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 up to 20 % of cases, but access of drug users to treatment for hepatitis C is low. A policy briefing and a scientific monograph on hepatitis C produced by the EMCDDA are available online (EMCDDA, 2003c; EMCDDA, 2004d) (76).
The situation of drug users with regard to access to liver treatment remains in most countries to be improved. As treatment guidelines are considered an important tool for steering the provision of medical treatment, the EMCDDA carried out an analysis of guidelines for the treatment of HCV infection in drug users in the 15 'old' EU countries and Norway in 2003/2004 (77). The study found that in many countries a review of national guidance was underway, taking improved treatment options and considerably enhanced 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.
Special funding is to be made available by the Global Fund against AIDS, Tuberculosis and Malaria (GFATM) to provide anti-retroviral treatment to patients in Estonia and the candidate country Bulgaria: the projected number of persons who will receive anti-retroviral treatment is 500 in Estonia and 200 in Bulgaria (GFATM Secretariat, 2004).
The main trends in the provision of low-threshold service for drug users, originally centred on needle and syringe exchange, include increased integration with other survival-orientated services, for example shelters, and healthcare and medical services, and the extension of opening hours into evenings, nights and weekends.
Faced with an increasing number of chaotic drug users with little inclination of contacting services, Dutch drug services revert to ‘friendly’ persuasion to get normally out-of-reach drug users into care. This approach – called ‘interferential’ care – provides an outreaching and assertive health service to a vulnerable group of people with multiple problems who despite an alarming situation that seriously threatens their quality of life do not make use of regular health care facilities (Roeg et al., 2004).
Contact with drug users and those at risk is essential for the transmission of health education messages and the prevention of drug-related health damage. This has been achieved to a high degree in the Czech Republic, where a dense network of 93 services spread across the country reached more than 22 000 individual problem drug users in 2002 – more than half of the estimated population of problem drug users (Czech Republic national report, 2003, p. 35).
Several other countries acknowledge the role of low-threshold drugs services as a platform for offering basic medical care, such as wound and abscess treatments, for example the Norwegian ‘field nursing stations’. In Finland, low-threshold medical services, called ‘health counselling centres’, successfully conduct testing and vaccination campaigns. The opportunity to receive medical care is attractive even to drug users who are otherwise difficult to reach, and contact with medical staff provides a chance, over and above the occasions afforded by needle and syringe exchange, to obtain resources and referrals to services such as HIV counselling and testing, medical care and drug treatment (EMCDDA, 2004a).
The need for low-threshold services is greater in countries with ‘older’ epidemics, where long-term injectors have considerable health problems and are more marginalised and socially excluded: the increasing range of services offered might also reflect an increasing service dependency of this group.