Introduction

With estimates of 150 000-200 000 people currently infected and 8 000- 10 000 new infections per year (Crofts 1997) Hepatitis C in Australia is a significant disease. It is significant in its impact on the health and lifestyle of hundreds of thousands of Australians. The health economic impact of Hep C is still being measured but could be considered to be comparable with HIV.

It makes public health and health economic sense to improve efforts on the reduction of disease transmission. In Australia, prevention has been planned at the national and state levels. The behaviour change required to prevent Hepatitis C transmission must be carried out by individuals in a range of situations. This is the challenge of prevention.

The Story So Far

Hepatitis C is the third epidemic of blood borne virus faced by people who inject illicit drugs in the last three decades. Hepatitis B has been a constant source of illness in the IDU population. HIV was the overbearing threat that emerged in the eighties and remains a potential for explosive growth. Non A Non B Hepatitis has been with us for decades but it wasn't until the 1990's that we could test the prevalence and incidence of Hepatitis C.

Hepatitis C prevention programs have been able to build on the successes achieved in HIV prevention among People who inject drugs. These have been built on Needle and Syringe exchange programs, Community based peer education, increases in the availability of methadone and policy reform to facilitate the operation of these agencies. There are significant differences between Australia's response to HIV among injecting drug users and the activity required to have an impact on the hepatitis C epidemic.

In October 1994 the Australian Health Minister's Advisory Council endorsed the National Hep C Action Plan.

The plan was developed by state and federal health officials and addressed the approach to Hep C including epidemiology and surveillance, Testing, patient care and support and a coordinated approach to prevention and research.

As recommended in the action plan a national reference group was formed to develop a coordinated education and prevention approach. This plan was drafted by a committee consisting of federal and state heath department officers from the communicable diseases and drugs of dependence sections, Community representatives of the drug user organisations and hepatitis C councils, researchers and medical practitioners. This approach was endorsed by the Health Ministers Advisory Council in October 1995.

IDU were identified as the primary focus for Hep C prevention education. Other groups identified included Health care workers, people with Hep C, Tattooists and body piercers, people working and residing in Custodial institutions, general community and key decision makers.

The evaluation of the second national AIDS Strategy by Professor Feacham in 1996 recommended the integration of Hep C and HIV prevention efforts targeting IDUs. This process is overseen by the Australian National Council on AIDS and Related Diseases.

The Education and prevention approach outlined specific roles for Federal State and Local Government and a significant role for the community sector. The community sector in relation to Hepatitis C is mainly made up of the state based Injecting Drug User Organisations and their National Body and the state based Hepatitis C councils and their national body.

The aim of preventing all blood borne diseases has been taken by community based drug user organisations in Australia for some years. With low levels of HIV infection, drug use groups recognised that Hep C was far more relevant and current to injecting drug users. They therefore used Hep C as the baseline for intervention.

Among other things this led to the debunking of public health messages which advocate the bleaching of syringes. This is now considered a worse case scenario and is only supported after other avenues have been exhausted or are inappropriate or unavailable. The cleaning processes used with bleach have not been shown to kill the hepatitis C virus. To promote them as a primary intervention is therefore ethically questionable and ineffective as public health.

Challenges in Education

Challenges are posed in preventing hepatitis C in the Australian context by its higher prevalence and incidence. The nature of the virus with its high viraemia and low inoculant doses mean that efforts that were effective against HIV need to be developed and expanded.

Simplistic health slogans are inappropriate for the complexity of Hep C. Messages such as "Just say No to Sharing" do not contain enough information to provide guarantees of safe practices. IDU need to be provided with sufficient information, opportunity and equipment to carry out aseptic injecting technique at each injecting event.

This poses a challenge to governments as it demands the production and distribution of explicit materials targeting injecting drug users. The resources though potentially controversial can be carefully targeted and distributed to reduce community concern. Resources need to be produced that are "culturally appropriate". Drug user organisations are therefore a well placed group for the development and distribution of these education resources.

There are a range of cultures at force here. The government and health departments do not wish to be seen as promoting drug use in any way. The community has had such an extended period of anti-drug use materials that nonjudgemental material may be at risk of being interpreted as being pro drug use.

The community based drug user organisations need to produce materials that do not marginalise drug users and are acceptable in a drug using milieu or "By users for users" (AIVL 1990).

As drug use occurs among individuals of a rich variety of sub-cultures materials need to be produced that target both drug users generally and specific sub-cultural targets or Tribes utilising appropriate iconography and language.(Duckett 1995) Many people who use drugs do not identify with the drug user stereotype. Materials that target this stereo type will miss their mark with significant proportions of people who inject currently illicit drugs.

Another of the challenges of Hepatitis C is the need to provide education to users early in their drug using careers. The explicit materials and access to equipment needs therefore to be provided to young people.

To be appropriate agencies need to address the range of issues that are real and relevant to the drug users life and situation. This may mean also addressing legal rights, overdose, dependency, detox issues, housing and other issues relevant to the whole health and well-being of individual drug users. This provides opportunities for the utilisation of a broad based harm reduction approach.

The fact that drug use and the learning of ritual and practices occurs in cultural and social contexts provides an avenue for public health measures to be incorporated into the behaviour of drug users. Generally injecting is a behaviour learned in a social environment. This behaviour is then passed on through oral historical networks. The injecting procedure will continue unchanged unless either the set of the drug user changes or the setting of the drug use changes.

The set of the drug user can be altered in a positive way by the provision of an understanding of aseptic injecting technique. This may occur through peer networks where a person receives training and information about the validity of a specific technique. The information must be relevant and understood for it to have any longevity in the behavioural repertoire of the user. This underscores the importance of peer involvement in the developing and targeting of information and education and the adult education principle of the importance of understanding the why as well as the how of any activity or process.

Although community based drug user organisations probably have a better understanding of the nature and processes of drug users learning and behaviour there is great shortage of social and behavioural research to inform and guide interventions and by which to evaluate programs.

Accurate information provided in a non-judgemental manner is rapidly taken up and distributed by users throughout their networks. This information needs to be detailed and specific in a language understood by the target group of users. Audio visual materials provide an excellent medium for education.

Challenges in Service Delivery

The setting can also impact on the behaviour of the user. Situations such as incarceration remove the user from access to new injecting equipment, may increase the desire to be intoxicated, increase the number of users encountered, increase the proportion of users encountered with blood borne pathogens and increase the number of people with whom equipment is shared, while there is a reduction in other available intoxicants such as alcohol or cannabis.

The setting plays a key role in that the home or that of another drug user is the most likely place that injecting occurs. In the case of homeless IDU the unavailability of privacy, adequate light, running water and stockpiles of clean equipment will increase the opportunity and likelihood of risk activity occurring. In this environment injecting is also done quickly to avoid detection this increases the risk associated with injecting.

The disadvantages faced by homeless IDU can in some ways be mitigated by the provision of safe spaces in which equipment can be obtained, injecting can occur and equipment can be safely disposed of. There are no safe injecting sites in Australia at this stage.

The ultimate challenge to services to effectively reduce the incidence of Hepatitis C transmission is a resource and availability one. Although Australia provides roughly eleven million syringes and needles per year this is not sufficient to provide clean equipment for each injecting event. To have an impact on the Hepatitis C epidemic this number will have to be significantly increasecl,(approximately doubled).

Success here depends not just on increasing the number of syringes but also their accessibility by an increase in the outlets. Some suggestions for enhancing current NSEP provision that they be provided on the same basis as sealed pornography which would make them available from 24hr petrol stations .

Challenges in Community Attitude.

Support for effective public health interventions.

Policy reform is necessary for the interventions to be effective. Short of drug law reform there are a number of steps that can be taken to increase the effectiveness of public health interventions with people who use currently illicit drugs. It is important to retain a flexible policy environment that can be responsive to health needs.

Policy reforms in Australia include the legalisation of possession of syringes and of the provision of syringes by authorised personnel. In one state the charge of self administration of a prohibited substance has been abolished. The value and effectiveness of laws that inhibit public health interventions need serious review.

Attitudes to people who inject illicit drugs are often negatively based on stereotyped images,(some of which come from anti drugs education campaigns) This discrimination interferes with the ability of people to access services, their relationships with the medical and health sectors and may also separate a drug using individual from the support of their family and community.

Effective interventions need to be based in the recognition of the Human Rights of drug users as members of a community.

Any erosion of these rights will also erode the effectiveness of public health interventions.

Influences on Future Outcomes

The drug users are concerned about their health and prepared to change their behaviour as has been shown in Australia from ANAIDUS and ASHIDU studies and many other locations.(ref)

The Australian government recognises the public health and health economic benefit of Hepatitis C prevention programs.

The challenges for successful interventions for the prevention of hepatitis C will depend on the social and community support for NSEP, Education and policy reform programs into the future.

They will depend on the research that informs education and evaluation of programs.

They will depend upon the partnerships of people who use drugs, the broader community, government at each level and medical and research science.

For a culture of change in behaviour among people who inject drugs toward behaviours that reduce and eliminate risk of Hep C transmission the support and development of the drug user community is vital. It is the broader society's only access to these groups and behaviours.

The imperative for action is enormous. With an infection occurring as often as every fifty minutes the time to act is now!

These changes are inevitable if we recognise the human rights of people who inject drugs.

References

Crofts et al 1997 "The Epidemiology of Hepatitis C In Australia."

Australian Health Ministers Advisory Council(AHMAC), 1994 "National Hepatitis C Action Plan." Commonwealth Department of Health and Family Services.

AHMAC Hepatitis C Education and Prevention Reference Group, 1995 " The Nationally Coordinated Hepatitis C Education and Prevention Approach."

Feachem, Prof R.G.A, 1995 "Valuing the Past Investing in the Future; Evaluation of the second national AIDS strategy." Commonwealth department of Health and Family Services

Duckett M, 1995, "An Evaluation of the Tribes Campaigns" NSW Users and AIDS Association.

AIVL 1990, "Handy Hints"

Wodak et al 1992 "Australian National AIDS and Drug Use Study"

Loxley et al 1994 "Australian Sexual Health and Injecting Drug Use Study"