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    World Hepatitis Day – Saturday July 28th

    Every year on July 28th we raise global awareness of viral hepatitis. This year’s theme, Finding the Missing Millions, is aimed at finding the estimated 300 million people worldwide who are unaware that they are living with viral hepatitis. To find out more or to get involved, CLICK HERE.

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    World Hepatitis Day – July 28th

    Friday, July 28, 2017 marks World Hepatitis Day. This initiative is in response to the May 2016 World Health Assembly’s where 194 governments  adopted the World Health Organization’s Global Strategy on Viral Hepatitis, which includes a goal of eliminating hepatitis B and C in the next 13 years.

    Last year’s theme was “NOhep” while this year’s theme is “Show Your Face.” This campaign invites you to share a photo of yourself accompanied by your own personal “I AM” message to help put a human face to the elimination of viral hepatitis.

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    HCV Among People Who Inject Drugs in Rural Puerto Rico


    Although we know that the microbial differences between HIV and HCV have an impact on prevalence, how drugs are obtained and used may also influence prevalence. Recent studies show Puerto Rico has one of the highest HCV prevalence rates in the world.


    The authors looked risk factors of 315 rural Puerto Rican people who inject drugs (PWID) and also compared the behaviours of HCV negative and HCV positive participants.


    INSTI Rapid HIV and OraQuick Rapid tests were used to determine HIV and HCV status. Additional data was acquired through questionnaires.


    • Over three quarters (78.4%) of the participants were positive for HCV and significantly fewer (6.0%) were HIV positive.
    • All HIV positive individuals were also infected with HCV.
    • Both HCV positive and HCV negative reported the same frequency of injection drug use during the last year.
    • Each additional person who used equipment before the participant was associated with an increase 18% increase in the odds of being HCV + positive.
    • Frequency of injection with a used cooker was over twice as common as injection with a used needle.

    HCV + (pos) Characteristics

    • 3 years older (than HCV negative)
    • Began injecting at a younger age (20.7 vs 26.3)
    • Injected for 9.4 more years than HCV negative group
    • Used cookers, cotton and water after an average of 2 or more people


    This adds to current research showing that a notable proportion of HCV infections are due to cooker or cotton sharing.

    Abadie, R., Welch-Lazoritz, M., Gelepi-Acosta, C., Reyes, J.C., and Dombrowski, K. (2016). Understanding differences in HIV/HCV prevalence according to differentiated risk behaviors in a sample of PWID in rural Puerto Rico. Harm Reduction Journal. 13:10-13.

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    Recommendations for HCV Infection Management


    • Hepatitis C virus (HCV) infection in high income countries ranges from 50%-80% among people who inject drugs (PWID) and epidemics are also beginning to emerge in middle and low income countries among their PWID populations.
    • Among people who inject drugs, the rates of advanced liver disease complications, related healthcare costs, and liver associated morbidity and mortality are all on the rise.
    • Despite the increased burden of liver disease, treatment uptake and completion remains very low.


    The authors make recommendations based on scientific research and expert opinion, which are updated to be in line with international guidelines.

    Summery of some of the recommendations:

    Impact of drug use on treatment adherence and sustained virologic response (SVR) 

    If one receives approximately 80% of scheduled treatments he is generally considered to be adhering to the to HCV therapy however, this does not distinguish between missed doses and the stopping of treatment.

    In addition, studies have found that lower education and unstable housing are associated with adherence and treatment completion. Other factors associated with low SVR among PWID, include low social functioning, a history of untreated depression, and continued drug use during treatment

    • Adherence assessments should consider missed doses and treatment discontinuation
    • Individuals should be counselled on the importance of adherence in attaining an SVR
    • A history of IDU and recent drug use at treatment initiation are not associated with reduced SVR and decisions to treat should be made on a case-by-case basis
    • Those with ongoing social issues, history of psychiatric disease and those with more frequent drug use during therapy are at risk of lower adherence and SVR and should be to be monitored closely.

    Treatment management recommendations

    Several models have shown that HCV treatment can be delivered successfully to PWID whether it be within a general hospital, drug detoxification clinics, opioid substitution therapy clinics, prisons or a community-based clinics.

    • HCV treatment for PWID should be looked at on a case by case basis and delivered by a multidisciplinary team
    • Access to harm reduction programs, social work and social support services should be a component of HCV clinical management
    • Peer-based support should be evaluated to improve HCV clinical management


    Although there are number of barriers to care for people who inject drugs (PWID), research has shown hepatitis C virus (HCV) treatment to be safe and effective. Enhancement of HCV assessment and treatment strategies is greatly needed due to the burden of HCV-related disease.

    Grebely, J.A., Robaeys, G., Bruggmann, P., Aghemo, A, Backmund, M., and Bruneau, J. (2015).

    Recommendations for the management of hepatitis C virus infection among people who inject drugs. International Journal of Drug Policy. Vol. 26. Pp 1028-1039.

  5. Injecting Risk Behaviours after Hepatitis C Virus Treatment in Australia


    Hepatitis C virus (HCV) infection prevalence is high among people who inject drugs (PWID) and is a major cause of morbidity and mortality among this population. Due to concerns that HCV treatment may increase injecting risk behaviours among people who inject drugs (PWID) the authors compared recent (past month) injecting risk behaviours between PWID who received and did not receive HCV treatment.


    • Of the 124 Australian participants with a history of injection drug use, 69% were male with 68% treated for HCV infection.
    • HCV treatment was not associated with an increase in recent injection drug use (adjusted odds ratio (aOR) 1.06, 95% CI 0.93, 1.21). This is consistent with previous study findings.
    • HCV treatment was not associated with recent used needle and syringe borrowing (aOR 0.99, 95% CI 0.89, 1.08).
    • Treatment was associated with a decrease in recent ancillary injecting equipment sharing (aOR 0.85, 95% CI 0.74, 0.99). This is important given that sharing of equipment contributes to HCV transmission.
    • Although a small sample, the 24 participants who remained in follow-up (24 weeks) showed a significant decrease in injecting equipment sharing during follow-up. This is at least interesting to note because the side effects of interferon-based therapy mimic opioid withdrawal, which is a concern for some physicians (they worry that treatment might lead to relapse or an increase in drug use).


    Hepatitis C virus assessment and treatment for people who inject drugs should be enhanced due to its effectiveness as it does not lead to increases in injection risk behaviours and has already been shown to be safe and effective for PWID populations.

    Alavi, M.,  Spelman, T.,  & Matthews, G.V. (2015). Injecting risk behaviours following treatment for hepatitis C virus infection among people who inject drugs: The Australian Trial in Acute Hepatitis C. International Journal of Drug Policy. Vol. 26. Issue 10, pp. 976-983.

  6. How does a Positive or Negative Hepatitis C Virus Test Impact Behavior?


    • Worldwide, Hepatitis C virus (HCV) prevalence among injection drug users is estimated between 50% and 90%.
    • HCV testing and counselling can be used as an opportunity to influence behaviour and transmission of HCV at the time of test notification. For example, a study conducted in Montreal showed a decrease in syringe sharing after participants were made aware of both positive and negative HCV test results in an addition to a reduction of alcohol use. However the results were limited due to a small sample size.


    • The authors used data from the International Collaboration of Incident HIV and HCV Infection in Injecting Cohorts (InC3 Study), which is a multicohort study of pooled data from prospective studies of people who inject drugs (PWID) in Canada, USA, The Netherlands, and Australia. Participants were recruited and followed between 1985 and 2011. The sample included 829 people who inject drugs.


    • Notification of a HCV test result showed a reduction in recent injection drug use and recent syringe sharing for both those who received a positive and negative HCV test result (5% and 3% reduction, respectively). There were no significant differences between the two groups.
    • Recent Australian and Canadian data show some sustained behavioural changes associated with the notification process.
    • The proportion of participants using alcohol increased among those who received a positive HCV test
    • Younger (under 25 years) PWID populations who received a positive HCV test significantly increased alcohol consumption in comparison to the HCV-negative group.


    Timely notification of HCV test results is a key opportunity for risk behavior reduction counseling. In addition, there is need to expand post-test counseling services and monitoring in order to address post-diagnosis alcohol use.

    Spelman, T., Morris, M.D., and Zang, G. (2015). A longitudinal study of hepatitis C virus testing and infection status notification on behavior change in people who inject drugs. J Epidemiol Community Health. 69(8): 745–752.

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    Targeting Hepatitis C virus Treatment ~ Who should be treated to first?


    Due to the high cost of improved Hepatitis C virus treatment, in most cases, it is not feasible to offer treatment to all injection drug users at once. In order to optimize the benefits for the overall injection population, targeting HCV treatment appropriately is vital. Previously, treatment has been withheld from active injectors because of the risk that they may become re-infected and limit the benefits to themselves and the whole population.


    The authors of this study look at the population-level benefits of treating one chronically HCV infected injection drug user in a population of high- and low- risk users. They then compared the benefits of treating one high or low risk user to develop an optimal treatment strategy.


    • High-risk injectors share injecting equipment approximately 7 times more frequently than low-risk injectors.
    • When approximately 32% of injectors are infected with Hepatitis C, the preventative impact of treating high and low risk injectors is equivalent

    (1 high-risk injector = 1 low-risk injector).

    • When Hepatitis C Virus is rare, the benefits of preventing high-risk injectors spreading it to larger numbers outweighs the risk that they will become re-infected.
    • When the virus is already very common, fewer injectors can be infected, which reduces the spreading potential of high-risk users. At this point, it is better to focus efforts toward treating lower risk injectors who are less likely to become re-infected.


    To enhance the preventative impact of hepatitis C virus treatment, interventions should be targeted based on how often the patient shares injecting equipment. When Hepatitis C virus is relatively uncommon among injectors, it is best to cure infected high-risk injectors. When the virus is relatively common, low-risk injectors should be targeted.

    De Vos, A.S., Prins, M., and Kretzschmar, M.E.E. (2015). Hepatitis C virus treatment as prevention among injecting drug users: who should we cure first? Addiction. Vol.110, pp. 975-983.

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    Exploring Methods and Treatment for Hepatitis C virus in People Who Inject Drugs


    Population size is a key factor in modeling of cost-effectiveness analysis and resource allocation, yet there is no gold standard method of estimating the size of “hidden” populations such as people who inject drugs (PWID) and there is no ideal method for all drugs and settings. Chronic hepatitis C virus (HCV) infection is high (approximately 50%) in current PWID. Due to the development of effective treatment for hepatitis C virus (HCV) there is growing interest to understand how increased treatment uptake will impact the burden of HCV.


    • Direct methods use data from general population surveys asking people about their drug use.
    • Advantages: accurately estimates prevalence when the population is representative and people honestly disclose drug use.
    • Disadvantages: 1) relies on household surveys so excludes people who are homeless or in unstable housing; 2) if contacted, PWID may be reluctant to disclose injection drug use.
    • Indirect methods involves adjustment of prevalence data from known, non- random samples such as drug treatment agencies, harm reduction services, and criminal justice agencies.
    • Advantages: uses data from multiple sources.
    • Disadvantages: linked data sources can introduce biases that are difficult to disentangle (such as cross-references between criminal and health data sources).
    • In England, approximately 85% of HCV occurs in current or former PWID. This was estimated through indirect methods and has resulted uncertainty in the number of PWID carrying HCV antibodies. Separating out different populations of PWID is complex, but it is critical for prevention and prioritization of treatment.
    • In order to assess transmission of HCV, it is important to define current/recent PWID from former PWID. However, this is difficult due to the relapsing nature of drug dependence it is difficult to determine a cutoff for permanent vs. short term quitting of injection drug use.
    • Assessing HCV prevalence overtime needs to sample PWID from multiple sites such as community, needle exchange and specialist drug treatment.

    Role of OST, NST and Prisons in Prevention of HCV

    • HCV incidence is decreased in PWID in opiate substitution treatment. HCV testing and notification is increased. OST clinics provide an opportunity to give HCV care and treatment.
    • Needle syringe programs also reduce HCV incidence, especially in combination with OST.
    • In order to assess impact of interventions on HCV transmission and prevalence, it is key to have information on the coverage and duration of time PWID are in OST and NSP.
    • Approximately, 41% of current PWID populations in Australia spend time in OST and 12% in prison. The high HCV incidence of HCV in prisons and high rates transitioning between prisons and communities is also important in designing HCV treatment as prevention and estimating population size and effects.


    In order to develop appropriate public health policy and services to people who inject drugs (PWID), the ability to estimate current and former PWID populations is vital for both HCV treatment and prevention in new and existing measures such as opioid substitution treatment and needle and syringe programs. Improving epidemiological data on people who inject drugs is key for increasing the effectiveness of future interventions

    Larney., L., Grebely, J., Hickman, M., De Angelis, D., Dore, G.J., and Degenhardt, L. (2015). Defining populations and injecting parameters among people who inject drugs: Implications for the assessment of hepatitis C treatment programs. The International Journal of Drug Policy. Vol 26:10. Pp. 950-957.

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    Remaining Hepatitis C Virus in Syringes Depends on Needle-Syringe Design and Dead Space Volume

    Hepatitis C Virus prevalence in people who inject drugs (PWID) ranges from 40%-90%. The volume of residual fluid within syringes depends on needle size and length, amount of space remaining in the hub of the syringe once the needle is attached and if the needles are detachable from the syringe barrel. Although they retain the least volume, syringes with fixed needles are not always acceptable to people who inject drugs (PWID). This has lead to the development of detachable needle-syringe combinations to reduce dead space.


    • The 1ml insulin syringes with fixed needles were the most effective at reducing HCV retention in syringes.
    • This remained the case whether HCV recovery was assessed immediately after use, after storage at room temperature, or after rinsing with water.
    • Authors found that Noloss low dead space (LDS) syringes with standard needles and the standard Nevershare syringes with Total Dose LDS needles retained levels of viable HCV comparable to high dead space (HSD) immediately after use.
    • Specific recommendations cannot be made for any one LDS syringe-needle combination over the others or in place of od HDS syringes due to inconsistent patterns across the three experiments (immediate testing, storage, and rinsing with water).
    • At this time, lower dead syringes cost more without providing much benefit, therefore economically, there is no benefit to recommending them as an HCV prevention measure.

    People who inject drugs who use syringes with larger volumes and detachable needles need to be made aware that they are at increased risk for HCV transmission compared to fixed needle syringes if injection equipment is reused. This applies even when using two part low dead space (LDS) syringes and after several rinses with water. HCV prevention should focus on traditional harm reduction approaches such as preparing drugs and injecting them only with new, sterile equipment, minimizing contamination of injection locales, and hypochlorite bleach disinfection. Further research is needed on the overall impact of syringe type on HCV transmission among people who inject drugs.

    Binka, M., Painstil, E., Patel, A. et al. (2015).Survival of Hepatitis C Virus in Syringes Is Dependent on the Design of the Syringe-Needle and Dead Space Volume. PLOS.

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    World Hepatitis Day – July 28, 2016

    2016 is a pivotal year for viral hepatitis. At the World Health Assembly in May, WHO Member States adopted the first ever Elimination Strategy for Viral Hepatitis, with ambitious targets and a goal to eliminate hepatitis as a public health threat by 2030. This will be the first time national governments sign up and commit to the goal of eliminating viral hepatitis.

    To mark this historic moment, the theme of elimination for World Hepatitis Day (WHD) 2016 will be used. This means every activity that addresses viral hepatitis is a step towards elimination. In other words, no matter what your plans are to mark WHD, be it a rally or press briefing or screening events, they can all come under the theme of elimination.

    To elevate the theme of elimination NOhep, a global elimination movement, will be launched to bring people together and provide a platform for people to speak out, be engaged and take action to ensure global commitments are met and viral hepatitis is eliminated by 2030.

    In order to achieve the NOhep objective of reaching 300 million by 2030, we need your help. Whether you do something as large as launching NOhep on WHD in your country or as simple as signing up to the movement, every action has an impact. Be part of making the elimination of viral hepatitis our next greatest achievement.

    1. SIGN UP: Log on to to sign up to the movement.
    – Please note that will be officially launched on July 28th
    4. ADD NOhep logo to your materials