Treating co-infection of HIV and hepatitis C (HCV) in Thailand makes sound economic sense, Noah Methany argues in a policy paper published by the Thai AIDS Treatment Action Group (TATAG) on July 28, 2010, in recognition of World Hepatitis Day. Outlining the public health crisis of HIV and HCV co-infection faced by people who inject drugs in Thailand, the paper makes recommendations to the government to help stop and reverse this dual epidemic. While Thailand boasts a universal health care system that claims healthcare for all without discrimination, people living with HIV who are co-infected with HCV, notably current or former drug injectors, face unique barriers to effective treatment, notes the author. Increased access to antiretroviral treatment in low- and middle-income countries has increased life expectancy and improved the quality of life of people living with HIV. But many find they are now dealing with other chronic health problems, of which hepatitis C is one. Hepatitis C, a blood-borne viral infection, spreads easily through the sharing of injecting equipment, and disproportionately affects injecting drug users (IDUs). HCV is transmitted when infected blood from one person enters another’s bloodstream through any kind of contact. Unlike HIV it can live outside of the body for a long period of time, making it ten times more infectious than HIV, notes Methany. HCV is the world’s leading cause of liver disease. It can progress silently from fibrosis (mild scarring of the liver) to cirrhosis (severe scarring). Those with cirrhosis are at increased risk for liver cancer and liver failure. People living with HIV have weakened immune systems so HCV progresses more rapidly than in people who are HIV-negative. End-stage liver disease is becoming a growing cause of death among people living with HIV. Additionally, Methany notes, “HCV complicates a person living with HIV’s treatment because it can triple the risk of antiretroviral-associated liver toxicity.” There is a general lack of awareness of the disease amongst the medical community as well as those at risk. Diagnosis, management and treatment are complex and costly and are considered the main barriers to improving access to treatment. “It is incredibly ironic that we have dramatically altered the prognosis for HIV – a currently incurable disease – only to see co-infected people dying from complications of hepatitis C, a disease that we can cure,” noted Tracy Swan of New York’s Treatment Action Group, the paper’s editor. IDUs may also have to face other problems when trying to access health care that include denial of, or discriminatory treatment and a lack of confidentiality. WHO estimates that three percent of the world’s population or 180 million people have been infected with HCV, with an additional three to four million newly infected each year, many of whom remain undiagnosed. WHO estimates 32.3 million people living in South East Asia are infected with HCV. An estimated two to nine million IDUs are living in the Asia-Pacific region, of which 750,000 are estimated to be living with HIV. While there are few epidemiological studies on the prevalence of HIV and HCV co-infection in Asia, an estimated 60-90% of IDUs are living with HIV. According to WHO and UNAIDS 610,000 Thais are living with HIV/AIDS; 5 to 10% are estimated to have got it from injecting drugs and at least half of all injecting drug users in Thailand are living with HIV/AIDS. The International Harm Reduction Association estimates up to 90% of injecting drug users in Thailand have become infected with HCV, notes Methany. A two-step process is required to determine infection with HCV. The first part-an antibody test shows if a person is or has been infected. A viral load test is then needed to determine whether infection is chronic or not. Liver enzyme levels are needed to monitor people with HCV. Length of treatment is determined by genotypic testing. Methany notes that while there are at least six different genetic versions of hepatitis C virus, genotypes 1,3 and 6 are the most common in Thailand. A three to twelve month course of treatment with a combination of two drugs – pegylated interferon (PEG-IFN) and ribavirin (RBV) – is the current standard of care. While generally there is a 50% treatment success rate, response varies and is related to genotype. Ribavirin is available as a generic product, whereas the two versions of pegylated interferon are still under patent. The current costs of treating hepatitis C is approximately US $38,000 for a 48-week course of treatment, prohibitive for many health care systems. In Thailand these drugs are not on the Thai National Essential Drugs List and so are not included in the Thai universal coverage scheme. Contrary to arguments that treating HCV and HIV co-infection in Thailand is too expensive, the author cites two studies that showed treating people with ribavirin and pegylated interferon to be cost-effective and increased life expectancy. Researchers showed that treating Thai HCV (genotypes 2 and 3) patients compared to no treatment resulted in a lifetime cost saving of 556,862 baht (US$16,784). Noah Methany argues that not only is it Thailand’s constitutional and moral obligation to provide treatment for Thai HCV patients but it also makes economic sense. Methany proposes the following policy recommendations to address the challenges faced by Thais, current or former injecting drug users, who are co-infected with HIV and HCV.

• Immediately scale up of evidence-based harm reduction programmes that promote access to clean injecting equipment/sterile syringes, which prevent new HCV infection.
• Increase support for Thai civil society involvement in HCV awareness campaigns through promotion of capacity building and education of advocates, patients, healthcare providers and policymakers.
• Provide universal access to free testing for HCV and offer follow-up diagnostic tests on a routine basis to IDUs who test positive for HIV.
• Provide national level data collection on HCv incidence and prevalence among Thais living with HIV/AIDS.
• Include pegylated interferon and ribavirin on WHO and Thai Essential Medicines List.
• Develop Thai-language national guidelines based on international best practices for HCV treatment and care.
• Increase political support for the Thai Government Pharmaceutical Organization (GPO) to produce generic versions of pegylated interferon and ribavirin, and
• Increase political support for Thai government officials to exercise legal, TRIPS flexibilities (such as compulsory licences and parallel importation) to gain access to cheaper HCV treatment.

Methany, N and Swan, T (ed) Illuminating a hidden epidemic: the public health crisis of HIV/HCV co-infection among injecting drug users (IDU) in Thailand. Thai AIDS Treatment Action Group (TTAG) Foundation, July 28, 2010. www.ttag.info