Changes to the national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs between 2013 and 2016: a cross-sectional survey of 34 European countries

Background: Hepatitis C virus (HCV) infection is the leading cause of cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC) worldwide. In Europe, people who inject drugs (PWID) represent the majority of HCV infections, but are often excluded from treatment. The aim of this study was to report on national HCV strategies, action plans and guidelines in European countries that include HCV treatment for the general population as well as for PWID. Data on access to direct-acting antivirals (DAAs) were also collected. Methods: In 2016, 38 non-governmental organisations, universities and public health institutions that work with PWID in 34 European countries were invited to complete a 16-item online survey about current national HCV treatment policies and guidelines. Data from 2016 were compared to those from 2013 for 33 European countries, and time trends are presented. Differences in the data were analysed. Data from 2016 on general access to DAAs in PWID are presented separately. Results: The response rate was 100%. Fourteen countries (42%) reported having a national HCV strategy covering HCV treatment; 12 of these addressed HCV treatment for PWID. Respondents from ten countries (29%) reported having a national HCV action plan. PWID were specifically included in seven of them. Twenty-nine countries (85%) reported having national HCV treatment guidelines. PWID were specifically included in 23 (79%) of them. Compared to 2013, respondents reported that an additional seven countries (25%) had national strategies, an additional eight countries (29%) had action plans and an additional six countries (19%) had HCV treatment guidelines. However, PWID were not included in two, four and six of those countries, respectively. DAAs were reported to be available in 91% of the study countries, with restrictions reported in 71% of them. Conclusion: Respondents reported that fewer than half of the European countries in this study had a national HCV strategy and/or action plan, with even fewer including PWID. However, when compared to 2013, the number of such countries had slightly increased. Although PWID are often addressed in clinical guidelines, strategic action is needed to increase access to HCV treatment for this group and the situation should be regularly monitored

The Berlin Hepatitis C Manifesto: access to prevention, testing, treatment and care for people who use drugs.

The treatment of hepatitis C has entered a new era since the advent of curative pharmaceuticals. As policy, government and civil society assemble in response, there are still gaps to be addressed. The Manifesto on Hepatitis C and Drug Use, launched in Berlin during the Correlation Hepatitis C Initiative conference in October 2014, was formulated and endorsed by many key organizations in the hepatitis field. The Manifesto takes strides to pinpoint shortcomings in hepatitis action oriented towards the population most affected by the hepatitis C virus (HCV): active drug users. Despite a considerable amount of evidence that active drug users are disproportionately affected by HCV, barriers to care remain. Engagement with representatives of communities of people who inject drugs (PWID) is imperative in order to effectively create guidelines which reflect reality. Unfortunately, widespread systemic stigmatization and lack of trust between affected communities, decision-makers and healthcare professionals have reproduced this divide. The Berlin Manifesto has identified a disconnect between evidence and action which must be answered. In this roundtable discussion, experts from diverse parts of the hepatitis community have contributed their perspectives and experience on access to prevention, testing, and treatment for HCV in PWID. The authors discuss relevant topics such as realities of access to HCV treatment in the United Kingdom, interventions of a regional network of active drug users in Europe and lack of PWID involvement in government policy in Catalonia. Collectively they challenge the neglect of HCV in PWID by many decision-makers and health care professionals and promote a scale-up of integrated prevention and treatment strategies focusing on this population. The authors' conclusions aim to clarify the discourse on hepatitis in order to prevent disease, save lives and work towards eventual hepatitis elimination

Novel health systems service design checklist to improve healthcare access for marginalised, underserved communities in Europe.

BACKGROUND content: Marginalised communities such as homeless people, people who use drugs (PWUD), lesbian, gay, bisexual, transgender and intersex people (LGBTI), prisoners, sex workers and undocumented migrants are at high risk of poor health and yet face substantial barriers in accessing health and support services. The Nobody Left Outside (NLO) Service Design Checklist aims to promote a collaborative, evidence-based approach to service design and monitoring based on equity, non-discrimination and community engagement. METHODS content: The Checklist was a collaborative project involving nine community advocacy organisations, with a focus on homeless people, PWUD, LGBTI people, prisoners, sex workers, and undocumented migrants. The Checklist was devised via a literature review; two NLO platform meetings; a multistakeholder policy workshop and an associated published concept paper; two conference presentations; and stakeholder consultation via a European Commission-led Thematic Network (including webinar). RESULTS content: "The NLO Checklist has six sections in line with the WHO Health Systems Framework. These are: (1) service delivery, comprising design stage (6 items), services provided (2 items), accessibility and adaptation (16 items), peer support (2 items); (2) health workforce (12 items); (3) health information systems (7 items); (4) medical products and technologies (1 item); (5) financing (3 items); and (6) leadership and governance (7 items). It promotes the implementation of integrated (colocated or linked) healthcare services that are community based and people centred. These should provide a continuum of needs-based health promotion, disease prevention, diagnosis, treatment and management, together with housing, legal and social support services, in alignment with the goals of universal health coverage and the WHO frameworks on integrated, people-centred healthcare."CONCLUSIONS content: The Checklist is offered as a practical tool to help overcome inequalities in access to health and support services. Policymakers, public health bodies, healthcare authorities, practitioner bodies, peer support workers and non-governmental organisations can use it when developing, updating or monitoring services for target groups. It may also assist civil society in wider advocacy efforts to improve access for underserved communities

Hepatitis C services at harm reduction centres in the European Union: a 28-country survey

Background: In the context of the WHO’s 2016 Viral Hepatitis Strategy and the introduction of treatment that can cure more than 95% of cases with hepatitis C virus (HCV) infection, the European Joint Action on HIV and Co-infection Prevention and Harm Reduction (HA-REACT) undertook a study in the member states of the European Union (EU). It aimed to determine service providers’ understanding of the current services in their respective countries and the barriers experienced by PWID in accessing HCV testing, care and treatment services in their country. Methods: In 2017, 38 purposively selected harm reduction service providers completed a 26-item Englishlanguage online survey addressing the availability, accessibility and funding of HCV services at harm reduction centres. HCV-related data and reported findings were extracted by country or by responding organization. Results: Responses were received from all EU member states. Respondents from 23 countries reported that HCV tests are offered by harm reduction services in their countries, and eight countries reported that addiction specialists in their countries are able to prescribe HCV therapy. Almost half of the respondents (45%) said that their respective organizations had established referral systems with centres providing HCV treatment. Conclusions: Not all EU member states have harm reduction services that provide HCV tests, and many do not have established referral systems with treatment providers. Moreover, the inability of addiction specialists to prescribe HCV treatment points to missed opportunities to make treatment more accessible. Further, discrepancies were noted between the available HCV services and stakeholders’ knowledge about their availability

Securing sustainable funding for viral hepatitis elimination plans

The majority of people infected with chronic hepatitis C virus (HCV) in the European Union (EU) remain undiagnosed and untreated. During recent years, immigration to EU has further increased HCV prevalence. It has been estimated that, out of the 4.2 million adults affected by HCV infection in the 31 EU/ European Economic Area (EEA) countries, as many as 580\xC2\xA0000 are migrants. Additionally, HCV is highly prevalent and under addressed in Eastern Europe. In 2013, the introduction of highly effective treatments for HCV with direct-acting antivirals created an unprecedented opportunity to cure almost all patients, reduce HCV transmission and eliminate the disease. However, in many settings, HCV elimination poses a serious challenge for countries' health spending. On 6 June 2018, the Hepatitis B and C Public Policy Association held the 2nd EU HCV Policy summit. It was emphasized that key stakeholders should work collaboratively since only a few countries in the EU are on track to achieve HCV elimination by 2030. In particular, more effort is needed for universal screening. The micro-elimination approach in specific populations is less complex and less costly than country-wide elimination programmes and is an important first step in many settings. Preliminary data suggest that implementation of the World Health Organization (WHO) Global Health Sector Strategy on Viral Hepatitis can be cost saving. However, innovative financing mechanisms are needed to raise funds upfront for scaling up screening, treatment and harm reduction interventions that can lead to HCV elimination by 2030, the stated goal of the WHO

Marginalisation, social inclusion and health; experiences based on the work of Correlation - European Network Social Inclusion & Health.

This paper describes the efforts within the European Union to tackle the issue of social inclusion. Based on that, the text focuses on a particular aspect: the relationship between social inclusion and health regarding four main groups at risk for marginalisation: (undocumented) migrants, drug users, sex workers and youth at risk. Based on the experiences and results of the work of Correlation – European Network Social Inclusion & Health - the text describes approaches and methodologies to improve social inclusion and access to health for the target groups mentioned abov

Drug consumption rooms: evidence and practice.

For the past 10 to 20 years, drug consumption rooms (DCRs) have become an integrated part of the drug treatment and harm reduction strategy in a variety of countries in Western Europe, North America and Australia. However, they have not yet been established in the majority of countries worldwide. This briefing paper provides a short summary of the background, history and objectives of DCRs, and analyses available evidence regarding their impact. The second part of the briefing paper consists of an overview of the various DCRs in different countries, with a particular focus on the concepts used to develop these facilities with regard to the local political, cultural and social situation of each country

Civil society involvement in harm reduction drug policy:reflections on the past, expectations for the future

BACKGROUND A range of civil society organisations (CSOs) such as drug user groups, non-governmental/third sector organisations and networks of existing organisations, seek to shape the development of drugs policy at national and international levels. However, their capacity to do so is shaped by the contexts in which they operate nationally and internationally. The aim of this paper is to explore the lived experience of civil society participation in these contexts, both from the perspective of CSOs engaged in harm reduction advocacy, and the institutions they engage with, in order to inform future policy development. METHODS This paper is based on the presentations and discussions from a workshop on 'Civil Society Involvement in Drug Policy hosted by the Correlation - European Harm Reduction Network at the International Society for the Study of Drugs Policy (ISSDP) annual conference in Paris, 2019. In the aftermath of the workshop, the authors analysed the papers and discussions and identified the key themes arising to inform CSI in developing future harm reduction policy and practice. RESULTS Civil society involvement (CSI) in policy decision-making and implementation is acknowledged as an important benefit to representative democracy. Yet, the accounts of CSOs demonstrate the challenges they experience in seeking to shape the contested field of drug policy. Negotiating the complex workings of political institutions, often in adversarial and heavily bureaucratic environments, proved difficult. Nonetheless, an increase in structures which formalised and resourced CSI enabled more meaningful participation at different levels and at different stages of policy making. CONCLUSIONS Civil society spaces are colonised by a broad range of civil society actors lobbying from different ideological standpoints including those advocating for a 'drug free world' and those advocating for harm reduction. In these competitive arena, it may be difficult for harm reduction orientated CSOs to influence the policy process. However, the current COVID-19 public health crisis clearly demonstrates the benefits of partnership between CSOs and political institutions to address the harm reduction needs of people who use drugs. The lessons drawn from our workshop serve to inform all partners on this pathway