International Journal of Drug Policy - 2015

Volume 26 Supp 1 Feb 2015

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International Journal of Drug Policy 26 (2015) S22–S26 Contents lists available at ScienceDirect International Journal of Drug Policy j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o Commentary Prevention, treatment and care of hepatitis C virus infection among people who inject drugs Philip Bruggmann a,∗ , Jason Grebely b a Arud Centres for Addiction Medicine, Zurich, Switzerland b The Kirby Institute, The University of New South Wales Australia, Sydney, Australia a r t i c l e i n f o Article history: Received 11 June 2014 Received in revised form 11 August 2014 Accepted 23 August 2014 Keywords: Hepatitis C PWID a b s t r a c t People who inject drugs (PWID) represent the core of the hepatitis C virus (HCV) epidemic in many countries. HCV transmission continues among PWID, despite evidence demonstrating that high coverage of combined harm reduction strategies, such as needle syringe programs (NSP) and opioid substitution treatment (OST), can be effective in reducing the risk of HCV transmission. Among infected individuals, HCV-related morbidity and mortality continues to grow and is accompanied by major public health, social and economic burdens. Despite the high prevalence of HCV infection, the proportion of PWID who have been tested, assessed and treated for HCV infection remains unacceptably low, related to systems-, provider- and patient-related barriers to care. This is despite compelling data demonstrating that with the appropriate programs, HCV treatment is safe and successful among PWID. The approaching era of interferon-free directly acting antiviral therapy has the potential to provide one of the great advances in clinical medicine. Simple, tolerable and highly effective therapy will likely address many of these barriers, thereby enhancing the numbers of PWID cured of HCV infection. However, the high cost of new HCV therapies will be a barrier to implementation in many settings. This paper highlights that restrictive national drug policy and law enforcement are key drivers of the HCV epidemic among PWID. This paper also calls for enhanced HCV treatment settings built on a foundation of both prevention (e.g. NSP and OST) and improved access to health care for PWID. © 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( Introduction The hepatitis C virus (HCV) epidemic has been coined a "viral time bomb" by the World Health Organization. HCV is a preva- lent chronic infection with potentially deadly consequences. Recent estimates suggest that globally, the HCV viremic (RNA posi- tive) prevalence is forecasted at 1.1% (0.9–1.4%) corresponding to 80 (64–103) million viremic infections (Gower, Estes, Hindman, Razavi-Shaerer, & Razavi, 2014). Despite the looming public health threat that HCV imposes, it receives little public attention. This silent disease often progresses with few symptoms, even during advanced stages of disease. As a blood borne virus, the major route of transmission in most countries is injecting drug use. People who inject drugs (PWID) are heavily affected by this infectious disease. However, despite the high prevalence, ongoing transmis- sion and increasing HCV-related disease burden among PWID, HCV ∗ Corresponding author at: Arud Centres for Addiction Medicine, Konradstrasse 32, 8005 Zurich, Switzerland. Tel.: +41 58 360 50 50. E-mail address: (P. Bruggmann). testing, prevention, assessment and treatment remain subopti- mal in this group, and the time-bomb still ticks on. Over recent years, the development of simple, tolerable and highly effective interferon-free directly acting antiviral (DAA)-based therapies for HCV infection has brought great optimism to the sector. However, in order for the roll-out of these new IFN-free regimens to elimi- nate HCV among PWID, drastic changes and the breaking of some taboos will be required. Transmission of HCV infection Although risk factors commonly associated with transmission of HCV infection include blood transfusion from unscreened donors, unsafe therapeutic injections, and other health-care related proce- dures, the majority of new and existing infections in most countries have occurred as a result of injection drug use (Hajarizadeh, Grebely, & Dore, 2013). Among PWID, the major route of trans- mission is through the sharing of drug preparation and injection equipment (e.g. syringes, needles, filters, water and cookers) (Pouget, Hagan, & Des Jarlais, 2012). The hepatitis C virus is resilient and is capable of surviving on drug preparation equipment 0955-3959/© 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (

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