According to a recent Bristol-Myers Squibb Foundation-funded study, in people who inject drugs, the prevalence of HCV is approximately 45%.
HCV is spread through exposure to infected blood via contaminated needles and syringes, cookers and tourniquets. Sharing contaminated needles and syringes is the most common mode of HCV transmission. People who inject drugs tend to be stigmatised at healthcare facilities, with some healthcare workers telling them to get clean before being tested and/or treated for HCV. “This is contrary to the World Health Organisation’s (WHO) international HCV treatment guidelines which states people who inject drugs should be offered HCV treatment,” says Professor Ian Sanne, CEO of Right to Care.
Sharing contaminated needles and syringes is also a known risk factor for contracting HIV. The prevalence rate of HIV/HCV together is approximately 12.7% among people who inject drugs.
“While initial infection with HCV has relatively few symptoms, approximately 80% of those infected will go on to develop a chronic infection. After several years, this can lead to cirrhosis of the liver or liver cancer. Both conditions can lead to death. For those needing a liver transplant, the wait is extremely long and it places a significant financial burden on the healthcare system,” says Sanne.
“Right to Care has worked in both Myanmar and the Ukraine where HCV elimination strategies have been implemented with success. In Ukraine, the WHO estimates that over 5% of the population are infected with HCV. In Myanmar, some 2% of the population are HCV-infected. In both these countries, the HIV/HCV co-infection epidemic is driven by those who inject drugs with 60-90% infected.
“Unlike HIV, HCV can be cured though a 12-week treatment programme of direct acting antivirals (DAAs). The results of Right to Care’s experience in Ukraine and Myanmar are that DAAs can be provided at low cost and we have achieved cure rates as high as 99% in Ukraine and 98% in Myanmar,” he says. “We also found that people who inject drugs tend to adhere well to their treatment.”
“Our experience in these two countries can inform how an HCV eradication programme in South Africa could work. But the treatment is expensive. In the United States, the cost of a 12-week programme is as much as $80,000. Access to DAAs is a major challenge for far too many people. We must also fast track approval of the newer drugs that have been approved in the EU and US. Just as we got drugs discounted for HIV, we can and must do the same for HCV.
“We need a discussion on access pricing to enable low and middle-income countries to offer HCV treatment, including in South Africa. HCV treatment costs have been reduced to $200 and $600 in many countries, depending on whether the drug is branded or a generic. New HCV combination medicines are currently awaiting approval by the South African Health Products Regulatory Authority.
Sanne explains that SA is geared to roll-out an HCV programme. “We have the infectious disease specialists and the necessary infrastructure. We have experience in rolling-out education, awareness and screening initiatives. An HCV programme would need to include integrated HIV and HCV prevention services, including clean needle and syringe programmes, opioid substitution therapy and harm reduction initiatives. It would also require anti-stigma campaigns for healthcare workers around the needs and rights of people who inject drugs.”
“This engagement will also focus on how to address the challenges that people who inject drugs face. As well as economic barriers and a lack of facilities for diagnosis and treatment of HCV, they fear discrimination and even prosecution when seeking support at healthcare facilities. When they do finally seek help, they tend to be well advanced in the illness leading to a high number of liver related deaths.”
