Increasing NSP funding is essential to the frontline health sector’s capacity to maximise the potential that new hepatitis C drugs have to greatly reduce population-level incidence, according to Kirby Institute’s Professor Lisa Maher, AM
“We need to reverse the real-dollar NSP funding reductions if we want to optimise our investment in these new treatments and protect people from not only primary infection, but from re-infection following treatment,” Lisa says.
The new Direct-Acting Antiviral (DAA) hepatitis C drugs are not the silver bullet some people claim, Lisa says.
“The new drugs alone are not sufficient to rid Australia of hepatitis C even though they are game-changers. For NSPs, it’s wonderful to be able to offer patients access to highly efficacious, well-tolerated curative treatments,” Lisa says.
“But I guess I’m a bit skeptical about whether we’ll be able to treat our way out of this epidemic, given that this has never been achieved in the history of infectious diseases without a sterilising vaccine. And we don’t have that for hepatitis C.” Lisa cites the United Nations 90-90-90 HIV targets, which aim for 90 per cent of people living with HIV diagnosed, 90 per cent of people who are diagnosed on treatment, and 90 per cent of those on treatment virally suppressed by 2020.
“Even if you reach the 90 per cent targets, the problem is the remaining 10 per cent,” Lisa says.
“Making prevention and treatment interventions widely available and acceptable will not be enough. We need to focus on equitable access and engaging those who are most at risk.
“This means reducing stigma and discrimination and removing human rights barriers to prevention, care and treatment such as laws that criminalise drug use. However, there are few interventions to address these barriers and little evidence as to their efficacy.”
Lisa argues that if you’re looking to eliminate hepatitis C then you’ve got to target current injectors.
“We’ve got these great new treatments, but there is a lack of awareness among people about whether they are actually infected and whether they actually need treatment.”
Lisa says there could be between 10 and 40 per cent of people that will not be reached or may be unwilling to be treated. Almost 90 per cent of Australia’s estimated 93,000 people who currently inject drugs have at some time been tested for hepatitis C antibodies, according to the Kirby Institute’s Australian Needle and Syringe Program Survey (ANSPS).
However, as Lisa explains, antibody tests simply indicate exposure to the virus. They do not distinguish between active and chronic infection.
The antibody tests don’t indicate if a person has cleared the virus, whether through treatment or spontaneous clearance (which occurs for between 20-25 per cent of people who contract hepatitis C), she says.
For that a confirmatory test (usually an RNA or PCR test) is required, and only 46 per cent of people who currently inject drugs have ever had one.
Recent Kirby Institute work shows that people on Opioid Substitution Therapy (OST) such as methadone or buprenorphine – and who also inject drugs – are more likely to have had a confirmatory test, as are people who had an antibody test in the previous 12 months.
Lisa argues NSPs have a central role in encouraging confirmatory testing, because they are one place that people who inject drugs are already connected with.
“What is interesting,” Lisa says, “is that people who got their last hep C test at a primary health centre aimed at people who inject drugs were twice as likely to have also had the confirmatory RNA test than injectors who had the initial hep C test at a GP or general medical centre.” RNA tests look for the virus in the blood.
And while not all NSPs are equipped to provide treatment – one-stop-shops like Sydney’s Kirketon Road Centre are unfortunately few and far between – NSPs can play a key role in referrals and linking people to services.
Lisa also says that there should be funding for RNA testing on the dried blood spots that the annual Australian Needle and Syringe Program Survey collects for antibody testing.
“If we have a surveillance system where we can conduct RNA testing, we have a mechanism to measure and monitor incidence and chronic infections, as well as the impact of treatment on the residual pool of chronic infection.
“We need to do that in order to evaluate the success of the National Hepatitis C Strategy and to assess the impact of this huge investment in DAAs, and any potential treatment as prevention effects.
“We need to maximise opportunities for everybody who injects drugs to reduce the likelihood of exposure and re-exposure, particularly if we want to see a treatment effect at the population level.”
– Gideon Warhaft
* Lisa Maher is a Program Head at the Kirby Institute for Infection and Immunity, Professor in the Faculty of Medicine at UNSW Australia, and a National Health and Medical Research Council Senior Research Fellow.
PROFESSOR LISA MAHER:
Lisa Maher has international experience in research, program development and service delivery with people who inject drugs, sex workers, men who have sex with men and marginalised youth.
Her current research focuses on the prevention of infectious disease in vulnerable populations. In 2015 Lisa was awarded a Member of the Order of Australia for significant service to medicine in the field of epidemiology.
In the late 1980s she lived in New York during the HIV and crack cocaine epidemics, immersing herself in illegal drug dens and shooting galleries in central Brooklyn to produced detailed ethnographic studies of some of the most marginalised people in America.
Returning to Australia in the 1990s, Lisa used the same ethnographic techniques to study young drug users in Cabramatta during the heroin epidemic.
Senior colleagues point towards her unique ability to combine both qualitative and quantitative research to paint an unusually insightful picture of issues. She is also known for her passion in advocating policy change based research, and the deep respect she has for people who inject drugs.