We, members and representatives of the viral hepatitis community - a community that includes people living with viral hepatitis, doctors, nurses, social workers, researchers, public health experts, and people who use drugs - are concerned over the growing gap between the enormous impact of hepatitis B and hepatitis C over people who use drugs and their almost non-existent access to prevention, diagnosis and treatment services around the world.
Sharing unsterile drug injecting equipment puts people at high risk of hepatitis B and hepatitis C infections. Globally it is estimated that among the 15.6 million people who currently inject drugs 52% are hepatitis C antibody positive, and 9% are living with chronic hepatitis B infection1 ; From a public health and human rights perspective, improving access to prevention and treatment for people who use drugs is crucial to reducing hepatitis C incidence and eliminating the epidemic, as sharing of needles, syringes and other injecting equipment is estimated to account for 23% of new infections2.
Improving access to prevention and treatment for people who use drugs is crucial to reducing hepatitis C incidence.
Ensuring access to interventions such as low-threshold needle and syringe programmes, opioid substitution therapy, hepatitis C treatment and other harm reduction interventions are essential to reduce hepatitis C incidence and prevalence among people who inject drugs3,4, and these interventions are cost-effective5,6. In 2016, the Member States of the World Health Organization (WHO) adopted the first ever Global Health Sector Strategy (GHSS) on viral hepatitis7. It identified harm reduction as one of five core interventions needed to reach the goal of viral hepatitis elimination by 2030.
Despite the evidence and WHO recommendations, comprehensive harm reduction services are inaccessible for most people who use drugs worldwide. In 2017, among the 179 countries and territories where injecting drug use has been reported, just 86 (48%) have implemented opioid substitution therapy and 93 (52%) have needle and syringe programmes8. Furthermore, the regional and national coverage varies substantially and is most often below WHO indicators, with less than 1% of people who inject drugs living in countries with high coverage of both services8. Even where services do exist, people who use drugs face more difficulties in accessing hepatitis C prevention and treatment due to poor access to health services, their exclusion through treatment criteria, threats of violence and abuse when disclosing status as drug users, and universal stigmatization. As a result, the hepatitis C epidemic continues to grow among people who use drugs9.
Comprehensive harm reduction services are inaccessible for most people who use drugs worldwide.
This lack of access to hepatitis care for people who use drugs is deeply rooted in and driven by our laws and policies which criminalize drug use, drug possession and, ultimately, people who use drugs themselves10,11. Punitive drug law enforcement is a direct barrier to harm reduction services in many ways:
- the prohibition of drug paraphernalia possession impedes harm reduction service delivery and uptake;
- many national laws impose severe and disproportionate custodial sentences for minor, non-violent drug offenses (such as drug use, possession and low-level supply);
- people who use drugs are frequently incarcerated or extra-judicially detained, often leading to interruption of medical treatments, without access to prevention and other harm reduction services, and at heightened risk of hepatitis infection;
- policies criminalizing drug use fuel stereotypes and negative assumptions of people who use drugs, ultimately reinforcing stigmatization and discrimination.
Even in countries that have integrated harm reduction into domestic public health policies, criminalization remains a glass ceiling – as the fear of arrest continues to drive people away from prevention and care services.
A number of countries, such as Portugal and the Czech Republic, decriminalized minor drug offenses years ago with significant public health benefits12,13. These policy changes have proven very successful and have led to an increase of access to harm reduction and health services by people who use drugs – contributing to decreased new HIV infections, and reduced harms associated with drug use and drug dependence14. While our laws and policies that prohibit drugs are portrayed and defended as necessary to preserve public health and safety, the evidence overwhelmingly demonstrates that they have driven unnecessary and disproportionate human rights violations including violence, disease, discrimination, and the undermining of people’s right to health10,11,12. Growing recognition of the need for evidence-based drug policy reform has led several world leaders, public health experts, the WHO and other United Nations Agencies to recommend the decriminalization of minor, non-violent drug offenses, and a strengthening of health-oriented alternatives to criminal sanctions9,15,16,17,18,19,20,21,22.
A number of countries decriminalized minor drug offenses years ago with significant public health benefits.
We, the viral hepatitis community, whole-heartedly support Member States’ commitment to the goal of eliminating viral hepatitis by 2030. In order to achieve that goal, we call on world political leaders to remove all barriers to the uptake of the full range of prevention services by people who use drugs by reforming laws, law enforcement procedures and discrimination that hinder access, including the criminalization of minor, non-violent drug offences and to adopt an approach based overwhelmingly on public health promotion, respect for human rights and evidence.