We can’t get there without harm reduction
In 2016, the World Health Assembly unanimously voted for a call to eliminate viral hepatitis by 2030. The World Health Organization immediately followed suit and called for all member states to eliminate hepatitis B and hepatitis C. Elimination is defined as a 90% reduction of new cases and a 65% reduction in deaths associated with these two viral infections. It’s a worthy goal: The WHO estimates that approximately 7 million deaths could be prevented worldwide if we met these goals.
In 2021, the United States introduced its most recent plan to address viral hepatitis—The Viral Hepatitis National Strategic Plan: A Roadmap to Elimination (2021–2025). This plan outlines five goals over five years:
- Prevent new viral hepatitis acquisition
- Improve viral hepatitis-related health outcomes
- Reduce viral hepatitis-related disparities and health inequities
- Improve viral hepatitis surveillance and data usage
- Achieve integrated, coordinated efforts that address the viral hepatitis epidemics among partners and stakeholders
This plan is excellent and there is no doubt that it could dramatically impact viral hepatitis in the U.S. But there is a long way to go and a lot of work to do. Right now, at our pace, we will not achieve HCV elimination by 2030. In fact, many experts think it won’t happen until well after 2030.
Indeed, we won’t get there without harm reduction. Harm reduction is a set of practices and ideas that are aimed at reducing the negative consequences around drug use and other behaviors that could lead to infectious disease, drug overdose and other issues. Harm reduction is also a philosophy: It believes in the non-judgmental provision of services to people who use drugs, respects the rights of people who use drugs and centers people in the work for prevention and treatment.
If we expand harm reduction tools like syringe programs and medications for opioid use (methadone, buprenorphine and, rarely used, naltrexone) and increase HCV testing and treatment, we can get there. In this 2024 Hepatitis Drug Guide, we wanted to focus on the testing and treatment side of things, and give an overview of HCV reinfection. The more we test and treat, and the more reinfections we can prevent, the sooner we will get to a country without hepatitis C.
This is easier said than done. We aren’t providing people with the harm reduction tools they need. Syringe access programs remain illegal in seven states; but even in the 43 where they exist, there is not nearly enough coverage to reach everyone who needs it. Providing people with new and unused syringes and injecting equipment is essential to prevent new HCV cases.
We aren’t testing enough people. Approximately 40–50% of people living with HCV don’t know they have it. In fact, we don’t even have very good estimates of how many people are currently living with HCV in the U.S. Estimates from the Centers for Disease Control and Prevention put it at 2.4 million people, but some statistics suggest it’s more likely to be over 4 million. We need to expand testing, especially among folks who use drugs.
We aren’t treating and curing enough people, especially the people who use drugs. Treating and curing HCV has a host of benefits for individuals living with HCV, but they also offer important public health benefits. The more people we cure, the less HCV transmission we will see.
Hepatitis B and C elimination is defined as a 90% reduction of new cases and a 65% reduction in deaths associated with these two viral infections.
We need harm reduction to prevent reinfections. We can treat and cure people who use drugs, and then provide them with sterile syringes and other safer use supplies, plus access to medication-assisted treatment and other services. Same with sexual transmission of HCV for men who have sex with men who are living with HIV. Provide people with reinfection education, condoms and other services after they are cured, and we will see less HCV transmission.
Most importantly, we need the philosophy of harm reduction. We need to provide services in a non-judgmental and non-stigmatizing way. We need to create welcoming spaces for people to come and receive new injection equipment, talk to someone about buprenorphine, and get tested for HCV—and get cured. Harm reduction does that. Syringe service programs offer all of that.
We will reach HCV elimination, but we need to expand harm reduction to get there.