A March study published in The Lancet Regional Health — Americas highlights one particular strategy that could dramatically improve hep C treatment access for people who use opioids. The randomized controlled trial found that when people enrolled in opioid treatment programs (OTP) were offered hep C treatment on-site at those same programs, they were nearly four times more likely to initiate it compared to people who were given off-site referrals. 

Though the likelihood of patients completing the regimen and confirming they’d been cured was similar, the higher uptake in the OTP route would mean more people getting cured. The study is the first randomized controlled trial in North America to compare the two methods.

“[W]e’re able to show that integrating hepatitis C testing and treatments into OTPs transforms the hepatitis C care cascade,” lead author Dr. Oluwaseun Falade-Nwulia, an associate professor at the Johns Hopkins School of Medicine, told Filter.

Falade-Nwulia said this involved first training OTP providers to deliver hep C care to their patients. Next, finding people with lived experience to offer peer support through the treatment process.

Among patients offered on-site hep C treatment at OTP—commonly known as methadone clinics—nearly nine out of 10 initiated it. Only two out of 10 initiated care treatment through an offsite referral. After nine months, 61 percent of participants in the on-site treatment group had been cured of hepatitis C, compared to just 14 percent in the referral group.

Hepatitis C treatment does not require abstinence from substance use.

A decade ago, hep C treatment was revolutionized with the arrival of direct-acting antiviral (DAA) medications, which replaced interferon-based therapy. Interferon injections had to be administered every few days for the better part of a year, came with severe side effects and ultimately had a low success rate. DAA are oral medications, often taken for just eight weeks, that almost never cause any side effects and have a 95-percent success rate. And, critically, DAA do not require abstinence from substance use, which was a barrier with interferon.

Falade-Nwulia lamented that hep C is “still such a major public health issue,” when strategies like on-site treatment at OTP could have such a big impact. But what may seem like a straightforward intervention becomes complicated by the health care industry.

Hep C treatment is extraordinarily expensive, and so patients must first be enrolled in insurance that will cover it. In many states, patients must obtain prior authorization from Medicaid before they can receive DAA—a process that can delay care or discourage providers from offering it altogether. Seventeen states currently impose some form of prior authorization requirement. So hep C continues to spread among those least able to access treatment.

“The way OTP reimbursement is structured currently in the US limits the ability of the OTP to get additional compensation for providing this additional service,” Falade-Nwulia said. “I think we really do need policy change to provide additional support to OTPs to be able to integrate this care in their settings.”

“This is just such a low-barrier, low-threshold approach.”

One clear advantage of the OTP strategy is that it leverages existing infrastructure, upskilling staff and peers to support patients more effectively. It is not a complex or high-tech intervention, and it may be one of the most effective.

“This is just such a low-barrier, low-threshold approach,” Falade-Nwulia said. “I think the additional cost at the system level is significantly outweighed by the potential benefit, both to the people accessing services at these OTPs and the larger society that will be protected from ongoing transmission of hepatitis C.”

Still, Falade-Nwulia said that scaling this model will require addressing significant policy and financial barriers. The study demonstrated what is possible under ideal conditions; such a high level of support isn’t typically available in OTP programs. AbbVie Inc., which funded the study, also provided the DAA—sidestepping the insurance hurdles that bar so many low-income people from treatment. Abbvie manufactures Mavyret, one of the most widely used DAA.

“In states that still have prior authorization requirements for Medicaid approval of hepatitis C treatment, it will be critical to have [them] removed for OTPs to even begin to consider integrating hepatitis C treatment into their routine care,” Falade-Nwulia said.

Image (cropped) via New York State Department of Health

The post Partnering With Methadone Clinics “Transforms” Hep C Care, Study Finds appeared first on Filter.

Hepatitis is the second-deadliest virus in the world, after the COVID-19 virus. It inflames the liver and, over time, can cause serious complications like cancer.

Hepatitis A and B have vaccines, but no cure. The viral strain that most impacts drug users including myself is hepatitis C. Although hep C has no vaccine (researchers have been working toward controlled trials to develop one) it does have a cure.

And yet, the World Health Organization estimated that 242,000 people died from hep C complications in 2022. That is an astounding number.

The WHO goal is to end global epidemics of AIDS, viral hepatitis and sexually transmitted infections by 2030. For hepatitis, this means WHO member states are aiming to reduce hep B and C transmission by 90 percent and reduce deaths by 65 percent.

Direct-acting antiviral (DAA) treatment is highly effective for curing hep C. These daily medications are taken orally for eight to 12 weeks, and have minimal side effects.

“We have the tools we need,” states the World Hepatitis Day website. “But progress is still too slow. Resources are not being mobilized; stigma and discrimination are not being addressed; and despite commitments made by governments and institutions, millions are being left behind.”

With World Hepatitis Day marked on July 28, I want to highlight what Scotland has been doing at the forefront of hep C harm reduction, particularly among people who inject drugs.

Many providers withhold the cure from people who inject drugs, even though they’re the most vulnerable to hep C.

On World Hepatitis Day 2020, Tayside in eastern Scotland announced it had effectively eliminated hep C—the first region in the world to do so. Efforts like the NHS Tayside project focused on making the cure accessible to people who use drugs, especially those who inject, and not requiring abstinence from any substance use while they were on the medication.

This is the most effective approach and is practiced by government-funded harm reduction groups outside Scotland, including in the United States. But it’s not usually the norm the way it is in Tayside. Instead, it’s common for providers to withhold the cure from active injection drug users specifically, even though they’re the people most likely to contract hep C. Health insurance companies often make mandatory drug-testing a condition of getting the cost of medication covered. The full eight- to 12-week regimen can cost upwards of $10,000 out-of-pocket.

People don’t have to stop or reduce substance use—of any kind—while on the DAA medication in order for it to work. Commonly injected drugs like fentanyl or methamphetamine don’t make the medication less effective.

Since hepatitis affects the liver, substances that can speed up the progression of liver disease, like alcohol or combustible cigarettes, are a particular concern. Smoking-related illness is a leading cause of death among people with hep C, making tobacco harm reduction alternatives particularly important for this population.

But it’s a misconception that continuing to smoke cigarettes while taking DAA medication makes the medication less effective. The same is true of alcohol—cirrhosis, for example, has a greater risk of harm for people with untreated hep C, but research suggests that drinking alcohol doesn’t get in the way of the medication and that requiring abstinence from alcohol is an “unnecessary barrier” to getting cured.

Tayside met people where they were at.

Jason Grebely, president of the International Network of Health and Hepatitis in Substance Users, told Filter that Tayside’s work all started back in the days of interferon therapy. Interferon was the main medication that preceded modern DAA, which arrived within the past decade. But 20 or 30 years ago, Scotland started to see a rising number of people with hepatitis C and advanced liver disease.

“Tayside [is] a reasonably small area, but they developed a really strong public health approach and targeted a range of different interventions,” Grebely said. “They [found] where people who use drugs were attending services, and bolstered the services that were happening in those areas.”

Medication to cure hep C is available at hospitals, but that doesn’t make it accessible to people who inject drugs. Tayside made sure that providers were also bringing the cure to people at drug treatment centers, syringe service programs, community pharmacies, outreach clinics and prisons. They recognized that the way to access more people was through peer workers and harm reduction groups that already had established communities. Basically, they met people where they were at.

Public health researchers working with the government made the case for hep C treatment to be scaled up. Early on, they saw the value of DAA medications and persuaded the Scottish government to invest in elimination efforts.

“Scotland really did the modeling work, which actually demonstrated what was gonna happen in the future if we did nothing to improve how we addressed hepatitis,” Sharon Hutchinson, a professor of epidemiology and population health at Glasgow Caledonian University, told Filter. “[And] what could be achieved if we did scale up treatment.”

Though the COVID-19 pandemic slowed progress slightly, the government of Scotland has committed to eliminating hep C by 2025. Hutchinson said that the key is close coordination with a government that recognizes the effectiveness of harm reduction approaches, the way it did in Tayside.

“Finding your champions and that investment from the government, I think is so important,” she said. “It makes me wonder why more high-income countries can’t or aren’t doing it.”

Photograph (edited) of hepatitis C rapid test via New York State Department of Health

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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.”

Innovative Funding Models

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.

Funding Isn’t the Only Problem

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.”

What’s Next for HCV Treatment?

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.

The post We Can Cure Hepatitis C. So Why Aren’t We? appeared first on Filter.

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

The post On World Hepatitis Day, People Who Use Drugs Should Be the Focus appeared first on Filter.

There is a clear moral imperative to provide health care to people in prisons. What’s more, lack of access to HCV care in prisons threatens to derail worldwide efforts to eliminate the disease.

In 2016, the World Health Organization set global goals for HCV elimination. But so far, only about one in five people who have hepatitis C have been diagnosed, and only 13 percent of those living with HCV have received treatment. As countries develop national HCV elimination strategies, seeking to scale up access to testing and treatment, a cornerstone of their programs must be reaching everyone in need—and people who are incarcerated must be central to these plans.

A key tenet of disease elimination is health equity. Hepatitis C elimination cannot be achieved unless everyone is able to benefit from its promise.

Hepatitis C rates among people in prisons are among the highest in the world: up to 10-to-25 times higher than in the general population.* The blood-borne virus is most often transmitted through sharing of injecting equipment in drug use—in the absence of access to sterile supplies. Left untreated, chronic hepatitis C can lead to severe health consequences, including liver damage, cirrhosis (liver scarring), liver cancer and death.

Safe oral medications, taken for two or three months, cure over 95 percent of people treated. Unfortunately, people in prison often face the greatest obstacles to accessing this lifesaving treatment. Barriers include lack of policies for testing and treatment, lack of financing for HCV care in prisons, low awareness of effective HCV testing and treatment strategies in these settings, and biases against incarcerated people in general and people who inject drugs in particular.

A key tenet of disease elimination is health equity. Hepatitis C elimination cannot be achieved unless everyone is able to benefit from its promise. The ideals known as the “Mandela Rules,” which have been adopted by the UN as a global standard, state that human rights for people who are incarcerated should be equivalent to everyone else. Denying access to HCV medicines in prison settings may be against local laws in some cases; in all cases, it is a clear violation of human rights.

In October 2022, to develop a roadmap for concerted global action on expanding HCV care in prisons, INHSU Prisons (a Special Interest Group of the International Network on Health and Hepatitis in Substance Users) and the Coalition for Global Hepatitis Elimination (CGHE, a program of the Task Force for Global Health), convened a workshop. Held in Glasgow, Scotland, it was a satellite meeting alongside the 10th International Conference on Health and Hepatitis Care in Substance Users.

Providers, community advocates, researchers and people with lived experience of hepatitis C and/or prison came together. We sought both to identify the most pressing real-world barriers to the provision of prison-based HCV care, and to share practicable solutions to overcome them.

Many people’s lives and health depend on our continuing, urgent attention to this issue.

The global recommendations proposed in this workshop have now been compiled in a new report: “Expanding Access to hepatitis C prevention, testing and treatment in prisons: Recommendations from the 2022 INHSU Prisons Workshop.”

The final report offers 10 recommendations to expand access in prison settings. They’re geared at policymakers and those involved in the implementation of HCV testing and treatment services. 

These recommendations include: 

* Invest in strong surveillance systems that track the number of HCV infections, persons screened, and persons treated for HCV in prison setting

* Adopt routine, opt-out HCV screening policies upon entry to prison settings and invest in person-centered training for staff 

* Expand needle-syringe exchange and opioid agonist therapy programs within prison settings to reduce transmission of HCV and other blood-borne infections

* Set global, national, and local targets for HCV screening and treatment in prison settings and track progress

* Implement point-of-care HCV testing, reflex HCV RNA testing, peer navigation programs, rapid treatment initiation initiatives, and linkage to care programs postrelease to ensure all persons progress along the cascade of care to cure

* Expand HCV prescribing beyond specialists in prison settings

* Explore innovative financing approaches to ensure access to HCV treatment in prison settings

* Present economic, public health, human rights, and legal cases to policymakers and prison officials for financing HCV care for persons who are incarcerated

* Address stigma and discrimination through investing in strong patient advocacy, peer navigators, and prison staff education and training

* Spread the message that “prison health is community health” and prison-based HCV testing and treatment is a key determinant of national HCV elimination

The recommendations are based on real-world experiences shared by a global network of contributors with lived experience, along with researchers, clinicians and community advocates. The full workshop report features a summary of the presentations, discussions, and case studies informing the recommendations, and is available on the CGHE website.

The report will be a novel resource to support global and local efforts for scaling up HCV prison initiatives, with case studies on addressing challenges in a wide range of settings, from countries at all income levels—including both those with no access to HCV treatment in prisons and those with established programs looking to improve.

The Coalition for Global Hepatitis Elimination and INHSU Prisons will continue to promote HCV elimination among people who are incarcerated and share data and experiences on progress happening around the world. Many people’s lives and health depend on our continuing, urgent attention to this issue.

*Larney et al., 2013; Dolan et al., 2016; Moradi et al., 2018; Salari et al., 2022

To learn more about the Coalition for Global Hepatitis Elimination, visit its website or contact globalhep@taskforce.org. To learn more about INHSU and INHSU Prisons, visit their website or contact info@inhsu.org. 

Photograph by Jobs for Felons Hub via Flickr/Creative Commons 2.0

The post Ten Key Recommendations to Expand Hepatitis C Care in Prisons appeared first on Filter.

People who haven’t been impacted by incarceration often assume that tattoos inked in prison signify whatever the person did to end up there. In reality, most prison tattoos are not about “crime”—they’re about what comes after being convicted.

Teardrop tattoos are broadly associated with gang-related murder, but can also carry the alternative meaning that the person was raped by another prisoner. While a cobweb tattoo on an elbow can signify a racially motivated murder, cobwebs elsewhere on the body often symbolize the feeling of being trapped.

Prison tattoos are an evolving form of protest art, critiquing the injustices of the criminal-legal system and empowering the silenced through creative expression. Microphone tattoos can represent the feeling of having no voice in a carceral setting; alternatively, they can appear on prisoners who have gained power and influence—”holding the mic”—within that setting.

Even the process of tattooing itself is an act of resistance—tattooing is illegal for prisoners, and any equipment associated with it is contraband.

For veteran artists like JonJon, 41, tattooing is a lifeline within the critically underresourced Georgia Department of Corrections (GDC) system. Customers pay him in commissary goods, cigarettes, stamps or whatever they have access to.

“Tattooing is how I’ve survived roughly 20 years in prison,” JonJon told Filter. “It’s all I know, and it’s how I eat.”

In GDC facilities, a common tattoo is the “hanging man”—a symbol of being sacrificed on the “tough-on-crime” alter, by way of excessive sentencing. Another is the “13 & ½”—12 jurors, one judge, a half-ass chance. Monkeys dressed in prison-issue uniforms have a few different meanings, all of which are fairly self-explanatory.

Artist sketch: Caged monkey trying to lead the semblance of a normal life, in an abnormal environment

Artist sketch: “Trying to find the beauty in our death,” referring to incarceration

“During the AIDS epidemic of the ’90s, when we were first coming in, there were all these old men that had this tattooed chain thing,” JohnBoy, 58, told Filter. “A cross formed using a pickaxe and a shovel, with a ball and chain at the bottom of it. ‘Chain gang’, right? So if you had that tattoo, it didn’t say you’d been in prison—but you only got that in prison.”

Another design popular in that era was the outline of the state of Georgia, with bars and handcuffs linked through. “A ‘fuck you’ to the state, and its history as a prison [labor] force,” JohnBoy said. 

JohnBoy has been an intermittent tattoo artist over the course of his 30-plus years in GDC facilities. On one man, he inked a planet surrounded by rings and stars, bearing a jagged crack representing the daughter who died the same day he was arrested. Another man got a list of everything he’d been before he was sent to prison—Marine, dad, husband, coach—on his chest, in the same place his ID card was when clipped to his shirt. He told JohnBoy that he wanted the tattoo to help him not forget who he was—but also so that if he died in prison, his body would bear the record, too.

“It’s like, ‘Look at my mutilated skin! I am known by people! I matter to the people who matter to me!’”

“My first prison tats were in opposition to the things ‘normal’ people did,” JohnBoy said. “They were a way I showed that I was more than my crime and that I had a point of view, too. That’s incredibly important when you’re staring down the barrel of a life sentence, and you’re now effectively a person with no legal or political voice.”

Like in the free world, tattoos bearing the names or birthdates of loved ones are common. But in prison, these are often inked mournfully, to commemorate what someone couldn’t be there for—funerals of parents; births of grandchildren. Often these tattoos take the place of holiday or birthdays gifts that prisoners are unable to get for their loved ones.

“Rows of tombstones with RIP and lists of next of kin are the tangible evidence of our existence in the world,” JohnBoy said. “It’s like, ‘Look at my mutilated skin! I am known by people! I matter to the people who matter to me!’”

A tableau showing one man’s journey from gang member to prison minister

The skull of a different prisoner being suffocated by two snakes—”Justice” and “Law”

“If you’re a tattoo artist here, you meet all kinds but you’re … common ground for everybody,” AG, 41, told Filter. “Neutral territory. Nobody fucks with the tattoo man.”

A long-time artist who, like JohnBoy, is serving a life sentence, AG was first incarcerated in a county jail more than a decade ago. “Modern” tattoo guns weren’t available, and all tattoos were done via “pick-poke”—ink on a staple, paperclip, sewing needle, old piece of wire or whatever else was handy. 

“They were rude and crude,” AG recalled. These tattoos don’t age all that gracefully, at least compared to what he began seeing after he was sent to the GDC prison system. “Guys were making tattoo guns using motors out of electric razors, CD players … any kind of small motor would make it work. And really that’s evolved, because today we have the water guns.”

Running the water from a sink across a DIY tattoo gun provides power that moves the needle. Highly effective, depending on your water pressure.

Sky without fences

Self-portrait, JonJon

But even as AG has seen some prison technologies advance, he’s seen others degrade. “We used to have more regular access to real tattoo ink, as it used to be a regular staple on the black market,” AG said. “But guys make more money prioritizing other things to come in.”

Ink these days is either baby oil or vaseline. Pour into a shoe polish can with a wick added so it burns off like a candle; catch the soot; mix with some water—and you have ink. Not sterile, but serviceable.

In 2022, a Minnesota prison began a pilot program to mitigate transmission of HIV and hepatitis C via tattoo needles. Prisoners reached by Filter were in broad consensus that a tattoo harm reduction program would be welcome in GDC, and desperately needed. It’s unclear how many of the system’s nearly 50,000 prisoners have untreated hep C—GDC conducts minimal testing, and does not track transmission.

“A lot of people say, ‘Well, I’ve never heard of people getting tattoos like that on the street,’” AG said. “Well, of course not. The reason why it happens here is because there’s so little left. So little to live for, and you have to live up to something.”

All names have been changed at sources’ request.

Top image courtesy of JohnBoy. Inset self-portrait courtesy of JonJon. All other images courtesy of Anonymous.

The post An Act of Resistance: The True Meanings of Prison Tattoos appeared first on Filter.

Before the sun set, this group of mobile harm reduction workers had sent encrypted text messages to people in the area who needed these supplies, detailing times and locations for secret drop-offs. Everyone was told to look out for the gray car.

“We’ve been forced to work in the shadows.”

For the next several hours, I sat shotgun criss-crossing Kanawha (pronounced: Kuh-Naw) County, pulling into parking lots of big box stores and fast food restaurants which, for a brief moment, became sites of health care and civil disobedience. As we arrived at each parking lot, people would approach the car, warily at first. Once the car doors were open and the coast was deemed clear, the hand-offs quickened and people walked briskly away with a word of thanks and their injection supplies.

“It feels like we’re doing a drug deal,” one of the harm reduction workers said, driving to the next parking lot. “We’ve been forced to work in the shadows.”

***

For many people who use drugs, especially in rural states, harm reduction programs function as their only lifeline. Pharmacies refuse to sell syringes. Emergency departments send them home with little more than a brochure of phone numbers. Abandoned by mainstream health care institutions, syringe service programs keep them connected not only to health care, but to kind and caring people.

But that connection has been severed in West Virginia by a state law passed in April 2021. Passing out syringes without explicit approval from state health officials, local commissions and the county sheriff now carries misdemeanor charges, fines of up to $10,000 and possibly jail. For harm reduction programs to operate legally, they must also abide by a strict “one-to-one” rule, which means people can only receive one new syringe for every used one they return. By contrast, the Centers for Disease Control and Prevention promotes “needs-based” syringe programs, which are far more effective at reducing the spread of HIV and other infections. Since the new law took effect, several harm reduction programs have shuttered across West Virginia, leaving vast stretches of the state with no services whatsoever.

The crackdown on harm reduction and the resulting syringe scarcity has been catastrophic for public health. In 2018, only two new cases of HIV were detected in Charleston. But that year, state and local officials decided to shut down a syringe program. By 2020, 40 new people in Charleston who inject drugs were diagnosed with HIV—roughly the same number of new cases as in New York City, which is 47 times more populous. Epidemiologists familiar with West Virginia’s outbreak suggest these numbers are merely “the tip of the iceberg,” and that many more cases statewide have gone undiagnosed and undetected.

In these deserts of care resourceful people and organizations create scattered oases.

The devastation convinced the Charleston group to operate a mobile syringe program without permission, in defiance of the law. They’re taking on immense legal risk, which is why their names are being withheld.

Tents in front of a boarded-up home in Charleston, West Virginia.

West Virginia is far from the only state where harm reduction programs face political, legal and cultural obstacles. Across rural America, programs that distribute naloxone, sterile injection equipment and fentanyl test strips, and which make referrals to low-barrier prescribers of medications like methadone and buprenorphine, are chronically underfunded and struggle to meet the needs of their communities. Meth use, a major contributing factor to rural overdose, remains substantially overlooked. If neighborhood backlash doesn’t drive out harm reduction programs, then councils and state legislatures are more than happy to step in.

Today, demand for harm reduction services across America far outstrips supply and capacity, especially in remote parts of the country where syringe or methadone programs are hours and hours away. Still, rural America contains multitudes, and in these deserts of care resourceful people and organizations create scattered oases. In Charleston, that means breaking the law to distribute supplies to people who drive in from all over the state. Elsewhere, harm reductionists are leveraging online platforms and civic institutions as unlikely sounding as the church.

***

In Kanawha County, one tall woman with bleach-blonde hair was especially grateful for the injection supplies, she said. Earlier in the week she had run out of syringes and resorted to injecting methamphetamine in her neck using an intramuscular needle intended for naloxone, a process she described as horribly painful (the gauge of an IM syringe is far too big for veins).

In a McDonald’s parking lot, a man in his 30s wearing a flat-brimmed New Era hat asked if tonight’s kits had those little blue plastic vials of sterile water. “No, not this time,” one of the workers said, regretfully. The group couldn’t afford to order more water units. In yet another parking lot, the workers handed supplies to a friendly woman named Tabitha, who told all the workers to text her when they got home; like a mom to teenagers, she wanted to make sure they were safe.

“That’s mostly what we’re confronting out here—people’s pain.”  

Next, we pulled into a Wendy’s, which was not on the itinerary as an official drop-off site. There we saw two young men slouching on the curb, wearing black zip-up hoodies. The workers offered them supplies, which, it turned out, they needed. One of them, who told me his name was Chris, said, “Everyone’s passing around HIV. There’s no new rigs.”

“Charleston wears its pain on its sleeve,” one of the rogue workers said. “That’s mostly what we’re confronting out here—people’s pain.”  

***

Hundreds of vials of naloxone sat on an altar at the United Methodist Church in Columbus, Ohio. The opioid-overdose antidote was due to be blessed in a church service led by preacher and harm reductionist Blyth Barnow. Barnow cheekily titled her service “Naloxone Saves,” a play on the ubiquitous “Jesus Saves” bumper-sticker slogan. Wearing a black dress, she stood at the dais and began preaching the Christian theological basis for harm reduction, connecting naloxone distribution to key concepts like resurrection. This medicine, she said, gives ordinary people great power.

With the lights dimmed, Barnow invited those who’ve lost loved ones to overdose to light a candle in their memory. Across working-class communities in Ohio, where Barnow was born and raised, there are always people in the crowd who have lost family and friends. Overdose deaths recently jumped by 26 percent—to 5,585 lives lost in 2021. Like West Virginia, Ohio’s rate far exceeds the national average.

In the flickering orange glow, Barnow’s voice boomed, “We must step in and help to distribute lifesaving tools like naloxone, fentanyl testing strips, and sterile equipment. We must commit to lifting people up when systems let them fall.” She then read from Matthew, 10:5-8: “Cure the sick, raise the dead, cleanse the lepers, cast out demons. You received without payment; give without payment.”

In each service, Barnow encourages people sitting in the pews to come up to the altar and take as many naloxone kits as they need, for free. “The hope is, whatever naloxone I bring with me that I leave with none,” she said.

Photograph courtesy of Blyth Barnow

I asked Barnow, who is the Ohio associate director for Faith In Public Life, if her strategy was working. Have any churches denied her?

“We had one church that wasn’t comfortable doing naloxone distribution without the health department there,” Barnow said. “So the health department came and distributed [naloxone] based on their protocols and I distributed based on my protocols. The health department distributed 25 Narcan kits and I distributed 75 kits.” Barnow said the health department workers were stunned that she gave away triple what they did. “They had never distributed more than 25 kits.”

“It’s hard to read it as anything other than hate for people who use drugs. Oftentimes, when we get into the nuance, it’s actually people holding a great deal of hurt and grief.”

Health departments in Ohio tend to ask a lot of questions and collect a lot of “data,” Barnow explained, which may make people skittish. Her approach is to make people feel welcome and not ask questions. 

“Watching people walk away from the altar with an armful of [intramuscular] naloxone, sometimes taking 25 kits at a time, and seeing that happen in a church sanctuary during a church service, is just deeply meaningful to me.”

Much of her pastoral work, Barnow continued, involves “holding space” and “sitting in the mess” with people while they work through their own internal conflicts.

“A lot of times we see the objections or hostility to harm reduction and it’s hard to read it as anything other than hate for people who use drugs,” she said. “Oftentimes, when we get into the nuance, it’s actually people holding a great deal of hurt and grief that they have never been able to share with another person.”

***

With President Joe Biden in the White House, some had hopes that a landscape hostile to harm reduction would change. For the first time in US history, the federal government included harm reduction as a central tenet of its national drug policy strategy. In another first, Biden’s American Rescue Plan created $30 million worth of grants for harm reduction programs. After decades on the fringes of drug policy, harm reduction was finally being recognized as a valid, necessary and effective approach.

But the recent, albeit partial, embrace of harm reduction at the federal level has often not translated to support at the local level, where America’s streak of punitive, zero-tolerance, abstinence-based drug policy and treatment still holds considerable sway. And that’s particularly true in rural states where conservative values, at least on their face, appear to clash with the practice and principles of harm reduction, which are rooted in self-determination and bodily autonomy. Whereas conservatives prefer people to be self-reliant and free from dependency—in this context, perhaps, “clean and sober”—harm reductionists recognize the importance of interdependence, and try to attach as few strings as possible to help. Few US drug laws have caught up to harm reduction’s view.

Words on a home in Charleston read, in part, “NO SELLING OR BUYING DRUGS ALLOWED HERE LORD HAVE MERCY ON ALL OF US AND USA.”  

So often, policy and laws that materially affect the lives of people who use drugs are decided not in Washington, DC, but in city councils, town halls, police departments and the pages of local newspapers. In Alabama, for instance, a new state law prevents telemedicine providers from prescribing a controlled substance unless the patient has had an in-person appointment within the previous 12 months. As a result, rural patients receiving buprenorphine remotely have been scrambling to find a doctor nearby.

In dense urban centers as well as sparsely populated rural areas, harm reduction programs are in the public’s crosshairs— frequently viewed as “enabling” and “coddling” people who use drugs, as prolonging addiction rather than spurring recovery. Harm reduction’s growth has put it on a collision course with America’s dominant paradigms.

“Rural and remote areas are really left out of the harm reduction equation.”

“That’s the climate that we are responding to right now,” said Jamie Favaro, the 42-year-old founder of NEXT Distro, an online platform that sends harm reduction supplies through the mail.

Like the underground syringe program in Charleston, NEXT Distro has found a way to get supplies to those in need, whose numbers have only swelled during the COVID-19 pandemic. Thousands of requests for injection supplies come from people in rural neighborhoods and small towns that lack the services of major metropolitan areas. These locations might be served by just one pharmacy, which may choose to not distribute naloxone, which may not dispense syringes without a prescription, and which might not even stock opioid use disorder medications like buprenorphine. State paraphernalia laws, meanwhile, criminalize the possession of fentanyl test strips, syringes and other supplies.

“Rural and remote areas are really left out of the harm reduction equation,” Favaro told Filter. That’s where NEXT comes in, mailing out the supplies to places without brick-and-mortar syringe programs. The legal assault on harm reduction and public health is perhaps most stark in Tennessee, from where Favaro receives numerous requests for supplies.

“In Tennessee, we call it the ‘Slate of Hate,’” said Lesly-Marie Buer, a harm reductionist and medical anthropologist from Knoxville. “It’s the anti-abortion, anti-trans, anti-LGBTQ legislation that comes up every year.”

This unified conservative caucus invariably targets harm reduction, too. Most recently, Tennessee legislators attempted to require that every single syringe program in the state receive a public written letter of support from local law enforcement. “Let me just tell you, that’s not going to happen,” Buer said. “It would be political suicide for a sheriff or police chief to support harm reduction.”

Out of Tennessee’s 95 counties, only seven are home to legally sanctioned syringe service programs, the majority located in densely populated metro areas. And unlike neighboring states, such as Kentucky, Tennessee has not expanded Medicaid, leaving over 100,000 residents without health insurance and access to critical care. The 10,000 square miles of West Tennessee, in particular, are a harm reduction and health care desert.

Map of Tenessee counties with syringe service programs via Tennessee Department of Health

In rural Tennessee counties, syringe programs must also be sited 2,000 feet away from any school or park. The state also recently criminalized homelessness, making it a felony for any unhoused person to camp on public land. Critics of the new law say the unhoused population is simply being pushed further from public view, and away from services that could be of help. These barriers on the ground make the work of NEXT Distro all the more salient.

To access supplies through NEXT, people are asked to fill out an “enrollment” form, which helps NEXT assess their needs. One question asks enrollees how often they have shared syringes with another person in the past month. The responses horrify Favaro. “In states like Pennsylvania, West Virginia, Tennessee, Ohio, we’re seeing up to 40 percent of people reporting active syringe sharing ‘all of the time’ or ‘most of the time.’” High levels of syringe sharing, Favaro explained, account for the ever-expanding clusters of HIV and hepatitis C in rural America.

“Never in my lifetime would I think I’d see young people my age dying of HIV.”

“I was 17 years old when I got my first job at an HIV drop-in site,” said Brooke Parker, an outreach worker for Charleston’s Ryan White Program. “I’m 37 now, and never in my lifetime would I think I’d see young people my age dying of HIV.” But, that’s exactly what she is seeing now. Part of Parker’s job is to ensure people living with HIV can access antiretroviral medication, but she cannot offer her clients one of the most powerful tools to prevent HIV from spreading: sterile syringes.

“An increase in acute [hepatitis C] infection in individuals 30 years of age or younger over the past decade has occurred in both nonurban and urban counties,” Dr. Stuart C. Gordon, director of hepatology at Wayne State University School of Medicine in Detroit, wrote in 2019. “But the incidence of infection has been twice as high in rural areas than urban ones.”

A sharps container in Charleston.  

Favaro’s voice carried with a mix of sadness and anger over the phone. “Right now, NEXT is receiving about 160 to 200 applications every week for our program,” she said, describing the surging demand as “incredibly overwhelming.” Lacking financial support—NEXT did not win a slice of the $30 million federal pie for harm reduction programs—it’s virtually impossible for Favaro to serve all applicants. NEXT is forced to triage and prioritize only those in severe need. “People just cannot access the supplies they need to be safe,” Favaro said.

***

Blyth Barnow, who identifies as queer, didn’t always have a warm view of religious institutions. She vividly remembers a minister condemning her partner who died of an overdose at their own funeral service. “My friends kept dying and I kept going to awful, awful funerals,” she told me. After years of running away from Christianity, Barnow decided to run toward it. “You’re a shitty pastor, so Imma be the fuckin’ pastor,” she thought. That eventually led to her project to spread harm reduction and drug policy reform through the church, showing churchgoers how their faith actually aligns with these goals.

Her Naloxone Saves service recontextualizes overdose prevention as an act of resurrection, her way of living into the harm reduction maxim of “meeting people where they’re at.” She uses the language, symbolism and principles of Christian theology to engage her faith community around harm reduction, melding worldviews often deemed immiscible, like oil and vinegar. But Barnow views churches across the Midwest as a potential vehicle to preach the gospel of harm reduction.

“I wasn’t born a harm reductionist,” Barnow laughed. “It took some convincing for me.” And yet, “It was through harm reduction that I came to understand that resurrection was a real thing.”

Getting churches on board with harm reduction can be an uphill climb. So is getting harm reduction on board with the church. Barnow attended seminary school in Berkeley, California while working at the Harm Reduction Coalition in Oakland. “I went to seminary as a harm reductionist, as a queer person, as a person raised working class and poor, whose partner was trans,” Barnow said. “A lot of my community has been deeply and negatively impacted by the institutional Christian church and far-right wing Christianity.”

It illustrates how cultures which, on their surface, appear to be hostile to harm reduction can be mobilized to advance it. 

So she’s not surprised when people in harm reduction are wary of involving the church in their work. “Like anything, it’s a slow trust-building operation.” Forging that trust has led to thousands of doses of naloxone distributed directly to communities hit hard by overdose deaths.

Barnow’s battle involved changing Ohio laws that placed onerous restrictions on distributing naloxone. Community-based programs seeking to do so required special permission through a Terminal Distributor of a Dangerous Drug (TDDD) license. This posed a major obstacle to scaling up desperately needed low-barrier naloxone distribution.

Barnow organized to change Ohio’s naloxone law by building power between the faith community and grassroots harm reduction organizations. Working together, this coalition slowly made inroads with key groups like the state’s Board of Pharmacy, and then approached state legislators.

In 2020, after years of painstaking work, Ohio’s new naloxone law allowed for more direct, community-based distribution, enabling Barnow to give away hundreds of naloxone kits through churches. It illustrates how cultures which, on their surface, appear to be hostile to harm reduction can be mobilized to advance it. 

***

West Virginia, home to “the most concerning” HIV outbreak in the nation and one of the highest rates of hepatitis C, has an overdose death rate more than double the national average. Methadone, proven to reduce mortality among people with opioid use disorder by 50 percent or more, is heavily restricted: Just nine clinics operate in the entire state, forcing people to drive enormous distances to access the medication that could save their lives.

“We have people at the methadone clinic where I go coming from two hours away, everyday,” Mandy Cavender, a 37-year-old resident of Charleston, told Filter. “Some of them pay cash money, $25.50 per day to dose. That’s on top of the gas money to get there. People come from way out there—it’s crazy.”

“Had I just been able to go to the needle exchange and get what I needed, I wouldn’t have HIV today.”

Not long after Charleston shut down multiple harm reduction programs, Cavender learned she was HIV-positive. She believes it could have been prevented.

“Had I just been able to go to the needle exchange and get what I needed, I never would have bought a bag of points on the street and I wouldn’t have HIV today,” she said. “Now I have something I have to live with for the rest of my life.” Cavender is both saddened and enraged by the state’s crackdown. “The cops and the city shut them down so hard,” she said, “which was one of the stupidest things they could have ever done.” 

Failure to contain HIV in more urban areas like Charleston has led to its spread in more rural parts of the state. Mountain State Spotlight, an investigative news outlet in West Virginia, reported that new HIV cases were found in 29 West Virginia counties last year, many of them rural and many of which had not seen a new case in years.

“Did you see the McDonald’s right up the street? The little park right next to it?” Cavender asked me. The pitch of her warm Southern drawl deepened. “That’s AIDS Park,” she said. “The walkways made of bricks with names on them. Every one of those names is someone who passed away from AIDS.”

One brick read simply: “In memory of Gary.” Another read: “Garden Friend Edie Maine Ashley.”

Standing on those bricks in the park, the ornate dome of West Virginia’s capitol building looms in the distance. “It’s not a secret, the IV drug use around here is extremely serious,” Cavender said.

I asked Cavender why she thought politicians, law enforcement and parts of the community came down so hard to shut programs dedicated to preventing even more names from being etched into those bricks. Her answer was chilling.

“The amount of homeless people, street people, got really high here,” she said. “It made everything so visible.”

Top photograph of Brooke Parker on her HIV outreach beat and all photographs unless otherwise stated by Zachary Siegel

Correction, August 24: This article has been edited to correct Jamie Favaro’s age.

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.

The post “Where They’re At”—Harm Reduction in Rural America appeared first on Filter.

There are other potential benefits as well. New research out of Australia, published in the Harm Reduction Journal, suggests that the vending machine sites could be a point of contact between people who use drugs and hepatitis C testing and treatment. In short, members of medical or harm reduction organizations could set up near the machines and offer people referrals or contact details for hepatitis C services. In the research, some respondents expressed support for this idea. However, others appeared to be deterred by the presence of people there, indicating that they viewed the machines as private spaces, and preferred to avoid personal engagement in that setting.

“We were just trying to see if we could understand more about the people using the machine,” Carolyn A. Day, associate professor in addiction medicine at the University of Sydney and one of the authors of the paper, told Filter.

The teams included peer workers, and offered vouchers for research participation or hep C testing and treatment uptake.

The research began in 2020. It focuses on a particular harm reduction vending machine located near the emergency department and public opioid treatment program in the Royal Prince Alfred Hospital, a large teaching hospital in inner-city Sydney. Established in 2013, the machine provides free sterile syringes in an effort to prevent blood-borne disease transmissions through shared needles.

First, the team looked at footage from a nearby CCTV camera—present because the machine is in a hospital—over a random two-week period to get a sense of the number of people who made use of the machine, and the times of day they used it. According to Day, the footage didn’t contain enough detail to identify any of the people using the machines.

The researchers saw 428 cases of people using the machine during the two-week period, mostly between around 8 am and 8 pm, with Saturday the busiest day. The next stage of the study involved having researchers sit near the machine—predominantly at times when it was expected to see the most traffic—for a period of 10 weeks.

These teams included peer workers, and offered vouchers for research participation or hep C testing and treatment uptake. They would either ask to survey or interview the people who made use of the machine, or—if the person seemed apprehensive of their presence—leave them alone. “If someone clearly, through their body language, did not want someone to speak with them, we respected that,” Day said. “But generally, we did try to reach many people. Our response rate was not what we necessarily would have hoped because some people just wanted to remain private.”

In all, the researchers came away with 70 surveys answered and 15 interviews. In the surveys, 61 percent of respondents reported having received hepatitis C testing in the past six months, and 38 percent reported having had hepatitis C treatment. Further, from the fieldwork, the researchers found that there is potential to use harm reduction vending machines as a way to engage with people who use drugs and refer them to hepatitis C treatment or testing.

Some people approached the researchers and engaged in long conversations. Sometimes they would recognize the peers who were present, and sometimes, the researchers wrote, “the expertise of peers regarding injecting practices was gratefully received by people using the [machines] and assisted with building trust.”

For many people, it’s the very anonymity of the machines that makes them accessible.

However, the researchers also found that most of the people who used the machine were not willing to interact with them. As they noted in their published paper, past research “suggests women may experience gender-specific barriers to [hep C] care, and may be reluctant to access face-to-face drug health services because of stigma and concerns about child protection.” And respondents in some of the interviews expressed concerns over privacy. 

“I just try to be as quick as possible and look around and try to avoid being seen by people,” Kate, a 49-year-old woman who uses heroin, told the researchers.

“There’s cops all over the footpath outside having a smoke or whatever and I’m just off my chops and I’m thinking, ‘Look, I just don’t want to talk to them today,’” said Paul, a 41-year-old man who uses methamphetamine.

There were even occasions when the researchers believed that their presence may have deterred a person from using the machine. As such, trying to offer hepatitis care at these locations might be viewed as an encroachment—for many people, it’s the very anonymity of the machines that makes them accessible.

According to Day, the research suggests that harm reduction vending machines should continue to be available in a discreet way, and there may also be a need for more of them in more private locations to meet people’s needs. There could also be value, however, in putting information about hepatitis C treatment and testing on the machines themselves—possibly available through QR code—or together with the items in the machines.

“From a service perspective, it’s that balance between fully respecting people’s desire to be anonymous, [enabling them to use the machines] in a way that protects their anonymity,” she said. “But at the same time, we want to make sure we’re providing them enough information and enough opportunity for low-threshold access to some of the services if that’s what they desire.”

Photograph via US Department of Veterans Affairs

The post Hep C Outreach and Anonymity at Harm Reduction Vending Machines appeared first on Filter.

As reported by the Salem News, the North Shore Health Project (NSHP) a nonprofit based in Gloucester, first approached Ipswich to propose an SSP, offering to be the town’s provider. The three members of the town’s Board of Health took up the idea at their May 9 meeting. On May 23, they announced they will continue exploring the idea at their next meeting, on June 6.

“We are interested in learning more about syringe service programs, and the information we receive will help guide us as we consider all options,” Board Chair Susan C. Hubbard said in a press release. The board has scheduled for Kevin Cranston, assistant commissioner for the Massachusetts Department of Public Health (MDPH) to attend the June 6 meeting and weigh in on how the state can be involved in setting up an SSP.

“No overdose death is insignificant, because they’re always accidental and preventable.”

SSP are proven to reduce transmission of blood-borne disease like HIV/AIDS and hepatitis C by providing sterile injecting equipment. They also offer the opioid-overdose reversal drug naloxone, together with many other services and referrals to people who use drugs.

Susan Gould-Coviello, executive director of NSHP, told Filter that her organization has been funded by the state to expand its operations to other towns in the North Shore area. They already work with and serve residents in Ipswich, a coastal town of around 14,000 people in Essex County, and are sure it would benefit from its own SSP.

“They generally have over the last five years an average of three or four overdose deaths a year,” she said, “which sounds small—but no overdose death is insignificant, because they’re always accidental and preventable. We do know there is drug use in Ipswich.”

Gould-Coviello added that hepatitis C diagnoses, primarily associated with injection drug use, have increased among residents.

Ipswich Police Chief Paul Nikas said during the May 9 meeting that he was “not adverse” to an SSP. But Gould-Coviello said he asked some pointed questions, including where the SSP would park its mobile outreach van, and he wondered if the SSP would attract more drug use to the town. As the Centers for Disease Control and Prevention note, research demonstrates that SSP do not increase drug use or crime. But Nikas’s support will be symbolically important, Gould-Coviello said, and could strongly influence the board’s final decision.

If that decision is positive, Ipswich’s SSP will also need to be approved by the state. The state would then find a provider to contract with. Very likely that would be NSHP, Gould-Coviello said, because it’s the only harm reduction provider in the North Shore region.

To date, 95 percent of NSHP’s funding comes from the MDPH. That money pays for staff and supplies, but not for other services the harm reduction workers offer. “We buy food carts [and groceries] for our clients, we buy sleeping bags and tents, we provide transportation to treatment centers,” Gould-Coviello said. “All of those are paid for with private funds.”

“We intend to keep this ball rolling, because the more syringes we can get in the hands of drug users, the more likely they are to live healthier lives.”

Massachusetts first began formally authorizing SSP in 1993. State law at the time was restrictive, allowing the MDPH to authorize just 10 programs statewide. And over 20 years later, only six SSP were in operation in the state. The law had a vague requirement that SSP get “local approval”—and for many programs, that’s proven a major obstacle. Tapestry Health, for example, which operates an SSP in Holyoke, ended up in a court battle a few years ago, after the city council tried to shut it down—despite the city’s health board, mayor and police chief all supporting the SSP. (Tapestry continues to operate in Holyoke today.)

In 2016, the legislature amended state law by lifting the cap on SSP, meaning more could open statewide. It also clarified that any SSP must be authorized by the MDPH, with additional approval needed from its local board of health—but not from elected officials. Within the first year after a new SSP opens, the MDPH must also report on its progress to the state legislature.

Since 2016, SSP have spread significantly in Massachusetts, with 41 cities and towns now hosting one.

“We intend to do this in other communities and keep this ball rolling, because the more syringes we can get in the hands of drug users, the more likely they are to live healthier lives,” Gould-Coviello said.

Photograph via US Department of Veterans Affairs

The post Ipswich, MA, Considers Opening Its First Syringe Program appeared first on Filter.

Hep C, a curable liver infection that is commonly transmitted through shared needle use, currently affects more than 30,000 people in Alabama. Yet the state “denies [hep C] treatment to otherwise eligible Medicaid enrollees who cannot prove they did not use drugs or alcohol within the last six months.” Prospective patients must also agree to not use drugs, including alcohol, during the treatment. Out of pocket, a standard regimen of hep C medication costs tens of thousands of dollars.

Use of state-banned drugs like heroin, fentanyl, cocaine and methamphetamine does not interfere with the efficacy of the medication. The only substance of concern is alcohol, since hep C affects the liver and the additional strain from alcohol can make it more difficult for the medication to do its job. But the public health-based approach is to not withhold lifesaving treatment just because someone consumes alcohol; rather, patients are advised to abstain for the duration of treatment—typically eight to 12 weeks—if possible, and if not to just reduce their drinking as best they can.

Alabama Medicaid patients found to be using drugs, including alcohol, while taking the medication face their treatment being discontinued. But it is unclear how Alabama Medicaid would monitor this, or whether drug-testing would be involved. Neither Alabama Medicaid nor the DOJ responded to Filter’s request for comment.

The policy could not only prevent some patients from curing their hep c now, but prevent them from ever being cured.

Discontinuing hep C treatment partway through can result in a patient’s system developing a resistance to the medication, meaning that this policy could not only prevent some patients from being cured during the current attempt, but prevent them from ever being cured.

“On an individual level, for a single person seeking hep C treatment, it means the difference between being cured of hepatitis C and continuing to live with this very dangerous illness that, in many cases, can lead to liver scarring, liver cancer and even death,” Suzanne Davies, an attorney and CHLPI clinical fellow, told Filter.

Alabama is not alone in maintaining these prohibitive requirements around hep C medication. “A lot of state Medicaid organizations put a lot of restrictions into their policies,” Davies said, prompted by “what they perceived to be the high cost of treating people.”

If these states “made an effort to do the opposite of what they are doing,” she continued, “then that would have a really big public health impact in not just curing individual people, but helping to make sure that [hep C] doesn’t continue to spread.”

Still, Davies added that Alabama’s sobriety clause is something of a hold-over from an earlier time, as in recent years many states have removed these policies.

While CHLPI and AIDS Alabama could have started a legal case against Alabama Medicaid—and did against Texas Medicaid’s practices in 2021—they decided to go through the DOJ because it is the federal entity tasked with enforcing Title II of the Americans with Disabilities Act, which oversees anti-discrimination among state or local government entities like Medicaid.

“In this case, looking at the past couple of years, we have noticed that the [DOJ] has been involved in several settlements with public entities and private entities involving issues regarding substance use disorder,” Davies said. “People had reported discrimination against them based on their substance use, and the [DOJ] had settled cases with some of those entities.”

Petitioning DOJ to investigate state Medicaid systems can be an effective way of combatting Title II discrimination. In an administrative complaint of this kind, one party submits information about what happened for the DOJ to evaluate, and then decide whether to begin its own investigation into the matter.

DOJ taking up the complaint “would be such a big step in the right direction,” Morgan Farrington, founder of Alabama-based harm reduction organization GoodWorks, told Filter.

But the timeline on which DOJ will respond to the complaint is uncertain. It “could be a fast turnaround,” Davies said, “or it could take years.”

Photograph via Centers for Disease Control and Prevention

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