Poverty, stigma and criminalization are chronic problems among people who use and inject drugs. But hepatitis C virus (HCV) is no longer such a problem, since it is usually cured by eight to 12 weeks of oral, direct-acting antivirals (DAAs).
Delivering DAAs to people who use and inject drugs in the context of the chronic problems facing them is an opportunity to recognize and support the contribution of people with lived experience, and to build and strengthen systems and programs. These systems and programs must provide welcoming, respectful and safe spaces for people who use and inject drugs, as they will still need healthcare and other services after being cured.
Engaging and retaining clients with peers
Although a cure takes just 12 weeks, people who use and inject drugs may need much more time to be ready for HCV treatment. It’s clear that peers (i.e., people with lived experience) can engage people who use and inject drugs, and that they are an integral part of the response to HCV. The process of engagement takes time, and requires investments in cultivating and supporting peers and the programs and structures in which they work.
Expanding access with nurse-led care
Nurses play an important role in HCV services. Nurse-led care enhances the accessibility and reach of HCV testing, care and treatment, and other healthcare services for people who use and inject drugs. They have simplified treatment through clinic ‘makeovers’ that increase access to and efficiency of HCV services.
Nurses have more time to spend with people, and are more geared towards delivering people-centric care and relationship building. Nurses can bring the clinic to the people – in prisons, drug services and even to their homes.
Linking services to people, not people to services
The places where people can be linked are the places where they already are. HCV services need to be available where people are – literally – and where they are comfortable, not just in medical settings. There is limited value to linking people who use and inject drugs to places that are not adapted to their needs, reflected by high rates of loss to follow up.
If you offer what people want and need, they are much more likely to return.
Harm reduction programs and services are the foundation for low-threshold, decentralized HCV care delivery to people who use and inject drugs. This includes Lucy Sunshine, an HCV service delivery van in rural Australia; mobile centres in Madrid and Portugal; in conflict areas, during perinatal care, and at a clinic in Sydney, Australia, where pets are welcome and vet care is available, and at numerous other places and programs.
Rapid service delivery and incentives
Linkages to care can be improved by traditional means and new technologies. People need to feel both respected and welcomed. Testing and treatment delivery needs to be adapted to the needs of people who are using and injecting drugs, such as providing same-day services and treatment, offering people food while they wait, and through cash incentives.
A range of new testing technologies could support linkage to care, such as dried blood spot testing that can be done with a fingerstick instead of drawing blood, really rapid testing, where anti-HCV test results could be available in five minutes, and the potential to deliver viral load test results in 60 minutes, as well as promising new diagnostic tools in the pipeline.
Bringing service providers together
Collaborations are important for improving linkage to care, as well as the services that people ultimately receive. Healthcare providers and clinics can collaborate with peer workers, people who use and inject drugs and their organizations to enable delivery of culturally competent services and care without an appointment. Researchers can work with people who use and inject drugs to identify and generate the evidence that is needed for policy change.
In short, go to where people are, offer them what they want and provide it in one place.
Thanks to the International Network on Hepatitis in Substance Users (INHSU) conference organizers, including the Australian Society for HIV Medicine (ASHM), and to all of the people whose work, presentations, posters, experiences and words informed this summary.
Tracy Swan has been working in public health and social justice since 1990, when she began doing HIV-related work. In 1998, she also became a hepatitis C activist. She has worked for Treatment Action Group, Médecins Sans Frontières and has served as a community representative to the Food and Drug Administration’s (FDA) Antiviral Drugs Advisory Committee, the AIDS Clinical Trials Group and has been a member of the U.S. and WHO hepatitis C guidance panels. She was also one of INHSU’s rapporteurs.