People who inject drugs

9. SPECIAL CONSIDERATIONS FOR SPECIFIC POPULATIONS

Specialist care needs to address the additional needs of special populations of patients, including PWID, persons coinfected with or at risk for infection with HIV, children and adolescents, and those with cirrhosis.

9.1 People who inject drugs

Injecting drug use is prevalent in many countries around the world, affecting people in low-, middle- and high-income countries. Approximately 67 of PWID are infected with HCV; 10 million of 16 million people in 148 countries. 6 PWID are at increased risk of HCV-related disease and all-cause morbidity and mortality, and therefore require specialized care. 38 Related guidance is summarized below, and in section 2.4 and Figure 8.1. When caring for PWID, the central tenets of respect and non-discrimination should be followed, and additional adherence and psychological support given as required. Screening As an integral component of a comprehensive package of harm reduction interventions, WHO recommends targeted HCV screening of PWID as a population with a high prevalence of infection. Repeated screening is required in individuals at ongoing risk, and the possibility of reinfection after spontaneous clearance or successful treatment should also be considered. Those who have been previously infected should be retested using RNA testing, as the antibody remains positive after the irst infection. HCV case-inding and treatment in specialist drug dependency services has also been shown to be cost–effective in high-income settings. The higher the treatment rates, the more cost-effective HCV case-inding becomes, as more of those identiied will be treated, and a greater population impact could be seen. 97 Screening for HBV and HIV is also recommended in PWID. Care Treatment of HCV in PWID requires integration of services, as other health-care needs are often also present. Dependency on opiates or other substances may be present and alcohol excess is also a common problem in PWID. Harm reduction strategies are required in order to prevent acquisition of other bloodborne viruses such as HBV and HIV. At all times, avoidance of discrimination or stigmatization of PWID is essential. Care should be given only with informed consent. Drug dependency services may be required for the provision of opioid substitution therapy and sterile injection equipment. In addition, alcohol reduction strategies may be required and HIV treatment may also be necessary. Acceptability of services is a vital component of health care, and peer interventions may help with reducing injecting drug use and promoting safer injection practices. d Guidance on brief behavioural interventions is available as part of the WHO ASSIST package. PWID are at risk of infection with HBV and should be vaccinated using the rapid vaccination regimen, as described in other WHO guidance. 190 Needle and syringe programmes should also provide sterile needles and syringes with low dead space to PWID. It is also suggested that peer interventions be offered to PWID to reduce the incidence of viral hepatitis. Treatment Treatment for HCV infection is both eficacious and cost–effective in PWID 164,191,192 and therefore WHO recommends that all adults and children with chronic HCV infection, including PWID, should be assessed for antiviral treatment. Treatment may also be effective as prevention, due to a reduction in transmission. 97,98,99 Consideration must be given to potential drug–drug interactions – between both prescribed and non-prescribed drugs. e Methadone levels may be decreased in persons treated with PEG-IFNRBV, for example. Although this interaction is usually subclinical, monitoring for symptoms of withdrawal is recommended. Concurrent infection with HBV, HIV andor TB is common in PWID and these require additional consideration, as discussed in Section 9.2.

9.2 Persons with HIV and HCV coinfection