Close to half of injecting drug users surveyed in South Africa are living with the potentially deadly hepatitis C virus, a study has found. But, says a Bhekisisa report, a drug that could cure them, and that is used in several countries, remains unavailable in South Africa.
The non-profit organisation TB/HIV Care Association released the study results – the largest ever survey to chart how many people in the country carry the virus. Hepatitis C causes liver damage and can be transmitted sexually or via shared needles, according to US medical research organisation Mayo Clinic.
The report says the study researchers tested about 3,400 people thought to be at high risk of contracting the virus because of potential risky sexual behaviour or sharing needles. The groups of people they focused on included men who have sex with men, sex workers and drug users (mostly those who inject drugs). The research was carried out in Cape Town, Johannesburg, Pretoria, Mthatha, Pietermaritzburg, Port Elizabeth and Durban.
Overall, 13% of people were found to be living with hepatitis C and close to half of all these infections were among injecting drug users. Almost 40% of the study’s participants were also HIV positive.
The report says the survey revealed high rates of hepatitis C and HIV co-infection (29%) among Pretoria drug users, which TB/HIV Care Association strategic advisor Andrew Scheibe attributes to the city’s long-standing injecting drug use culture.
In 2017, Tshwane became the first city in Gauteng to offer legally prescribed medication, known as opioid substitution therapy (OST), that helps people to reduce or stop using drugs such as heroin without debilitating withdrawal symptoms. A study found that OST helps to decrease illegal drug use, overdose deaths and new HIV infections among people who use drugs.
Researchers also showed that 4% of those surveyed in South Africa had hepatitis B, a virus that – like hepatitis C – can be spread via contact with sexual partners or infected needles and damages the liver. Unlike hepatitis C, there is no cure for hepatitis B but vaccines can protect people from contracting it.
The report says the study recommends expanding access to hepatitis B vaccination for high-risk groups as well as OST and needle exchange programmes that can reduce the risk of infection for people who use drugs.
Globally, more than 1.34m people died from viral hepatitis in 2015 with deaths outpacing those caused by HIV, according to the WHO’s 2017 Global Hepatitis Report. But, the report says, hepatitis has been largely ignored in South Africa, Charlotte Maxeke Academic Hospital’s head of infectious diseases Sarah Stacey warns. “We should be worried about hepatitis because it kills people.”
Historically, hepatitis C treatment has been priced out of reach of most – it can cost up to R120,000 for a year's course. Newer medication, however, could drop that price by up to two-thirds, according to international non-profit the Drugs for Neglected Diseases Initiative.
But, the report says, newer drugs have not yet been approved for use by the South African Health Product Regulatory Authority, the country's medicine regulator. Once these are registered, they will be available in certain sectors, but cost will still be a major barrier to widespread access, Schiebbe warns.
The report says the study was funded by the pharmaceutical company Bristol-Myers Squibb, which manufactures the hepatitis C medication, daclatasvir.
South Africa’s draft hepatitis treatment and prevention guidelines have yet to be passed by the national health council, national Health Department medical advisor Kgomotso Vilakazi-Nhlapo says. She estimates an extra R4bn will be needed over the next five years to decrease hepatitis infections.
Vaccinating people at risk of hepatitis B, and expanding health services such as OST and hepatitis C treatment – when it becomes available – are part of the country’s national HIV plan. But, the report says, South African National Aids Council’s Nevilene Slingers explained that the implementation of the strategy remains the responsibility of provinces. “Provinces (need to) make sure that the drugs and money to buy the drugs is available.”
Background: Viral hepatitis, on the increase globally since 1990, was a leading cause of death in 2013 (1.46 million deaths worldwide, a toll higher than that from HIV, TB or malaria). It’s estimated that, in the absence of any additional efforts or interventions, the world could see 19 million hepatitis-related deaths between 2015 and 2030. More than 90% of the hepatitis burden is due to infection with the hepatitis B virus (HBV) and hepatitis C virus (HCV).
Methods and Findings: The study was embedded into existing community based HIV services for KPs. Socio-demographic data was collected and point-of-care testing performed for HBV, HCV and HIV. HCV infections were confirmed by the NICD. HBV vaccination was offered to all individuals who screened negative for HBV. All new diagnoses (HBV, HCV and/or HIV) were referred to relevant treatment services (for example, the Liver Clinic at Groote Schuur Hospital in Cape Town). Participant demographics are presented in Table 1. A total of 3443 participants were included in the per protocol analysis. Participants were predominantly male (52%), black (61%) and living in private housing (74%). Almost all of the females were recruited from SW with a relatively small proportion of PWID and PWUD being made up of females (13% and 19% respectively). Most PWID (67%) and PWUD (53%) were homeless.
Recommendations and Conclusions: High HCV prevalence and low uptake of referrals support the need for expanded, community-based HCV screening, diagnosis and treatment, particularly for PWID. Integrated HIV and HCV prevention services, including needle and syringe programmes, opioid substitution therapy (OST) and harm reduction initiatives, are all critical as HIV and HCV share the same transmission route. Increased HCV education and awareness is required. There needs to be comprehensive post-test counselling to ensure that all clients understand their HCV status, the risks of not accessing care and the benefits of treatment. Ideally, this should be
supplemented with psychosocial support in order to build a sense of self-worth and the desire to access treatment. Higher than expected HCV prevalence among PWUD (7%) warrants further investigation and implementation of appropriate services.