July 28 marks the fifth annual World Hepatitis Day, dedicated to increasing awareness. But we cannot meaningfully increase awareness without focusing on people who use drugs, who bear a hugely disproportionate burden of disease and death from viral hepatitis.
A staggering 82 percent of 400,000 annual global deaths related to hepatitis C are among this population.
People who use drugs are vastly overrepresented in viral hepatitis-positive populations in most regions of the world. In Asia, for example, the prevalence of hepatitis C is estimated to be 99 times higher among people who inject drugs than in the general population. Worldwide, more than half of people who have both viral hepatitis and HIV are people who inject drugs.
Stigma, criminalization and a lack of political will have limited the quantity and quality of viral hepatitis services for people who use drugs—including those needed to detect, treat and prevent these diseases.
In many cases,treatment centers not only unjustly refuse to provide health care services, but even report people who use drugs to law enforcement.
People who use drugs experience informal and formal discrimination in various health care settings. Many viral hepatitis centers, specifically, still fail to fully include people who inject drugs—or worse, actively discriminate against them.
In many cases, staff at treatment centers will not only unjustly refuse to provide health care services, but even report people who use drugs to law enforcement. As laws criminalizing drug use in many countries keep people in the shadows, many have well founded fears that interacting with health systems could expose them to police harassment, violence and incarceration.
Hepatitis service providers may also have unhelpful and isolating treatment protocols, like requiring abstinence from drugs before treatment, which create further barriers to care.
This discrimination directly harms the population most vulnerable to viral hepatitis, undermining their right to health. And by causing underreporting and undermanagement, it undermines broader global efforts to reduce the burden of these diseases.
Underreporting contributes to a pervasive lack of data around viral hepatitis—among people who use drugs in particular, and in general. This in turn reduces advocates’ ability to establish the budgets needed to help everyone at risk.
This demonstrates a stark failure to offer viral hepatitis care in a manner that upholds the dignity and rights of people who use drugs.
In contrast, ending drug criminalization and discrimination would facilitate access to health care for people who use drugs, allow accurate data collection to inform better global responses to viral hepatitis, and assist in increasing budgets for harm reduction and integrated care
Overall, the world has made substantial progress toward eliminating viral hepatitis B and C, yet people who inject drugs have been left behind. In part, that’s because of where prevention and treatment programs are aiming—or not aiming—their efforts.
In many parts of the world, viral hepatitis B and C programs focus almost exclusively on the prevention of mother-to-child transmission (PMTCT). Addressing PMTCT is important to reducing the global burden of these diseases, but is insufficient when a sizable amount of new transmissions do not fall into this category. Exclusive focus on women and children through sexual and mother-to-child transmission leaves other at-risk populations ignored.
Even in high-income countries, hepatitis C treatment uptake among people who inject drugs is just 2 percent—despite 80 percent of this population expressing willingness to access treatment. This mismatch demonstrates a stark failure to offer viral hepatitis care in a manner that upholds the dignity and rights of people who use drugs.
Around the world, existing harm reduction centers can be scaled up to deliver non-discriminatory and non-paternalistic hepatitis services.
This is why it is imperative to integrate viral hepatitis prevention, diagnosis, treatment and care within holistic, person-centered harm reduction services.
Around the world, existing harm reduction centers can be scaled up to deliver non-discriminatory and non-paternalistic hepatitis services to a far greater degree than is currently the case. At needle and syringe service programs, for a start, providers can easily be trained to deliver education, testing and vaccination. It’s an obvious way of meeting people where they are, in environments where they are respected and comfortable, rather than tolerating barriers to health care access and delivery.
At a global level, harm reductionists and governments alike have made significant progress in decreasing HIV transmissions among people who inject drugs, by targeting care to at-risk populations, and thanks to numerous advances and innovations.
It is past time to translate these successes to viral hepatitis. By adapting proven frameworks, we can bring viral hepatitis care into the fold of integrated, person-centered harm reduction services. Doing so would make a rapid impact on prevalence—and show we refuse to accept that people who use drugs should disproportionately suffer disease and death.
Image by FF2011 via Wikimedia Commons/Creative Commons 3.0
