The trouble in engaging difficult to reach populations is, well, that they are difficult to reach.
The low-hanging fruit of diagnosing and treating people who have hepatitis C in routine clinical practice is well underway and we are having a significant amount of success in testing and treating baby boomers who are already engaged in care. The difficult-to-reach populations, however, represent the biggest barrier in terms of eliminating hepatitis C from the United States over the next decade.
Leading the way in tough-to-reach populations are those who are actively engaged in injection drug use (IDU), as several people in this cover story (page 14) have mentioned. To be successful in addressing IDU populations, we need to take a multi-dimensional approach that considers the social constructs among people who actively inject drugs.
Above all, we must suspend our naive perspective that all injection drug users are the same. We can reach different users using approaches tailored to their individual setting. Still, one thing that all injection drug users have in common is the use of needles and syringes to inject. Therefore, a primary approach in HCV containment (and the containment of other infectious diseases like HIV) is to assure that all people who are injecting drugs have access to clean needles and clean ‘works.’ Failure to assure this basic requirement will result in reinfection rates for those who are cured of HCV that will be high and will blunt the effectiveness of HCV treatment approaches while increasing costs. Simple approaches such as needle exchanges, which have worked in many European communities but also in targeted communities in the United States, needs to become a widespread policy for the U.S.
A second approach is the engagement of opioid injection drug users into substitution therapy clinics, using methadone or buprenorphine. Not every person who is actively using opioids is amenable to this, however in my experience, most active users at some point seek a way out of their current situation and need a safe haven to discontinue using street drugs. Therefore, in addition to needle exchanges, we need to have ready access to substitution therapy and mental health support systems for injection drug users that ultimately leads to testing and treating those infected with HCV and/or HIV.
Optimally, the diagnosis and treatment of HCV should be tightly linked to needle exchange programs and substitution therapy centers. This will provide access to those at highest risk for HCV and HIV where we can test and treat active and former injection drug users. By ramping this up in a rapid fashion, we have the best chance to bend the curve of new transmissions in this highly at-risk population and curb the reinfection rate among those still using.
With the explosion of the opioid epidemic in the United States and the intense focus on addressing the epidemic, there’s a platinum opportunity to stem transmission of HCV and HIV among opioid drug users as well. As the opioid epidemic is being addressed, it is essential that we combine HCV and HIV testing and treatment in conjunction with whatever programs are implemented for opioid use curtailment.
Michael S. Saag MD
Co-Chief Medical Editor
Disclosures: Saag reports receiving research support and acting as a scientific advisor to Bristol-Myers Squibb, Gilead, Merck and ViiV.