieve “gold tier” status under the WHO’s path to eliminating HCV.
In just a decade, the Northeast African country has gone from having one of the highest rates of HCV to near-total elimination. With 87 percent of cases diagnosed, and 93 percent of people diagnosed now receiving treatment, the nation’s success is remarkable.
Locally manufactured DAA treatments played a crucial role in Egypt.
Central to this achievement was government support at the highest levels, exemplified by the “100 million seha” (100 million lives) campaign. Offering free testing and treatment for all, the campaign began in 2014 and was reinforced by Egypt’s president in 2018.
This initiative led to the testing of over 60 million people and treatment for more than 4.1 million. The use of locally manufactured DAA treatments also played a crucial role—lowering costs, and resulting in a 99 percent cure rate among those treated.
Organizations like the Clinton Health Access Initiative and the Hepatitis Fund conduct valuable work to facilitate price and manufacturing agreements for some LMIC, which can lower DAA costs to $60 per treatment course. Sadly, it’s still the case that not every government is ready or able to step up with the required funding. But some countries are benefiting from other creative approaches.
In Iran, approximately 1.2 million adults are estimated to have substance use disorders, most commonly involving opioids. This population has high rates of HCV. In response, Dr. Maryam Alavi, a researcher at the Kirby Institute, led a team to launch a pioneering initiative known as ENHANCE Rafsanjan.
“ENHANCE was inspired by previous studies in Australia and globally,” Dr. Alavi explained in a short film from the International Network on Health and Hepatitis in Substance Users (INHSU). “We provided HCV testing and treatment in community-based drop-in centers and opioid agonist therapy clinics. We then used on-site rapid HCV antibody testing, and if an antibody test was positive, venipuncture blood samples were collected and sent for PCR testing.”
Treatment was initiated remotely by a specialist, while medication was dispensed on-site by peer-support workers and other harm reduction personnel. But perhaps the most fascinating aspect of the project is that it was funded by local philanthropists.
“We have to do our best to prevent the damage, and as an entrepreneur, I have the responsibility to act too.”
In the same short film—titled Connecting with Care – Hepatitis C model of care in Rafsanjan, Iran—Dr. Iranmanesh, a local business owner and philanthropist, emphasized the urgent need for society to help where it can.
“When a society is threatened by a destructive disease like HIV or HCV, we have to do our best to prevent the damage, and as an entrepreneur, I have the responsibility to act too,” he said.
The Rafsanjan micro-elimination project tested 7,115 people, with over 200 successfully treated and cured. Although primary responsibility for funding treatment for this life-threatening disease should fall on governments, initiatives like ENHANCE will hopefully help demonstrate to policymakers what’s possible, and encourage them to act.
It’s not just the cost of DAA that’s a challenge, however. Of the 160 countries analyzed in Marshall et al’s research, seven countries restrict access to these treatments for people currently using banned drugs, and five based on alcohol use.
Those examples directly demonstrate the harms of stigma. But relatedly, constant challenges around who is permitted to prescribe DAA medications have even wider implications.
“Around 61 per cent of countries have restrictions around who can prescribe DAAs,” Marshall said. “For example, it might be a gastroenterologist, a hepatologist or an infectious disease specialist who can write the HCV therapy script, but there may be a limited amount of these specialists available. That’s going to hugely impact the scale-up of treatment, especially when you factor in the stigma faced by people who use drugs that limit them from accessing health services in the first place.”
In Dundee, community pharmacists are available to test and treat the virus, so people have no need to schedule visits to less accessible health services.
There’s an obvious need to broaden prescribing powers. Take the city of Dundee, in Tayside, Scotland. It has been known as the overdose capital of Europe, with a population of injecting drug users who could be at high risk from HCV. And yet, the Dundee region is considered to be on track to eliminate the virus.
Syringe service programs, which ensure participants don’t need to share needles, are a big part of this. But so is the fact that community pharmacists are available to test and treat the virus, so people have no need to schedule visits to less accessible health services. Community pharmacies were already dispensing medications like methadone; tacking on a five-minute dried-blood-spot test, and DAA prescribing if needed, made perfect sense.
“I didn’t have to go to the hospital [for HCV treatment],” Scott, a Tayside community member, explained in a second INHSU Connecting with Care film. “My treatment was all done through the pharmacy, none of it was through the hospital. The tests, the treatment, the results, everything. I just pick up the tablets daily every day for 12 weeks when I would come in for my methadone.”
In the US, fewer than 10 percent of people who use drugs gain access to HCV treatment when they need it, due to limitations in health care capacity and access, with stigma a constant factor, and particularly in rural communities. But telehealth is proving to be another model that can help overcome these barriers.
Dr. Andrew Seaman, associate professor of medicine at Oregon Health & Science University, led a team of researchers that worked in partnership with people who use drugs in rural Oregon. They developed a study, presented at INHSU’s October 2023 conference, to compare peer-assisted telehealth with standard care through local providers.
Their findings were extraordinary. In the peer-assisted telehealth group, 85 percent of people initiated treatment (66 percent were cured), versus 13 percent initiating treatment in the standard care group.
“Health care providers can be out of touch, and there’s a lot of stigma, whereas peers have a PhD of living with substance use and are already in the communities.”
“The good news is that I really think this is scalable,” Dr. Seaman told Filter of this telehealth approach. “It decenters the role of medical providers and health systems and recenters and re-empowers communities and people with lived experience of drug use.”
“Health care providers can be out of touch, and there’s a lot of stigma, whereas peers have a PhD of living with substance use and are already in the communities,” he continued. “Peers form this bubble of trust around them and then invite their peers and health care providers in, forming a safe bridge between communities and health care workers.”
The recently published research about DAA access wasn’t all doom and gloom, as one finding illustrates.
“What was encouraging is that globally there seems to be very few liver disease restrictions,” Marshall said. “By this, I mean a restriction based on the stage of liver disease. That’s promising, as treatment shouldn’t be only available to people who have advanced liver disease, but attainable when the virus is first detected.”
Marshall noted that in past European and US studies, restrictions based on liver disease stage were common.
As for what’s next, Marshall would love to see major health organizations and national ministries work together to remove needless barriers.
“Many low- and middle-income countries now offer access to HIV treatment without restrictions, so we know that it can be done,” she said. “It’s just a matter of bringing in the HCV component, especially since in some of these countries, it’s the same population group that’s impacted.”
We need to reflect on the biases and systemic injustices that prolong the HCV epidemic, and work tirelessly to dismantle them.
The urgent need for equitable access to HCV treatment couldn’t be clearer. And although the determined efforts of communities and organizations demonstrate that solutions are within reach, every moment of delay results in preventable loss of life.
It is hard not to ask: If this virus disproportionately impacted another segment of the community, instead of people who use drugs, would there still be this delay in action? We need to reflect on the biases and systemic injustices that prolong the HCV epidemic, and work tirelessly to dismantle them.
Top image is a screenshot from the International Network on Health and Hepatitis in Substance Users film Connecting with Care – Hepatitis C model of care in Rafsanjan, Iran, showing Dr. Maryam Alavi with ENHANCE Rafsanjan workers and participants.