The two considerations in the box below are existing formal WHO recommendations that address focused testing for HBV and HCV infection and harm reduction for PWID.
Existing recommendation from the 2017 HBV and HCV testing guidelines (3)
In all settings (and regardless of whether delivered through facility- or community-based testing), it is recommended that serological testing for HCV antibody (anti-HCV)1 or HBsAg be offered with linkage to prevention, care and treatment services to the following individuals:
Adults and adolescents from populations most affected by HCV infection
2 (i.e. who are either part of a population with high HCV seroprevalence or who have a history of exposure and/or high-risk behaviours for HCV infection);
Adults, adolescents and children with a clinical suspicion of chronic viral hepatitis
3 (i.e. symptoms, signs, laboratory markers).
(Strong recommendation, low quality of evidence)
Note: Periodic retesting using HCV nucleic acid tests (NAT) should be considered for those with ongoing risk of acquisition or reinfection.
- 1
This may include fourth-generation combined antibody/antigen assays.
- 2
Includes those who are either part of a population with higher seroprevalence (e.g. some mobile/migrant populations from high/intermediate endemic countries, and certain indigenous populations) or who have a history of exposure or high-risk behaviours for HCV infection (e.g. PWID, people in prisons and other closed settings, MSM and sex workers, and HIV-infected persons, children of mothers with chronic infection, especially if HIV-coinfected).
- 3
Features that may indicate underlying chronic HCV infection include clinical evidence of existing liver disease, such as cirrhosis or HCC, or where there is unexplained liver disease, including abnormal liver function tests or liver ultrasound.
Existing recommendation from the 2016 updated guidelines on HIV prevention, diagnosis, treatment and care for key populations (5)
All people from key populations who are dependent on opioids should be offered and have access to opioid substitution therapy.
All other considerations discussed in this chapter are based on good practice principles.
7.1. People who inject drugs
7.1.1. Background
In 2017, there were an estimated 15.6 million PWID aged 15–64 years (168). PWID are at risk for infections, including HCV infection (169), mental health issues, psychosocial challenges, contact with law enforcement agencies (170) and premature death (171).
Fifty-two per cent of PWID (95% UI: 42–62) have serological evidence of past or present HCV infection (anti-HCV positive) and 9% (95% CI: 5–13) have HBV infection (HBsAg positive) (168). However, many infected PWID are unaware of their diagnosis and few initiate treatment (172), because of criminalization, discrimination, unstable housing and stigma in health-care settings (173). Around 58% of PWID have a history of incarceration (168). PWID are also at increased risk of new HCV infection and reinfection (47, 172). They require prevention services to reduce the risk of infection and reinfection after a cure (174).
7.1.2. Service delivery considerations
Prevention services and reducing harm from injecting drug use
High-coverage harm reduction programmes for PWID to prevent HCV transmission and reinfection. WHO already recommends both needle and syringe distribution and OST
(5) as effective interventions for HIV prevention, but only a high coverage of these interventions also prevents HCV transmission
(175) (176).
Education of PWID. Harm reduction interventions educate on prevention and provide access to sterile equipment. OST reduces the frequency of injection
(177), treats underlying dependence and helps to prevent overdose.
Access to low dead-space syringes. NSPs make use of low dead-space syringes
(178).
Testing
Routine targeted testing of all PWID for HCV, HBV and HIV infection was recommended in the 2017 WHO testing guidelines (3). Testing and treatment in drug dependency services or prisons is cost effective in high-income settings (132, 179). Specific interventions improve coverage (180). Regular testing for HCV is relevant to uninfected PWID, those cured, and those who had cleared the virus spontaneously. Previously infected persons are tested directly with HCV RNA as they will remain anti-HCV positive after the first infection (181).
Linkage and care
Following diagnosis, PWID can be referred to appropriate services. Specific interventions can improve linkage (180) to a package of care that includes treatment (182) and addresses other medical and/or psychosocial issues. Peer interventions and integrated comprehensive HCV care may increase acceptability, uptake and adherence. It can reduce injecting drug use and improve injection practices (183). See the WHO ASSIST package – guidance on brief behavioural interventions for substance use (184).
Treatment
Limited data (185–190) indicate high SVR rates among PWID treated with DAAs for HCV infection. DDIs can take place between both prescribed and non-prescribed drugs.
7.2. People in prisons and other closed settings
7.2.1. Background
Worldwide, at any given time, an estimated 10 million people are incarcerated (191). HCV infection is more common among incarcerated persons or those who have previously spent time in correctional facilities. A meta-analysis reported a global prevalence of HCV infection of 26% among general detainees, and of 64% among detainees with a history of injecting drug use (192). Incidence was estimated at 1.4 per 100 person-years, rising to 16.4 per 100 person-years in those with a history of injecting drug use (192). Overall, 58% of PWID have a history of incarceration and 56–90% of PWID would be incarcerated at some stage (168). Criminalization of drug use may explain the frequency of HCV infection in prisons and other closed settings. One in every five prisoners is held for drug-related charges (170). Transmission continues in closed settings because of injecting drug use, tattooing (193) and possibly sexual transmission among men. However, OST is available in the prisons of only 52 countries, and only eight countries have at least one NSP within a closed setting (194).
7.2.2. Service delivery considerations
Prisons are an opportunity to offer prevention, testing, care and treatment services to marginalized populations that otherwise might have difficulty in accessing care.
7.3. Indigenous Peoples
7.3.1. Background
Viral hepatitis disproportionately affects Indigenous Peoples in most parts of the world (9, 201). The world’s 370 million Indigenous Peoples face displacement, dispossession, loss of livelihood, systematic racism as well as abuse and lack of recognition, threatening the sacred relation between Indigenous Peoples and their landbase. Poverty as well as large health disparities are common among Indigenous Peoples. Access to health services is often further hampered by the remoteness of their communities or language and cultural barriers. In some countries, including Canada and Australia, rates of incarceration and injecting drug use are high in Indigenous Peoples, further increasing the risk of HCV acquisition (202, 203).
7.3.2. Service delivery considerations
The United Nations Declaration on the Rights of Indigenous Peoples highlights several key considerations for the health of Indigenous Peoples. Indigenous Peoples have the right to be actively involved in developing and determining the health programmes that affect them, and to administer, as far as possible, such programmes through their own institutions. Indigenous Peoples also have the right to access, without any discrimination, to all social and health services (204). Specific considerations in delivering HCV prevention, diagnosis and treatment services include:
employing and training Indigenous staff in HCV prevention, diagnosis and treatment;
catering to specific language or cultural needs, e.g. gender-specific service provision;
engaging with local Indigenous representatives to gain endorsement and acceptance;
consulting with community members to address concerns or provide information;
engaging with the community to increase availability of treatment.
7.4. Men who have sex with men
7.4.1. Background
HCV is not commonly transmitted through unprotected sexual intercourse among monogamous heterosexual partners (205–208). However, sexual practices that cause mucosal trauma, group sex, chemSex (the practice of non-injection and injection use of certain drugs before and during sex), and the presence of HIV infection increase sexual transmission of HCV among MSM (52, 209–211). Non-injecting HIV-infected MSM populations have a high incidence of HCV infection (212). Transmission increases with unprotected receptive anal intercourse, ulcerative STI lesions and lower CD4 counts (213). The implementation of HIV pre-exposure prophylaxis (PrEP) among sexually active HIV-negative MSM was also followed by reports of a rise in HCV incidence (214).
7.4.2. Service delivery considerations
The 2017 WHO testing guidelines recommend regular HCV testing for MSM
(3). Information can be provided on modes of transmission during male-to-male sex.
Treatment of HCV-infected MSM with DAA. Specific treatment of HCV/HIV-positive MSM may prevent onward transmission of HCV. Attention must be paid to DDIs with DAAs for persons on ART (
see
section 5.1.1).
7.5. Sex workers
7.5.1. Background
Sex workers of both genders are more likely to have HCV infection than the general population for a variety of reasons, such as higher rates of substance use and drug injecting, higher prevalence of HIV infection and more exposure to HCV (9).
7.5.2. Service delivery considerations
Various health and welfare needs may facilitate the engagement of sex workers in care.
Strategies to facilitate engagement in care. This may include outreach, on-site testing services, peer-based interventions, and linkage to other health and welfare services.
Linkage and referral to appropriate services upon request where substance use, including alcohol and injecting drug use, is present. This involves providing access to harm reduction interventions such as OST and NSP, where necessary.
