Ending the mass criminalisation of people who use drugs: a necessary component of the public health response to hepatitis C

There is clear evidence that the global HIV epidemic is fuelled by the war on drugs and by the criminalisation of people who inject drugs (PWID) [1]. We also have some evidence that the spread of hepatitis C virus (HCV) is fuelled in the same way [2], with the resulting stigmatisation and discrimination serving as barriers to HCV care and treatment. Hepatitis C, like HIV, is preventable and treatable. Unlike HIV, it is curable. Yet it remains a major cause of morbidity and mortality, particularly in PWID [3]. There is much higher prevalence of HCV than HIV among PWID, especially in prisons. Global prevalence of HCV is estimated to be about 80% among PWID, versus a prevalence of roughly 2%–3% in general populations [4]. A staggering 90% of people who have been injecting drugs for more than 10 years are HCV-positive, as are half of people who have been injecting drugs for less than 10 years [2]. All health outcomes for PWID, including those associated with hepatitis C, are far worse in countries where a criminalisation approach is heavily favoured over the provision of drug treatment and other health services. Countries that respond to injecting drug use with a balanced policy have better health outcomes [5]. The emphasis in many countries on the mass incarceration of drug users is putting prisons at the centre of the hepatitis C epidemic. Between 16 and 41 percent of incarcerated people have HCV, and between 29%–43% percent of people with HCV have been in a correction facility [6]. Despite the widespread need, treatment and care of HCV-infected people in prisons is severely lacking. Although HCV is the leading transmissible infection among PWID, the medical and drug policy communities have done little to address the HCV prevention and treatment needs of this population. The absence of attention to HCV in international drug policy development [3] has contributed to HCV becoming a global public health crisis. The purpose of this commentary is to show how HCV has largely been ignored in drug prevention and treatment policies and to explain why ending the mass criminalisation of people who use drugs is a necessary component of the public health response to hepatitis C. The following section discusses barriers to an effective HCV response in PWID with emphasis on the criminalisation of PWID. It is followed by a section on overcoming barriers. The paper then concludes by calling for a shift from criminalisation to health promotion for PWID.