Hepatitis C transmission is preventable. Effective prevention interventions reduce transmission and the subsequent impact of infection on individuals and the community. In Australia, the majority of hepatitis C transmission occurs through unsafe injecting drug use practices. Decreasing transmission between people who inject drugs is therefore a priority for this strategy.
Harm reduction is the basis of Australia’s public health response to the transmission of hepatitis C and other BBVs transmitted through unsafe injecting drug use practices. This encompasses a range of strategies, including distribution of sterile injecting equipment, peer education, access to opioid pharmacotherapies and primary care services.
Involving people who inject drugs in prevention, education and support efforts is integral to the success of this strategy. Peer education and support by and for people who inject drugs is a preferred option for obtaining credible and accurate information about hepatitis C. With appropriate training and support, people with or at risk of hepatitis C, in particular those who inject drugs, are best placed to communicate prevention messages. However, peer education with marginalised groups requires an understanding of the demands on potential peer educators and appropriately designed programs which support peer educators.35, 36, 37
Although injecting drug use is a relatively uncommon activity across all age groups, young people are more exposed to this practice. In surveys of young people attending music festivals, for example, approximately 25 per cent had been offered the opportunity to inject drugs, or had a friend or partner who had injected.38 While only a small proportion of these young people may go on to inject drugs, they are important targets for hepatitis C prevention messages.
The legal environment affecting injecting drug use practices presents specific challenges for implementing initiatives for reducing the harm associated with these practices. Several legislative barriers to broadening access to injecting equipment were identified in the Intergovernmental Committee on AIDS Legal Working Party report (1992). These barriers included self-administration laws and laws making unauthorised peer distribution of sterile injecting equipment illegal. The secondary distribution of sterile injecting equipment from people who inject drugs to their peers has the potential to increase access but it is illegal in many jurisdictions.39 There have been developments at the international level in ensuring that drug policy approaches support harm reduction efforts and that the negative impact criminalisation has on the health and human rights of people who inject drugs is addressed.40
Modelling commissioned by the Australian Government estimated that NSPs prevented 32 000 HIV and 97 000 hepatitis C infections among people who inject drugs from 2000 to 2009. This prevention equated to $4 directly saved for each dollar invested, saving the Australian health system a cumulative $1.28 billion.41 This study also indicated that expanding the program to increase distribution of sterile injecting equipment by an additional 50% could lead to maximal financial returns and would yield a further 37% decrease in HIV and 23% decrease in hepatitis C cases over the next 10 years.42
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Priority actions in prevention and education
- Increase access to sterile injecting equipment, particularly in priority populations.43
- Strengthen the capacity of education providers and the providers of services to young people to ensure they have access to harm reduction knowledge and skills.
- Strengthen collaboration with the alcohol and other drug sector.
- Enhance the capacity of the NSP workforce to engage with people who have, or are at risk of getting, hepatitis C infection and provide targeted education and health promotion interventions.
- Develop innovative health service delivery models, particularly for people who inject drugs.
- Enhance training and support for community based hepatitis C educators, including injecting drug user peer educators.
- Identify and work to address legal barriers to evidence-based prevention strategies across jurisdictions.
- Conduct a feasibility study into providing the full range of hepatitis C prevention interventions in custodial settings throughout Australia, with the view to piloting the provision of prison-based NSP.
- Continue to support, expand access to, and evaluate the effectiveness of the range of opioid pharmacotherapy programs throughout Australia in reducing transmission of hepatitis C.
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35 Mikhailovich K & Arabena K 2005, ‘Evaluating an indigenous sexual health peer education project’, Health Promotion Journal of Australia 16(3): pp. 189–193.
36 Treloar C & Abelson J, 2005, ‘Information exchange among injecting drug users: a role for an expanded peer education workforce’, International Journal of Drug Policy 16: 46–63.
37Treloar C, Laybutt B, Jauncey M, van Beek I, Lodge M, Malpas G & Carruthers S 2008, ‘Broadening discussions of ‘safe’ in hepatitis C prevention: A close-up of swabbing in an analysis of video recordings of injecting practice’, International Journal of Drug Policy 19: pp. 59–65.
38 Bryant J, Wilson H, Hull P & Treloar C 2009, Drug use, hepatitis C and exposure to injecting among young people in Queensland: The Big Day Out survey 2009. Sydney: National Centre in HIV Social Research.
39 Bryant J & Hopwood M 2009, ‘Secondary exchange of sterile injecting equipment in a high distribution environment: A mixed method analysis in south east Sydney, Australia’, International Journal of Drug Policy 20: 324:328.
40 Barrett D & Lines R et al. 2008, Recalibrating the regime: The need for a human rights-based approach to international drug policy. London: Beckley Foundation Drug Policy Programme.
41 National Centre for HIV Epidemiology and Clinical Research, 2009, Return on Investment 2: Evaluating the cost-effectiveness of Needle and syringe programs in Australia. University of New South Wales.
42 Ibid., p. 32.
43 Intergovernmental Agreement (IGA) on Federal Financial Relations <http://www.coag.gov.au/intergov_agreements/federal_financial_relations/index.cfm>