Viral Hepatitis C Pandemic: Challenges and Threats to Its Elimination

Laura Krekulova; Radkin Honzák; Lee W. Riley


J Viral Hepat. 2021;28(5):694-698. 

In This Article

PWID Playing the Leading Role in HCV Elimination

WHO considers hepatitis C among PWID to be very difficult to control and treat and, therefore, it called for extra attention to be paid to them in the elimination plan. HCV is transmitted with high frequency among PWID, and they represent the population with the highest HCV infection risk in developed countries. Unfortunately, due to their psychiatric comorbidity, PWID are often limited in their access to healthcare services. The majority of PWID are socially marginalized. Besides being addicted and infected, they also suffer from lack of access to adequate information. They are often unaware of their infectious status and of the possibilities to be diagnosed and treated for their disease. Based on our experience in practice, PWID have frequently zero interest in caring for their own health, because they see the more essential need to financially support their next illicit drug dose.

The incarcerated PWID population represents an additional challenge. In Europe and also globally, the anti-HCV antibody prevalence in the prison population is about 15%.[27] It varies across countries, ranging from 5% to 43%.[28,29]

There is consistency in the law that defines the right of prisoners to equivalent health care in the majority of developed countries, but nowadays the specific treatment of prisoners with HCV infection is limited worldwide. The access to care is highly variable even within a country and is also often very limited. In the prisons, where HCV treatment is available, the treatment uptake usually remains low.[27]

On the other hand, prisoners are likely to engage in a wide range of risky behaviour related to HCV transmission. Harm reduction services like needle and syringe exchange and OST are the most important approaches to reducing HCV incidence in prisons. Providing education and social support and promoting access to clean needles and OST protect prisoners from new infections, reinfections, and they also increase their motivation to undergo specific treatment for chronic hepatitis C.[28,30]

Improving diagnosis and treatment in prisons is one of the priorities for reaching the elimination of HCV transmission in the general population. With DAA treatment available and with the existence of non-invasive diagnostic tools (elastography), there is no excuse for the current situation and clearly, HCV infection management in prisons must be systematically improved worldwide. Hepatitis C diagnostic and treatment algorithms in prison-based programmes should be incorporated as part of each national HCV infection elimination plan. A way to implement these strategies more easily is to get the specialists' input into the prisons. It may include remote working, telemedicine and nurse-led services.[28,30]

The incarcerated individuals are an example of a marginalized population without contact with conventional healthcare services. To date, limited access to HCV infection care for prisoners is a missed opportunity.

Education of PWID is clearly needed to solve these problems, but it is extremely difficult to put this into practice effectively. Due to stigma, PWID have difficulties accessing healthcare facilities other than those specifically designed for them. Thus, one efficient educational approach is via engagement of fieldworkers and harm reduction programmes.

PWID are often unreliable, do not keep doctor's appointments and, above all, they use illicit drugs.

In fact, this problem of PWID non-compliance with the healthcare system designed for the so-called 'common population' has several more underlying reasons.

The truth is that PWID are often viewed as the least favourable of patients by the majority of healthcare professionals: the doctors, nurses and other medical staff. Outside of specialized addiction services and psychiatry, there is rarely anyone willing to work with PWID.

There are many reasons for this state of affairs, and some of them are rather more emotional than rational.

In general, we as professionals are not able to communicate with PWID properly, partly because we are subconsciously in conflict with them and with their self-destructive behaviour.

Honestly, we are scared because PWID behave and react differently than other patients and, according to our subconscious mind, they might be viewed as dangerous. Also, we lack the ability to motivate them to cooperate with us, again because we are in our own internal conflict and are often not willing to collaborate with PWID. These are important, if not the most important reasons, why the elimination of HCV infection poses such a challenge!