27 November 2023
This year, across all rapporteurs, there was an overarching call to end the discrimination that acts as such a forceful barrier to care. Without a radical shift towards stigma-free care, needless and preventable infections and death will continue.
Another theme to emerge is a lack of data across low-middle-income countries, and a lack of equitable access to vital testing and treatment for hepatitis C. While economic disparities do exist, countries like Egypt and Ukraine have continually shown that strong advocacy and political will, can lead to change.
It comes as no surprise, that the importance of peer-led approaches and involvement were surfaced by all rapporteurs. Speakers called for delegates to ensure that peers are not only recognised for the integral role they play in delivering care but ensuring that their voices are amplified and listened to.
Read on below to discover key takeaways from each of the rapporteur sessions. Thank you to all of our rapporteurs for taking part – it is not an easy job to summarise three days into five minutes, and your efforts and knowledge are greatly appreciated.
Community Rapporteurs
Mr Oliver Wehrli, Peerworker, Arud Centre For Addiction Medicine and Ahmed Said, Executive Director, Kwale Network of People Who Use Drugs (KwaNPUD)
- Peer involvement is good, but peer-led is better: INHSU 2023 showcased studies from across the world that demonstrated the benefit of peer involvement, but peer-led is the future, says Said. He called for a future where 80% of service delivery for community is delivered by community organisations, from planning and budgeting to distribution of resources.
- Recognise the bravery of individuals: Wehrli recognised the work of people who use drugs who put themselves at risk to establish harm reduction services to meet their community’s needs. From Drug Consumption Rooms set up unofficially in Canada to NSPs established in Kenya to the current advocacy for Long-Acting-Buprenorphine in Europe, these courageous initiatives create real, tangible, positive change
- Researchers and community need to work together: Recognising INHSU’s unique approach in elevating both researcher and community voices, the rapporteurs called for an ongoing partnership with people who use drugs
- Think beyond supply: Safe supply isn’t just about the drugs themselves, but every stage from production to transport to distribution. We should not forget about the safety of people across the supply chain, for example, the many people that die in South America through cocaine smuggling
The session closed with the need to abolish punitive policy and focus on a human-rights-based approach to harm reduction.
Epidemiology & Public Health Rapporteur
Dr. Heather Valerio, Research Associate, The Kirby Institute
Valerio’s presentation focussed on three key themes from across INHSU 2023; the elimination of HCV, the health and wellbeing of people who use drugs, and areas for future research.
- DAAs are being prioritised, but not everywhere: Valerio highlighted various regions that have actively prioritised DAA treatment to people who inject drugs, including Oslo and Egypt, to great success. However, other regions are being left behind such as Croatia, which have restrictions in place that stop access. These restrictions need to be lifted
- Women-only services are needed: There is an urgent need for interventions to reduce HCV incidence among women as multiple studies have highlighted that women are less likely to receive DAA treatment compared to men. It’s not just in DAA treatment that women are being left behind, but NSP and harm reduction services too. Women-specific services should be standard
- Focus on prisons: So long as drug possession and use remain criminalised, the momentum to test and treat HCV in prisons must remain a priority. Without this momentum, we will not eliminate HCV. Re-testing must be a part of this
- Harm reduction is about more than BBVs: Drug consumption rooms prevented 14-22% of new HIV infections and 27-32% of new HCV infections among people who inject drugs in three California counties across a decade. Impressive statistics on harm reduction initiatives were common across the conference, but Valerio reminded the audience that harm reduction is about more than just BBVs – it’s a human right and best practice
Valerio concluded with data on preventable deaths by overdose, a stark reminder that barriers to care and entrenched stigma and discrimination have devastating consequences.
Clinical Science Rapporteur
Dr. Andrew Seaman, Associate Professor of Medicine, Oregon Health and Sciences University / Central City Concern
During his Clinical Science rapporteur Andrew Seaman called for advocates and researchers to celebrate progress but to remember that sometimes iterative improvement isn’t enough. Whilst there is steady progress (when it comes to the health and wellbeing of people who use drugs) in some areas, many other areas still face seemingly insurmountable barriers. Seaman calls for transformative change.
- Nothing about us without us is not just a slogan: “Never about us, without us – is not just a slogan, and it’s not just about policy. Researchers must centre the people whose lives are impacted by their work.” Seaman discussed the difference between questions asked by people who use drugs, vs those that come from observations from another perspective. For transformative change, it’s about asking the right questions and listening to the answers
- Economic disparity continues (but there is hope): New data shows that testing and treatment rates among people who use drugs continue to be impacted by economic disparities. However, the influence of consistent political will in achieving equitable access, particularly in lower or middle-income countries, shouldn’t be underestimated. Seamen highlighted countries like Egypt and the Ukraine who have implemented successful elimination programs – even in the face of adversity – thanks to laser focus and consistent political will
- Stop the stigma: Multiple studies presented during INHSU 2023 discussed the impact of health system stigmatisation of people who use drugs, calling out the necessity to address stigmatisation to allow people to safely engage with health services. In a powerful address, Seamen said “Stigma is not a figurative or philosophical issue, it is literally killing people by the hundreds of thousands”
- Less lab work needed: Highlighting the successful point-of-care models showcased during the conference, Seaman suggests that one missing piece is the ability to assess fibrosis status and risk of decompensated cirrhosis without lab work. Without this, decentralised testing measures like point of care RNA and DBS may not translate into real uptake of test and treat models of care in more medically conservative regions
- Adherence to antivirals doesn’t need to be perfect: New literature presented at INHSU 2023 showed that adherence to direct-acting antivirals does not have to be perfect to achieve cure. The key seems to be a minimum of 50% adherence and avoiding early discontinuations and long-term treatment interruptions
In a powerful conclusion, Seaman called for more than just continual tweaks to the system – it’s time to tear things up and start anew if we really want change.
Models of Care Rapporteur
Alexandra Wade, Clinical Nurse Consultant, Mid North Coast Liver Clinic, Australia
Drawing on lessons across the conference, Wade emphasised the importance of a person-centric approach when developing models of care for people who use drugs.
- Take a holistic approach: Models should fit within the social determinants of health framework and consider social and economic environment, physical environment, and a person’s individual characteristics and behaviours
- Work together Develop integrated models of care that see collaboration between various stakeholders and sectors including AOD, mental health, cancer services, pharmacists, and social workers. Nurse-led programs are often very successful
- Embrace innovation: Innovation is at the heart of successful models. Incorporate phones, hotel vouchers, “seek and treat” initiatives, and after-hours outreach to enhance care accessibility
- Pre-treatment support: Offer rapid HCV/HIV testing, harm reduction services, insurance enrollment, and lab support for pre-treatment evaluations
- Utilise all available tools: Employ various tools such as dried blood spots, Point of Care testing, and venipuncture for comprehensive care. Consider testing for multiple BBVs at once
- Always be peer-led: A crucial element across models is the involvement of peers in shaping and delivering programs. One notable study, highlighted by Wade, was ‘Peer-Facilitated Telemedicine Hepatitis C Treatment for Rural People Who Use Drugs’ by Andy Seaman, MD, which used a peer-led telemedicine model to increase HCV treatment uptake in rural Oregan, USA. The study showcased an 85 percent initiation rate in the telehealth group versus 12.6 percent in standard care
Wade concluded by advocating for a flexible and adaptable approach, stressing the importance of always asking questions, ‘listen to the whispers’, involve people in solutions, asking if something works, and continually adapting strategies for sustained impact.
Social Science & Policy Rapporteur
Dr. Guillaume Fontaine, Assistant Professor, McGill University
Fontaine’s presentation summarised the social science and policy themes of INHSU 2023, calling for less stigma, more peer and community involvement, and a focus on implementation science and expanded drug policy research.
- Prisons are key to HCV elimination, but barriers persist: The availability of HCV services varies significantly depending on the country’s income status. Challenges encompass policymaker disinterest, limited HCV awareness, costly therapies, and regulatory limitations. In the EU/EEA, hurdles involve inmate engagement, resource scarcity, organizational challenges, and inadequate monitoring
- Peer-led models and community involvement are powerful tools: For healthcare engagement and equity, peer-led models and community involvement are as essential tools. However, not everyone with lived experience qualifies as a peer; specific personality traits and a lack of hidden agenda are necessary. The support of peer-led organisations is crucial for implementing this model effectively within healthcare services
- Say no to stigma: There is ongoing stigma around treatment access for people who use drugs, impacting their access to necessary healthcare and support. This needs to stop
- More drug policy research is needed: The criminalisation of drug use impacts public health and safety and limits access to healthcare for people who use drugs. The voices of people who use drugs need to be reintroduced into the public debate to change the existing stigmatising narrative and there should be a focus on assessing implementation barriers using a multilevel approach and expanding drug policy research beyond harm reduction and treatment
- The future is implementation science: The role of implementation science in overcoming barriers shouldn’t be underestimated. Future efforts should focus on leveraging the existing evidence base and understanding how and why interventions work
Concluding the rapporteur session, Fontaine discussed the need for expanding the scope of drug policy research to cover more comprehensive aspects like laws, law enforcement, and supply control.
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