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  Soon HCV cure rates will be 100% in genotypes 1, 2 and 3 in clinical studies with the advent of new HCV drugs, how will this evolve globally? Hepatitis C is a global health problem caused by infection with the hepatitis C virus. Although representative prevalence data are not available from many countries, available data indicate that approximately 3% of the world's population is infected with HCV. It is estimated that as many as 170 million persons world-wide may be infected with HCV. In many countries, the exact magnitude of the problem and the relative contribution of the various routes of transmission have not been defined with population-based studies. Wherever possible such studies should be performed to enable countries to estimate the burden of hepatitis C disease, to prioritize their preventative measures and to make the most appropriate use of available resources. To assess hepatitis C on a global scale, the World Health Organization (WHO) organized a consultation of international experts, in order to review the public health aspects related to hepatitis C infection and to make recommendations for its prevention and control. J Viral Hepat. 1999

The prevalence of hepatitis C is lowest in Northern European countries, including Great Britain, Germany and France. According to one survey, the prevalence of HCV antibodies in blood donors averages less than 1% for the region. (However, other studies have suggested that rates of infection may be much higher, comparable to rates in the U.S. - approximately 2.5%). Higher rates have been reported in Southeast Asian countries, including India (1.5%), Malaysia (2.3%), and the Philipines (2.3%). The incidence in Japan was 1.2%. Alarming rates were reported for many African nations, reaching as high as 14.5% in Egypt. These studies, when added together, suggest that over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the world's population. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS. Without large scale efforts to contain the spread of HCV and treat infected populations, the death rate from hepatitis C will surpass that of AIDS by the turn of the century and will only get worse.

Globally, 57% of cirrhosis was attributable to either HBV (30%) or HCV (27%) and 78% of HCC was attributable to HBV (53%) or HCV (25%). Regionally, these infections usually accounted for >50% of HCC and cirrhosis. Applied to 2002 worldwide mortality estimates, these fractions represent 929,000 deaths due to chronic HBV and HCV infections, including 446,000 cirrhosis deaths (HBV: n=235,000; HCV: n=211,000) and 483,000 liver cancer deaths (HBV: n=328,000; HCV: n=155,000)....Journal of Hepatology October 2006

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Hepatitis in drug users: time for attention, time for action

The Lancet,

Published Online: 28 July 2011

In place of saints' days or public holidays, public health practitioners celebrate disease days: World Cancer Day in February,1 Stroke Day in October,2 and World AIDS Day on Dec 1.3 The main reason for these days is to raise awareness, a key part of which is the presentation of descriptive statistics: without intervention, 84 million people will die of cancer between 2005 and 2015;1 every 6 s someone will die from stroke;2 and 33 million people are living with HIV.3

In The Lancet, Paul Nelson and colleagues4 review 4386 peer-reviewed sources and 1019 grey literature sources to estimate-at national, regional, and global scales-prevalence and population estimates for hepatitis B and C in injecting drug users (IDUs). The investigators provide the requisite bold statistics: 10 million IDUs might be positive for hepatitis C antibodies and more than 80% of IDUs in 12 countries are estimated to be infected. More than 6 million IDUs might be positive for hepatitis B core antibodies. The investigators do not estimate the burden of death and disease from these infections, but it is likely to be substantial: more than 1.5 million deaths occur every year from acute hepatitis B and C infections, hepatocellular carcinoma, and cirrhosis.5

July 28 is World Hepatitis Day, and the article by Nelson and colleagues4 forms part of the efforts to raise awareness about this disease. While focusing attention on hepatitis is a challenge generally, mobilisation of action to address the disease in drug users is even more difficult.

Drug users around the world face stigma, discrimination, mistreatment, and the systematic violation of their human rights.6 Harm-reduction strategies that, in addition to prevention of HIV infection, could help to reduce hepatitis B and C transmission are widely underfunded or blocked by local or national governments altogether. In June, 2011, the United Nations General Assembly feebly called on nations to give “consideration, as appropriate” to implementation and expansion of harm-reduction programmes.7 Not surprisingly, countries that do not find drug users worthy of consideration often find harm reduction inappropriate.8

Through country-by-country estimates, Nelson and colleagues provide an opportunity to examine striking disparities in rates of hepatitis B and C. Why is the prevalence of hepatitis C antibodies in IDUs in Hungary 23%, whereas it is about 90% in Estonia or Lithuania and 73% in Russia? Why do 85% of IDUs in Mexico have hepatitis B core antibodies compared with 20% of IDUs in Uruguay? These differences could be due to the limitations of the data: despite thousands of studies reviewed, grade A reports (ie, a multisite seroprevalence study with several sample types for at least one hepatitis marker) were only available for 20 of the 77 countries for which any data were available, and few studies provided truly national estimates.4 However, the differences may also show trends and patterns of drug use, or important differences in state policies and investment in harm reduction. Large between-country variations emphasise how high rates of hepatitis B, hepatitis C, or HIV infection in drug users are not inevitable.9 Moreover, the estimates provide a powerful means for health and human rights advocates to question government officials in countries with high prevalences, and to caution governments in countries with low prevalences about the potential costs (human and economic) of failing to put in place, or sustain, effective, rights-based policies.

Nelson and colleagues4 conclude that improved recognition of hepatitis in IDUs and development of comprehensive and effective strategies are needed. No doubt this is true, to some extent. However, the history of HIV in IDUs shows that much more than awareness and evidence-based approaches are needed to bring about change.10 A lesson to recall is the importance of looking to those most affected (ie, people who use drugs) for guidance and leadership in development of effective responses and identification of barriers to their implementation.

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Reuters

Until governments abandon the failed so-called war on drugs11 and their reliance on repression in response to drug use, we will continue to need days to recognise and raise awareness of hepatitis in drug users. At the same time, we should remember the harm that arbitrary detention, forced labour, physical abuse, and torture causes to IDUs.12 Health is often proclaimed to be at the centre of drug policy, but support for the protection and promotion of the right to health, and other human rights, of drug users is often wholly absent.13

Nelson and colleagues4 provide us with a first step and powerful data to draw attention to the problem of viral hepatitis in people who use drugs. The next step is to challenge governments to act, and hold them accountable for implementation of rights-respecting and evidence-based programmes.

I declare that I have no conflicts of interest.

References

1 WHO. World cancer day. http://www.who.int/mediacentre/events/annual/world_cancer_day/en. (accessed July 6, 2011).

2 World Stroke Campaign. About world stroke day. http://www.worldstrokecampaign.org/media/Pages/AboutWorldStrokeDay2010.aspx. (accessed July 6, 2011).

3 WHO. World AIDS day. http://www.who.int/mediacentre/events/annual/world_aids_day/en/index.html. (accessed July 6, 2011).

4 Nelson PK, Mathers BM, Cowie B, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: an analysis of systematic reviews. Lancet 201110.1016/S0140-6736(11)61097-0. published online July 28. PubMed

5 WHO. The global burden of disease: 2004 update. http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html. (accessed July 7, 2011).

6 Jurgens R, Csete J, Amon JJ, Baral S, Beyrer C. People who use drugs, HIV, and human rights. Lancet 2010; 376: 475-485. Summary | Full Text | PDF(140KB) | CrossRef | PubMed

7 United Nations. Political declaration on HIV/AIDS: intensifying our efforts to eliminate HIV/AIDS. http://www.un.org/ga/search/view_doc.asp?symbol=A/65/L.77. (accessed July 7, 2011).

8 United Nations Economic and Social Council. Fifth periodic report of the Russian Federation on the implementation of the International Covenant on Economic, Social and Cultural Rights. http://sim.law.uu.nl/SIM/CaseLaw/uncom.nsf/804bb175b68baaf7c125667f004cb333/ad942f90172714a7c12578a000341797?OpenDocument. (accessed July 19, 2011).

9 Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Strathdee S. 12 myths about HIV/AIDS and people who use drugs. Lancet 2010; 376: 208-211. Full Text | PDF(326KB) | CrossRef | PubMed

10 Pisani E. Tilting at windmills and the evidence base on injecting drug use. Lancet 2010; 376: 226-227. Full Text | PDF(280KB) | CrossRef | PubMed

11 Global Commission on Drug Policy. War on drugs: report of the Global Commission on Drug Policy. http://www.globalcommissionondrugs.org/Report. (accessed July 7, 2011).

12 Elliot R, Symington A, Lines R, Schleifer R. Treatment or torture? Applying international human rights standards to drug detention centers. http://www.stoptortureinhealthcare.org/news-and-resources/detention-treatment/treatment-or-torture-applying-international-human-rights-stan. (accessed July 7, 2011).

13 United Nations Office on Drugs and Crime. World drug report 2011. http://www.unodc.org/unodc/en/data-and-analysis/WDR-2011.html. (accessed July 7, 2011).

 
 
 
 
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