High rates of hepatitis C virus (HCV) infection among drug users are causing increasing concern among healthcare professionals. Between 60 % and 80 % of people who contract the virus become chronically infected, leading to end-stage liver disease in about 7 % of cases over 20 years time. 60 to 90 % of newly identified cases of hepatitis C infection are related to injecting drug use, however access of drug users to treatment for hepatitis C is low. Among injecting drug users in the enlarged EU, prevalence is between 25 and 97 %. In the general population the range is from 0.1 to over 1%, including both infections in ex-injectors and old infections caused by other routes than drug injecting.
A policy briefing on hepatitis C was produced by the EMCDDA in 2004.
The key issues presented are:
Across Europe a very high proportion of people who have ever injected drugs are infected with the hepatitis C virus.
Infection with hepatitis C can result in health problems ranging from chronic fatigue to severe liver disease and cancer of the liver.
The hepatitis C virus is highly infectious and is transmitted through direct contact with infected blood. The disease spreads rapidly among drug users who share needles and other injecting equipment.
Young and new injectors are at high risk of contracting hepatitis C shortly after they begin injecting. Wherever injecting drug use is likely to increase, such as in the new EU Member States, new epidemics of hepatitis C are likely to emerge.
It is difficult to monitor trends in hepatitis C infection because most people carrying the virus show only mild or no symptoms at all for 20 years or longer. However monitoring infection rates is important as it may provide crucial feedback on the effectiveness of interventions.
Treatment for hepatitis C infection has improved dramatically in recent years. However, the treatment of injecting drug users for HCV is controversial and many do not receive treatment.
The situation of drug users with regard to access to liver treatment remains in most countries to be improved. Medical treatment guidelines are considered an important tool in steering provision of hepatitis C treatment, and have in 2003/2004 been subject to an analysis by the EMCDDA. The results of the study covering the 15 ‘old’ European Union countries and Norway are published online.
National focal points, individual experts and professional societies and health administrations were approached and national and international databases searched to collect available official and semi-official treatment guidelines, treatment consensus documents or individual expert guidance from each country. Quality and content of consensus documents and official treatment guidelines were appraised, applying a standardised qualitative evaluation procedure, which included an assessment of the scientific rigour and evidence base of the guidelines, their clarity, applicability and editorial independence.
Recommendations for treatment of HCV in drug users varied substantially. Some guidance documents did not consider the case of drug injectors, some recommended to treat them only when drug-free, and others recommended to treat only those in long-term oral substitution treatment. The study also found that in many countries a review of national guidance was underway in 2003/2004, taking improved treatment options (through recent advances in medical research) and considerably enhanced treatment outcomes into account. Some new guidance documents referred explicitly to research that had documented the benefits for drug users if treatment was provided by interdisciplinary teams of hepatologists and drug use specialists.
To which degree access of drug users to hepatitis C treatment is influenced by permissive or restrictive guidelines, and which other variables might potentially play a role (e.g. lack of information among drug users on hepatitis C treatment options; limited readiness to enter treatment – even when medically indicated – among those who have no or mild symptoms; incompatibility of available treatment regimes with daily life) needs to be further explored.
An EMCDDA monograph entitled 'Hepatitis C and injecting drug use: impact, costs and policy options' reviewed the link between hepatitis C and drug injecting.
The monograph concluded that:
Although methadone therapy is cost-effective for HIV prevention and thus for public health in general, it would not be cost-effective solely for HCV prevention.
The evidence regarding the cost-effectiveness of needle and syringe programmes for HCV prevention is scarce and conflicting. However NSPs are cost-effective for HIV prevention and thus overall remain an important and cost-effective public health intervention.
At high levels of coverage, different interventions will act in synergy and mutually reinforce one another’s effects. Therefore it remains critical to implement different prevention measures simultaneously and to attain high coverage with them all.
Screening of current and ex-IDUs is indicated. Antiviral combination treatment should be offered to infected IDUs where indicated. In this decision, the benefit of preventing infections to others should be considered.
Anti-viral treatment is cost-effective for IDUs with moderate hepatitis or compensated cirrhosis. Studies have shown that IDUs can be treated successfully.
Modelling studies show that substantial screening and treatment can have strong effects on HCV prevalence.
Reduction of injecting risk behaviour has to be very substantial before an effect on HCV prevalence is to be expected. Targeting interventions at high-risk individuals can have a disproportionately large prevention effect. Interventions should aim to change behaviour before the start of injecting.
With highly infectious diseases such as hepatitis C, specific prevention measures should be targeted at new and young injectors who may not yet be infected.
To prevent the rapid spread of an IDU epidemic, ideally, harm reduction should be implemented before the epidemic starts to increase.
The future costs per year of new HCV infections may amount to 0.23 % of the EU healthcare budget. The current costs of illicit drug use amount to 37 euro per capita in France and are much lower than those of the use of alcohol or tobacco.