Barriers to hepatitis C diagnosis, management and treatment in four Asian Countries: India, Indonesia, Malaysia and Nepal.

Exposure to HCV is very common among PWID in Asia, as elsewhere; it is virtually universal among PWID living with HIV. However, the response to the HCV epidemic among PWID in the Asia and Pacific regions is almost non-existent, compared with the scale of the epidemic. While needle and syringe programs (NSP) are being established in many countries, and opiate substitution programs are being introduced and in some cases scaled-up, these programs are being driven by the need to control HIV – and are currently inadequate in scale to achieve this. While access to anti-retroviral therapy (ART) is increasing, the currently coverage and scale is inadequate, and does not take into account of the impact of untreated HCV co-infection.

Emerging challenges, or those previously existing but only now being recognised, are having an impact on efforts to control and respond to HIV, and will continue to do so; these include viral hepatitis co-infections (B and C), and dramatically changing patterns of drug use, especially the massive rise in the use of amphetamine-type stimulants (ATS), which are increasingly being injected in the region.

Given the much higher prevalence of HCV than of HIV among PWID in the region, and its much higher ‘infectiousness’ (i.e. a much smaller amount of blood necessary to carry infection), the coverage of preventive interventions necessary to control HCV transmission will be much greater than that necessary to control HIV transmission in the same communities.

HCV infection can be treated effectively with pegylated interferon and ribavirin combination therapy. However, the current cost of pegylated interferon is so high that the treatment is either not available or affordable for the vast majority of people who need it in low and middle income countries. Pharmaceutical companies hold patents on these drugs, and there are currently no generic versions available; Schering Plough’s patent on pegylated interferon α2b expires in 2015, while Roche’s patent on pegylated interferon α2a expires in 2017.

Co-infection with HCV and HIV increases morbidity and mortality and complicates treatment for both: poorer outcomes on ART, “flares” of HCV-related disease during immune reconstitution, less tolerance of treatment interruptions and a reduced response to HCV treatment.12,13 Increased treatment access for HCV is most urgent in those regions where co-infection with HIV is most prevalent, across Asia and in Eastern Europe; it is here that HIV epidemics are driven by largely uncontrolled epidemics among and from PWID – so HIV/HCV co-infection is a major feature of such epidemics.

The primary challenge for clinicians and patients for the treatment of hepatitis infections in low- and middle-income countries is the high cost of medicines.

WHO, UNAIDS and UNODC guidelines setting targets for national governments for universal access to HIV prevention, care and support include treatment for HCV and hepatitis B virus as part of the comprehensive package of services for PWID,14 but countries are unable to implement these treatments at scale because of their expense.

It is against this background that ANPUD embarked on this project, to begin to investigate and document the barriers to diagnosis, management and treatment of HCV amongst PWID. Four countries were chosen for the pilot study: India, Indonesia, Nepal and Malaysia, as being representative of these wide and varied regions.

This investigation and documentation provides some of the necessary foundations for the next steps, in which ANPUD will develop a regional hepatitis C advocacy strategy based on the study findings. These findings will help ensure that this strategy addresses the key issues in a prioritised manner, responding to and being driven by the needs of the community.