Hepatitis C is curable. But every year, nearly one million people still acquire the infection. People who inject drugs are among those most affected, often without access to the equipment and services that could help prevent it.
As a major funder in the fight against hepatitis C, Unitaid is supporting the global elimination targets through prevention, testing and treatment, focusing on the most marginalized and vulnerable populations.
Building on this broader work, Unitaid is now reaffirming its commitment to hepatitis C prevention and harm reduction through investing an additional US$7.8 million in three projects expanding hepatitis C prevention and care for people who inject drugs in ten low- and middle-income countries.
We spoke with Unitaid’s Technical Manager Karin Timmermans about what this work is showing and what needs to happen for more people to benefit. This interview has been lightly edited for length and clarity.
Hepatitis C is a virus that affects the liver and, left untreated, can cause serious damage and liver cancer over time. Anyone exposed to infected blood can acquire it, for example through unsafe medical procedures or a blood transfusion that has not been properly screened. For people who inject drugs, sharing needles and syringes carries a particular risk because even a tiny amount of blood remaining inside the equipment can transmit the virus to the next person.
We have medicines that can cure hepatitis C, and that’s fantastic. But we don’t have a vaccine or a medicine you can take to prevent it, like PrEP for HIV. We have tools to reduce the risk, but not everybody has access to them.
In principle, preventing hepatitis C transmission among people who inject drugs is quite simple: make sure everybody has enough clean, new needles and syringes. Most people don’t share because they like to share. They share because they lack access to new injecting equipment.
In practice, getting that equipment can be difficult. Needle and syringe programs may exist in only a few locations, and pharmacy supplies may cost more than people can afford. Where drug use is criminalized, carrying equipment can also expose someone to police harassment or arrest.
Stigma and discrimination can make people reluctant to seek health care or to return after being treated with no respect. And for someone without stable housing, looking after their health may be competing with many other concerns.
So people face both a higher risk of exposure and more barriers to prevention, testing and treatment. Infections can go untreated, and the virus continues to circulate through shared equipment, even though we have treatments that can cure it.
We’re focusing on making hepatitis C prevention, testing and treatment easier to access for people who inject drugs, with the ultimate goal of stopping the spread of the virus. One way we do that is by bringing care into harm reduction services, including in prisons.
These services help people reduce the health risks associated with drug use, without requiring them to stop using drugs to receive support. People are provided clean needles and syringes and treatment for opioid dependence. Offering hepatitis C care alongside that support helps us reach people where they already go and feel safe, and stay in touch throughout testing and treatment.
We’re also studying tools that could strengthen those services. Low dead-space syringes leave less blood behind after an injection and can reduce the risk of transmission if equipment is shared. Long-acting depot buprenorphine is a monthly injection to treat opioid dependence that can replace daily treatment and clinic visits, while reducing cravings and the need to seek opioids in ways that may put people at risk. We want to understand how these tools can help and what it would take to make them more widely available.
Not everybody chooses long-acting buprenorphine, but for those who like it, one injection can mean a month without daily medication or clinic visits. That can make it easier to get a job and keep it or simply have more time for family. It is also discreet: people don’t have to carry or safely store medicines, which can be difficult for those without stable housing. When I visited program sites in South Africa recently, several people told me how long-acting buprenorphine also made them feel less at risk of police harassment. What we’re seeing is that it is feasible to offer this option, and that people want to use it. For low dead-space syringes and needles, people have been quite receptive to new tools that allow less fluid to remain inside, reducing the risk of passing on infections if equipment is shared.
When we started this work, some of the communities we worked with said that nobody had ever asked them what they wanted before. In these projects, we have asked, and their answers are shaping the work.
People who use drugs know what makes a service useful to them, and what might stop them from using it. We’re working with them through the Portfolio Community Advisory Board, led by the International Network of People who Use Drugs, and they have an equal voice alongside clinicians, academics and WHO.
They helped us decide which research questions mattered most and challenged unnecessary requirements – things like drug testing that they felt would make it harder for people to participate. We worked through concerns together and found alternatives where people identified a red line.
They also helped simplify study documents and developed videos and leaflets so people could understand the research before deciding whether to participate. And they helped conduct it, asking others whether they would want to use these tools, and why.
WHO recommendations need evidence. Before these Unitaid projects, evidence on long-acting buprenorphine in low- and middle-income countries was missing. Our research has helped fill that gap, showing that it can be delivered in harm reduction settings across low- and middle-income countries, and that people want to use it. That has helped inform a WHO recommendation, giving countries a basis to consider it as another option for treating opioid dependence.
We now need to understand what happens over a longer period. How many people stop after one or two injections, and how many continue? Saying you would like to try a product is one thing; deciding whether it works for you after using it is another.
We also need to understand the full cost of providing it. The medicine costs more than oral methadone or buprenorphine, but monthly injections could reduce daily clinic visits and staff time. If we can show countries how the real costs line up, it will help governments decide if and how to offer it.
We have three complementary investments in this area that have been ongoing since 2023, led by Médecins du Monde, PATH and Frontline AIDS. We saw an opportunity to bring their research together into a stronger coordinated effort, and the additional US$7.8 million is helping us do that.
Together, these projects cover ten countries across sub-Saharan Africa, Egypt, Eastern Europe and Asia. Harmonizing research across such different communities and health systems gives us stronger evidence on where and how these tools can work, helping countries make informed decisions about introducing them.
The encouraging early findings also allow us to prepare for wider use. We’re following people over time to understand whether they continue using these options, while working with communities, health workers and ministries on awareness, national guidance and product registration.
That evidence can also encourage governments and partners such as the Global Fund to invest. As demand grows, larger purchasing volumes can help us negotiate lower prices. Step by step, the research helps create the conditions for more people to access these options beyond the projects.
I would want them to have access to harm reduction services, including in prisons, and to hepatitis C testing and treatment. We have a cure, and people should be able to get it. The same goes for care for HIV, hepatitis B and sexually transmitted infections.
People should also have a choice of quality harm reduction products and treatments for opioid dependence, with information to decide what works for them. Long-acting buprenorphine may be more convenient for some; others may prefer oral treatment.
Above all, I would want people to receive care with respect and dignity, and live without stigma, discrimination or criminalization. Addressing all of those barriers goes beyond Unitaid’s work, but it would make a real difference to people’s lives and their ability to seek care.
The additional funding brings Unitaid’s total investment in the three projects to approximately US$40.6 million and extends support through September 2028. Together, these investments reflect Unitaid’s commitment to ensuring that progress towards hepatitis C elimination reaches people too often overlooked by conventional health services.