On Tuesday 5^th September 2023, together with Clinton Health Access Initiative (CHAI) and World Health Organisation (WHO), Harm Reduction International (HRI) held a webinar on ‘Integrating Viral Hepatitis and Harm Reduction Services’.

Viral hepatitis— hepatitis C (HCV) and hepatitis B (HBV) — affects more than 325 million people worldwide, with 90 percent of infections concentrated in low- and middle-income countries. 80 percent of people living with hepatitis lack prevention, testing and treatment services leading to an estimated 1.4 million deaths per year. Although Hepatitis C is curable in more than 95% of patients with direct acting antivirals (DAAs), only 7% of those infected receive treatment.

This webinar presented models of harm reduction and viral hepatitis testing, treatment, and care integration in nine jurisdictions and provided an opportunity for governments and implementers to share and increase knowledge on the benefits of integration.

Objectives:

• Highlighted opportunities to integrate viral hepatitis with harm reduction services.
• Shared and discussed integration of viral hepatitis with harm reduction services.
• Highlighted ways to optimize current programs through integration.
• Roundtable discussion with 5 countries who outlined implementation plans and technical assistance needs in furtherance of implementation targets.

The webinar brought together government and civil society partners in 9 countries: Georgia, Viet Nam, India, South Africa, Indonesia, Myanmar, Mozambique, Kenya, and Nigeria to showcase key models of success and to discuss current and future plans to further integrate viral hepatitis programming and service delivery with harm reduction including plans for increased involvement of community and civil society in programme design and delivery.

Presentations were delivered by the International Network of People who Use Drugs (INPUD), WHO, CHAI and the Global Fund covering community perspectives on why integrated services is crucial; technical guidance and recommendations; and highlighting opportunities to integrate HIV and harm reduction services for People who use drugs. Country partners highlighted the need for increased domestic and international investments in Hepatitis C, Hepatitis B, HIV and Harm Reduction Programmes to improve affordability, accessibility, and efforts at integrating service provision to at- risk populations including People who Inject drugs. Partners also highlighted the need for continuous training and capacity building for health and peer workers.

A few highlights from the roundtable discussion below:

• In Nigeria, the viral hepatitis programme started in 2013 and is currently domiciled under the HIV programme. There is a national hepatitis repository, training manuals and a roadmap for state governments. With CHAI’s assistance there are improvements in access to diagnostics and the government is committed to global elimination targets. In terms of integration, there are guidelines for needle and syringe programmes, training manuals for HIV and viral hepatitis.

In June 2023, a national harm reduction assessment for key populations was conducted and gaps were identified. Preliminary findings indicate that there is ongoing but limited screening for HCV and HBV among key populations. However, diagnostics and treatment remain out-of-pocket which poses a real concern.

Some challenges persist including limited awareness levels among general and key populations, high cost of services and inadequate domestic programme funding, suboptimal data reporting and need for improved advocacy at all levels to keep cost down and achieve the goal of free screening in line with recommendations on universal health coverage.

• The government of Myanmar provides screening services (HIV and viral hepatitis) for People who inject drugs at designated harm reduction centres and methadone clinics. With the support of the Global Fund, phase one of a treatment programme for HIV/HCV coinfections has been launched with 2300 screened with a target of 10,000 screenings in phase two.

Myanmar needs to integrate viral hepatitis and harm reduction services as there is higher prevalence of viral hepatitis among people who inject drugs, and they can be easily found in drug treatment centres and methadone clinics.

Myanmar’s drug treatment programme has a total of 90 methadone clinics with the recent addition of 1 up from 89. Across the country, more than 25,000 clients are retained in the methadone maintenance therapy programme. All new clients have been screened for HCV, HBV, and HIV. For HCV there is need to refer clients if tested positive for diagnostics and treatment.

Prevalence of HBV in new methadone clients is at 7% and HCV in 37%. At Yangon Medical Hospital for example, there are 700 methadone clients with 296 tested positive with HCV. There has been challenges with referral services to other facilities as Yangon only has screening capacity.

Coverage remains a problem especially for clients who live far away in hard-to-reach communities. Need for more technical support and diagnostic facilities close to methadone clinics for easy transfer of clients to services. The HCV treatment gap remains significant especially among populations of people who inject drugs. Colocation of services and reaching people where they are is necessary.

• Kenya began harm reduction in 2009 and has over the years come to appreciate the benefits of integrating community and civil society in delivering services. Viral hepatitis is integrated within the national HIV programme. Around the time when harm reduction began with medically assisted therapy (MAT) programme, a comprehensive model of service delivery was adopted (a one-stop-shop) providing HBV screening and vaccination, diagnosis, and treatment of hepatitis C.

In terms of partnering with community and civil society, after Kenya began its MAT programme, it was quickly realised that not all people who use drugs were accessing the OST clinics. Government sought out civil society organisations with drop-in centres to reach those still in active drug use who have not opted into the MAT programmes. When government distributes commodities for screening and testing, this demographic is included.

Government of Kenya has a good relationship with the leadership of civil society and key population advocates. Treatment provision extends beyond MAT centres to civil society drop-in centres to cater to community groups.

Most important success of integration has been the use of peer-led strategies. Despite training the clinicians and health workers, Kenya recognises the important role of peer educators and outreach workers in ensuring clients follow the treatment regimens. Government sensitives peer educators to follow up and where clients miss daily usage in the first 3 months of treatment, peer educators immediately embark on defaulter-tracing. This has helped us have good treatment retention rate and a cure rate for 98.4 percent for the first-round cohort that received HCV treatment. There is no success of treatment without the community, also speaking on their behalf as advocates of the benefits of being treated. These are some of the small steps Kenya has taken and have recorded some success.

• Mozambique’s viral hepatitis programme is under the HIV/STI unit while harm reduction is under the mental health department of the Ministry of Health. However, the units collaborate and work as one group in terms of programming for hepatitis and harm reduction. Harm reduction programme started in 2018 with the adoption of WHO comprehensive package.

Currently, Mozambique is implementing 11 clinics to give needles and syringes to people who inject drugs. Civil society stakeholders’ partner with the government to do outreach and there’s currently 4 harm reduction drop-in centres in the country. Opioid Agonist Therapy (OAT) started as a pilot in 2019. Now in Maputo, there are at least 267 people who inject drugs who are enrolled in the OAT programme.  The programme runs as a one-stop-shop so clients can access treatment for HIV, STIs, viral hepatitis, sexual and reproductive health, and psychosocial support.

The hepatitis programme started as a screening, test and treat service. Unfortunately, like some of the panellists have noted, paucity of funding has affected the sustainability of programme. Currently there is an HBV pilot running focused on pregnant women while the HCV programme focuses of people who use drugs. We hope with the GF grant making process, Mozambique can access funding to scale programmes. Of those screened for HCV, 59 were treated, 17 awaiting treatment. The harm reduction programme has developed guidelines for key populations including for viral hepatitis, OAT (methadone) and NSPs, overdose management (naloxone).

Challenges include the need to advocate more for expansion of integrated programmes (only 4 sites across the country). In Maputo alone, at least 2000 clients are willing to engage the OAT programme for treatment which is a testament to the efficacy of the programme. Unfortunately, the NSP programme has been cut as politicians feel distributing needles and syringes is encouraging of drug use, so need for better sensitisation of policymakers and the public. Need for technical and financial resources to sufficiently cater to the needs of all clients (people who use drugs and others).

• At the UNODC, there is a team working on drugs and health, harm reduction and access to controlled medicines. When it comes to viral hepatitis, the UNODC focuses on prevention because it promotes evidence-based harm reduction in Indonesia and the region. It also tries to strengthen linkage to care and service delivery.

In the region, UNODC promotes voluntary community-based services for people who use drugs. One of the principles behind this is the ‘No Wrong Done’ approach which basically means whatever health and psychosocial support needed should be accessible.

UNODC is aware of the high rates of HIV and HCV coinfection in Asia – 9 out of 10 people who inject drugs live with HIV and HCV. Also observed recently is the rise in the use of stimulants. All countries in the region except for Myanmar and Viet Nam reported the main drugs of concern/treatment admissions are for stimulant use and usage in all forms are associated with increased risks of viral hepatitis and HIV and is an area which UNODC is engaging with stakeholders in addressing the issues. UNODC has promoted the need for availability and accessibility of harm reduction services including for stimulant users.

UNODC also focuses on drug policy advocacy with drug control agencies and ministries of health and civil society groups providing support and coordination to programmes to create an enabling environment where people can freely access care and treatment voluntarily.

Visit the links below for the full video recording, webinar programme, and presentations:

• Full video
• Programme
• Presentations