Harm Reduction International’s annual report on the global state of harm reduction includes an update on whether countries are on track to meet the World Health Organization target of eliminating hepatitis as a public health threat by 2030. Natalie Davies explores the findings.

The global state of harm reduction 2022 (Harm Reduction International)

The 2022 report from Harm Reduction International provides a “global snapshot of harm reduction policies and programmes” and includes the contributions of 192 people in 87 countries. Overall, it found that there has been an upward trend in harm reduction provision and acceptance. However, current levels of coverage might not be enough to address one of the major harms associated with injecting drug use – viral hepatitis.

More countries adopting harm reduction policies

Harm Reduction International reports that there has been an increase in the number of countries offering harm reduction interventions, including:

There has also been a substantial increase in the number of countries making supportive references to harm reduction in national policy documents (105 countries, up from 87). In Harm Reduction International’s words, “Harm reduction is stronger than in 2020”.

There has been no change, however, in the number of countries providing needle and syringe programmes and opioid agonist therapy programmes in prison. Currently, only nine countries operate needle and syringe programmes in prisons: Armenia, Canada, Germany, Kyrgyzstan, Luxembourg, Moldova, Spain, Switzerland, and Tajikistan.

Many countries not on track to meet targets to eliminate hepatitis

Harm reduction is a philosophy and a strategy, defined by “the aim to minimise the negative health, social and legal impacts associated with drug use, drug policies and drug laws”. One of the harms associated with illicit drugs is hepatitis C, which is a blood-borne virus that can be passed between people who use drugs when they share needles and syringes. Although the virus is preventable and treatable, many people who inject drugs are living with hepatitis C and are at risk of developing serious liver damage.

About hepatitis C

In the early stages of contracting hepatitis C most people either do not experience noticeable symptoms or they experience symptoms that are similar to many other short-term infections and so may not seek medical attention.

A small proportion of people infected with hepatitis C will naturally clear the virus from their body in the first six months, but around 3 in 4 people develop a chronic infection.

While chronic hepatitis C can lead to serious health problems such as cirrhosis and liver cancer, it can be successfully treated with direct-acting antiviral medications, which have fewer side effects than earlier interferon-based treatments.

The World Health Organization (WHO) has been working to eliminate the public health threat of viral hepatitis by 2030. Updated goals for 2022–2030 include an 80% reduction in the number of new hepatitis C infections by 2030, and a 50% decrease in the number of people dying from hepatitis C.

Unfortunately, the 2022 Harm Reduction International report suggests that most countries are not on course to meet the WHO targets, including 80% of high-income countries. In fact, 67% of high-income countries are projected to be off-track by at least 20 years.

Challenges specific to the population of people who use drugs

Hepatitis care can be difficult to access for people who inject drugs. Some countries in Western Europe, for example, have imposed restrictive guidelines for hepatitis treatment, including requiring patients to be enrolled in drug treatment or to show a negative drug test result. People who use drugs also tend to have poor access to healthcare services, and experience stigma when they tell healthcare workers that they use drugs.

To address these kinds of barriers, the report recommends that countries implement community-based test-and-treat services, and include people with lived experience in the service design as ‘peer navigators’ to help patients through hepatitis testing and treatment. An example of good practice is the C-FREE intervention, which Thailand introduced in six drop-in centres for people who use drugs. This provided harm reduction alongside testing for HIV, hepatitis B, and hepatitis C every three months, and gave people who use drugs a way of accessing care in a setting where they felt comfortable and accepted.

United Kingdom: progress at home

In December 2022, NHS England announced that the “NHS is on track to eliminate hepatitis C by 2025 thanks to a pioneering drug deal and a concerted effort to find people at risk, which is helping dramatically cut deaths five years ahead of global targets”. This announcement was referring to the prevalence of chronic hepatitis C, and not to the incidence of new infections or re-infections.

The 2023 Shooting Up report confirmed that “There is evidence for a continuing decline in the prevalence of chronic [hepatitis C] infection in this population, which is largely due to improved testing and access to direct-acting antiviral (DAA) treatment”. However, it added that “prevention of new and re-infections remains a challenge”.

Based on data up to the end of 2021:

  • The UK is on track to achieve an 80% reduction in the prevalence of chronic hepatitis C by 2030.
  • The UK has surpassed interim WHO targets to achieve a 10% reduction in mortality by 2020.
  • The UK is not on track to meet 2030 targets for reductions in the number of new infections and re-infections.

Injecting drug use is the “main driver of hepatitis C transmission” in the UK and, therefore, the main driver of new infections. One of the cornerstones of hepatitis C control is high-coverage needle and syringe provision. The 2030 WHO target is for each person who injects drugs to receive at least 300 sterile needles and syringes per year. The UK is not yet near this level. In 2019, two-thirds of people who inject drugs reported having adequate needle or syringe provision for their needs. Professor Susan Hopkins, Chief Medical Advisor at the UK Health Security Agency (UKHSA), acknowledged that “needle and syringe provision has remained suboptimal across all UK nations” and called for “adequate harm reduction” to be available and for resources to be put towards rebuilding drug treatment and recovery services.

by Natalie Davies

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