Beyond a ‘post-cure’ world: Sketches for a new futurology of hepatitis C

Applying a stigma and time framework to facilitate equitable access to hepatitis C care among women who inject drugs: The ETHOS Engage Study

BACKGROUND

Women who inject drugs are significantly less likely to initiate hepatitis C virus (HCV) treatment than men. Concerted efforts are needed to minimise gender-based inequalities in care. The study aim was to use a stigma and time framework to investigate how women who inject drugs experienced HCV care in healthcare settings.

METHODS

Semi-structured, in-depth interviews were conducted with 34 participants from the ETHOS Engage Cohort (n = 1,443) in Australia. Inclusion criteria were aged ≥18 years, history of injection drug use, and persons who injected in the prior six months or were currently receiving opioid agonist treatment. Drawing on the original qualitative dataset (n = 34), we conducted a secondary analysis focused on women participants' experiences of receiving HCV related care (n = 21/34). Utilising thematic analysis, we applied Earnshaw's theoretical framework, which incorporates time into stigma and health research via three "timescales" - historical context, human development, and status course.

RESULTS

Among the 21 women interviewed (mean age 42 years, 5 are Aboriginal, 11 received HCV treatment), the majority were currently receiving opioid agonist treatment and over half injected drugs in the past month. For historical context, most participants were diagnosed with HCV during the interferon era (1990s-2014). Participants had to navigate a sociomedical landscape not only largely bereft of adequate HCV medical knowledge, appropriate support, and adequate treatments, but were also generally assessed as "unsuitable" for treatment based on their perceived personhood as people who inject drugs. For human development, many participants reported encountering overlapping stigmatizing experiences (layered stigma) while receiving their HCV diagnosis in prenatal care and early postpartum. Under status course, participants acutely recognised the intersection of HCV infection, injection drug use, and gender, and reported concerns about being judged more harshly from healthcare providers as a result.

CONCLUSION

A stigma and time framework illuminated multiple overlapping stigmatizing experiences for women who inject drugs in HCV care and in turn, can help to inform tools and interventions to counter their impact.

The time of cure: hepatitis C treatment and the matter of reinfection among people who inject drugs

Australia has made considerable progress towards the public-health 'elimination' of the hepatitis C virus. Nonetheless, reinfection remains a key challenge, with little understanding regarding the lived complexities of post-cure life among people who inject drugs. Our analysis examines reinfection through the lens of 'time', a largely overlooked and under-utilised analytical concept within the field of hepatitis C. Drawing on qualitative data from a study examining treatment outcomes and reinfection, our analysis concentrates on three participant accounts or 'cases'. Working within a new materialist framework, we combine recent social science scholarship which, firstly, posits cure as a socio-material 'gathering', and secondly, proposes a 'futurology' of hepatitis C and its treatment. We found participant accounts troubled the neat binary of pre- and post-treatment life, instead detailing the challenges of remaining virologically safe while navigating complex, local life-worlds. Rather than a singular, post-treatment future instantiated by cure, participants described the fluid, emergent nature of what we might describe as 'lived' or 'embodied' time, including multiplicities of becoming in a perpetual present. We conclude that our understanding of reinfection needs to move beyond its current, narrow biomedical conception and organising temporal logic to honour and incorporate complexity in practice.

'There's too much power in this number. It's freaking the whole response out': The views of key informants on evidence and targets to achieve hepatitis C elimination goals in Australia

Enumeration of disease is a key management tool. Setting of targets, like for hepatitis C elimination, have deep meaning and effect. We use the case of elimination in New South Wales (NSW), Australia to examine key informants' understandings of the use of targets, and the evidence that informs them, to drive action in elimination. Twenty-eight key informants working in NSW, elsewhere in Australia and internationally in high-income countries participated in a semi-structured qualitative interview in 2022. Analysis was informed by scholarship calling for examination of the ways in which science constructs what is thought possible in action. Participants pointed to the power of quantified evidence and targets and their complex effects, and questioned the usefulness and certainty derived from these at the "pointy end" of elimination. Although a range of targets exist in global and local strategies, reaching testing targets was the assumed solution to achieving elimination. Achieving elimination was thought to require "off piste" and experimental approaches that went beyond available evidence. The different types of work that participants felt necessary for late-stage elimination may require additional metrics to explain return on investment ratios. What threshold would be used to reduce efforts in elimination was a major concern. These data indicate that understandings of the evidence underpinning elimination targets and how to achieve them are far from settled. At this point, elimination efforts may need to rely on locally produced and community-driven evidence and shift from evidence-based to evidence-making paradigm.

'We've got a present for you': Hepatitis C elimination, compromised healthcare subjects and treatment as a gift

With the advent of highly effective and tolerable direct-acting antiviral treatments for hepatitis C, widespread optimism for and investment in the project of disease elimination now informs the public health response. In Australia, the Commonwealth government has invested heavily in elimination by universally subsidising treatment, promising access for all. Reflecting concerns that commonly accompany ambitious public health projects, cost for governments supporting access to the treatment and cost for individuals consuming it have emerged as central issues. Drawing on 30 interviews with people who have been cured of hepatitis C with direct-acting antivirals, this article examines how cost shapes experiences of hepatitis C treatment and cure in Australia. Drawing on Lauren Berlant's (2011) influential work on 'cruel optimism', we analyse three interconnected ways that notions of cost shape participants' views of treatment as a beneficent gift from the state: (1) understandings of treatment access as a form of 'luck'; (2) conceptions of the cost of treatment; and (3) criticisms of others who are seen to waste state resources by not taking up treatment or by re-acquiring hepatitis C. We argue that, together, these dynamics constitute people affected by hepatitis C not as citizens worthy of public investment and fundamentally entitled to care, but as second-class citizens less deserving of treatment and of the health care to which they might otherwise be considered entitled. It is within this dynamic that the compromised quality of elimination optimism takes shape, binding people affected by hepatitis C to an inequitable relationship to health care, reproduced through the very things that promise to free them of such inequality - investments in access to treatment and cure.

'I'm not hep C free': afterlives of hepatitis C in the era of cure

Since the advent of more effective, new-generation treatment for hepatitis C, immense resources have been devoted to delivering cure to as many people with the virus as possible. The scale-up of treatment aims to prevent liver disease, liver cancer and onward transmission of hepatitis C, but social research shows that people also approach treatment with its social promises in mind, including the hope that it might reduce or eradicate stigma from their lives. Such hopes reflect broader ideas about medical cure, which is seen as an end point to illness and its effects, and capable of restoring the self to a (previous) state of health and well-being. But what does cure mean among people for whom treatment does not produce an end to the social effects of a heavily stigmatised disease? While new treatments promise to eliminate hepatitis C, accounts of post-cure life suggest that hepatitis C can linger in various ways. This article draws on interviews with people who have undergone treatment with direct-acting antivirals (n=30) in Australia to explore the meanings they attach to cure and their experiences of post-cure life. We argue that dominant biomedical understandings of cure as an 'ending' and a 'restoration' can foreclose insight into the social and other effects of illness that linger after medical cure, and how individuals grapple with those afterlives. Drawing on recent conceptual re-framings of cure from medical anthropology and disability studies, we suggest that thinking at the limits of 'curative reason' helps to better address the afterlives of chronic illness. In the case of hepatitis C, reconceptualising cure could inform improved and less stigmatising ways of addressing people's post-cure needs. And in the era of hepatitis C elimination, such reconceptualisation is increasingly important as the cohort of people undergoing treatment and cure expands worldwide.

The trouble with normalisation: Transformations to hepatitis C health care and stigma in an era of viral elimination

Modern health-care systems have customarily approached hepatitis C in ways that resemble the public health approach to HIV/AIDS known as 'HIV exceptionalism'. HIV exceptionalism describes the unusual emphasis on privacy, confidentiality and consent in approaches to HIV and was partly developed to address HIV/AIDS-related stigma. In the case of hepatitis C, exceptionalist approaches have included diagnosis and treatment by specialist physicians and other 'boutique' public health strategies. The recent availability of highly effective, direct-acting antivirals alongside goals to eliminate hepatitis C have heralded dramatic changes to hepatitis C health care, including calls for its 'normalisation'. The corollary to exceptionalism, normalisation aims to bring hepatitis C into routine, mainstream health care. This article draws on interviews with stakeholders (n = 30) who work with hepatitis C-affected communities in policy, community, legal and advocacy settings in Australia, alongside Fraser et al.'s (2017, International Journal of Drug Policy, 44, 192-201) theorisation of stigma, and Rosenbrock et al.'s (1999, The AIDS policy cycle in Western Europe: from exceptionalism to normalisation. WZB Discussion Paper, No. P 99-202) critique of normalisation to consider the perceived effects of hepatitis C normalisation. Stakeholders described normalisation as a stigma-reducing process. However, they also expressed concerns about the ongoing stigma and discrimination that is not ameliorated by normalisation. We suggest that in centring normalisation, changes in health care may exaggerate the power of technological solutions to transform the meanings of hepatitis C.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States

BACKGROUND

Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois.

METHODS

Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses.

RESULTS

We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care.

CONCLUSION

The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

Complicating cure: How Australian criminal law shapes imagined post-hepatitis C futures

In recent years, highly tolerable and effective drugs have emerged promising a radical new 'post-hepatitis C' world. Optimism about medical cure potentially overlooks discrimination and stigma associated with hepatitis C and injecting drug use. Legal frameworks are especially relevant to hepatitis futures, since the law has the potential to reinforce or alleviate stigma and discrimination. This article explores how hepatitis C figures in Australian criminal law and with what potential effects. Drawing on Bruno Latour's work on legal veridiction, Alison Kafer's work on futurity and disability and case law data collected for a major study on hepatitis C and post-cure lives, we explore how the criminal law handles hepatitis C in the age of cure. We find that law complicates cure, constituting hepatitis C as disabling despite the advent of effective cures. The law steadfastly maintains its own approach to disease, disability and illness, untouched by medical and scientific developments, in ways that might complicate straightforwardly linear imaginaries of cure, transformation and progress of the kind that dominate biomedicine. We explore the implications of these tensions between law and medicine.

Exploring the Public Health and Social Implications of Future Curative Hepatitis B Interventions

Hepatitis B is a significant global health issue where the 296 million people estimated to live with the infection risk liver disease or cancer without clinical intervention. The World Health Organization has committed to eliminating viral hepatitis as a public health threat by 2030, with future curative hepatitis B interventions potentially revolutionizing public health responses to hepatitis B, and being essential for viral hepatitis elimination. Understanding the social and public health implications of any cure is imperative for its successful implementation. This exploratory research, using semi-structured qualitative interviews with a broad range of professional stakeholders identifies the public health elements needed to ensure that a hepatitis B cure can be accessed by all people with hepatitis B. Issues highlighted by the experience of hepatitis C cure access include preparatory work to reorientate policy settings, develop resourcing options, and the appropriateness of health service delivery models. While the form and complexity of curative hepatitis B interventions are to be determined, addressing current disparities in cascade of care figures is imperative with implementation models needing to respond to the cultural contexts, social implications, and health needs of people with hepatitis B, with cure endpoints and discourse being contested.

Hepatitis C cure as a 'gathering': Attending to the social and material relations of hepatitis C treatment

Since the advent of direct-acting antiviral hepatitis C treatments, widespread enthusiasm about disease elimination has emerged. This article examines experiences of hepatitis C treatment and cure in this period. Mobilising Fraser and Seear's (Making disease, making citizens: The politics of hepatitis C, Ashgate, 2011) approach to hepatitis C as a 'gathering', we analyse cure not as a biomedical phenomenon but as a social and material event. To do so, we take a Science and Technology Studies-inspired approach to analyse three complementary cases drawn from an Australian project on experiences of hepatitis C, treatment and cure. First, we analyse the ways a friendship between two women combines with adjustments to treatment access to produce a gathering that makes cure possible. Second, we analyse the forces that gather and distribute responsibility when a cure does not occur in a context shaped by oversimplified treatment logics. Third, we analyse a gathering of relations in which hepatitis C lingers, thereby limiting the cure's possible transformative effects. We argue that, even in an era defined by highly effective medicines, the hepatitis C cure is not necessarily straightforward, but an unpredictable gathering constituted by a fragile coalescing of social and material forces.

Developing a primary care-initiated hepatitis C treatment pathway in Scotland: a qualitative study

BACKGROUND

The ease of contemporary hepatitis C virus (HCV) therapy has prompted a global drive towards simplified and decentralised treatment pathways. In some countries, primary care has become an integral component of community-based HCV treatment provision. In the UK, however, the role of primary care providers remains largely focused on testing and diagnosis alone.

AIM

To develop a primary care-initiated HCV treatment pathway for people who use drugs, and recommend theory-informed interventions to help embed that pathway into practice.

DESIGN AND SETTING

A qualitative study informed by behaviour change theory. Semi-structured interviews were undertaken with key stakeholders (n = 38) primarily from two large conurbations in Scotland.

METHOD

Analysis was three-stage. First, a broad pathway structure was outlined and then sequential pathway steps were specified; second, thematic data were aligned to pathway steps, and significant barriers and enablers were identified; and, third, the Theoretical Domains Framework and Behaviour Change Wheel were employed to systematically develop ideas to enhance pathway implementation, which stakeholders then appraised.

RESULTS

The proposed pathway structure spans broad, overarching challenges to primary care-initiated HCV treatment. The theory-informed recommendations align with influences on different behaviours at key pathway steps, and focus on relationship building, routinisation, education, combating stigmas, publicising the pathway, and treatment protocol development.

CONCLUSION

This study provides the first practicable pathway for primary care-initiated HCV treatment in Scotland, and provides recommendations for wider implementation in the UK. It positions primary care providers as an integral part of community-based HCV treatment, providing workable solutions to ingrained barriers to care.

Futures-oriented drugs policy research: Events, trends, and speculating on what might become

One concern in the field of drugs policy is how to make research more futures-oriented. Tracing trends and events with the potential to alter drug futures are seen as ways of becoming more prepared. This challenge is made complex in fast evolving drug markets which entangle with shifting social and material relations at global scale. In this analysis, we argue that drugs policy research orientates to detection and discovery based on the recent past. This narrows future-oriented analyses to the predictable and probable, imagined as extensions of the immediate and local present. We call for a more speculative approach; one which extends beyond the proximal, and one which orientates to possibilities rather than probabilities. Drawing on ideas on speculation from science and technology and futures studies, we argue that speculative research holds potential for more radical alterations in drugs policy. We encourage research approaches which not only valorise knowing in relation to what might happen but which conduct experiments on what could be. Accordingly, we trace how speculative research makes a difference by altering the present through making deliberative interventions on alternative policy options, including policy scenarios which make a radical break with the present. We look specifically at the 'Big Event' and 'Mega Trend' as devices of speculative intervention in futures-oriented drugs policy research. We illustrate how the device of Mega Trend helps to trace as well as to speculate on some of the entangling elements affecting drug futures, including in relation to climate, environment, development, population, drug production, digitalisation, biotechnology, policy and discourse.