The latest edition of the International Journal of Drug Policy features an article from the W3 Project that focuses on the nature of the policy influence of peer-based drug user organisations. In this guest blog, contributing authors Annie Madden and Charles Henderson provide some commentary on the issues raised in the article, particularly on peer-based drug user organisations and their relationship to hepatitis C elimination goals.

The full article is available here. If you do not have a subscription to the journal, follow the link at the end of the blog post for a pre-press version.

From the perspective of people who inject drugs, this recent paper from the W3 Project Characterising the policy influence of peer-based drug user organisations in the context of hepatitis C elimination does more than simply ‘add to the evidence-base’ in the rapidly expanding area of hepatitis C treatment literature. In our collective (and humble) opinion, this paper is ‘ground-breaking’ in the truest sense. The reason is it gives voice to those largely silent in the much heralded space of hepatitis C elimination goals – that is, self-determination and agency of people who inject drugs and their representative organisations realising the elimination ‘holy grail’.

In the sometimes heated discussions regarding “who is a peer?” and “when is enough peerness – enough peerness?” this paper attempts (perhaps for the first time) to take us into some genuinely new territory. In doing so, it tries to steer us away from resorting to tired, circular arguments and definitions about “who is peer?” which, although this may have good intentions in seeking to bind us in our ‘peerness’, too often just ends up limiting and confounding us.

Rather, this paper clearly positions peer-based drug user organisations in the policy framework; in the structure and the ‘doing’ of representing the needs, issues and rights of people who inject drugs. Steering us through and into the present so that the system is both open and responsive and in becoming so, will ensure as many individuals get treated for their HCV infections as is possible or, when it comes to universal access, that which is wished for.This paper provides a road-map of sorts for articulating and promulgating the where, when, why and the how to, in the overall elimination strategy for hepatitis C in Australia. It’s a combination of the pragmatic and the theoretical; but really, it’s a tell-all expose of just how important the role of peer influence and peer expertise is when it comes to addressing the health and human rights of people who inject/use drugs. The paper is succinct in describing the PWID/PWUD [1] peer context from history and development, current Australian situation and opportunity, through to positioning peer skill as the ‘extra ingredient’ vital to HCV prevention, testing, treatment and elimination. 

The truth of the matter is that the peer component in the hepatitis C context is too often undervalued and even misunderstood. Unfortunately this holds true not just in the past, but in the present as well. But, due to many recent developments, the present is far better equipped to partner, to improve and scale up HCV access to treatment than ever before. The opportunity for individual health gains with the offer of DAAs is right here, right now.

We will only realise the full benefit of these developments however, if the system recognises and openly acknowledges the critical place of peer skill and peer based approaches. Perhaps most importantly of all, there must also be an understanding that the ‘peer’ in this case is not merely someone who has had hep C in the past or has been previously treated with DAAs successfully, but someone who is immersed and currently connected to the community of people who inject drugs and therefore derives their knowledge, status and what needs to be done now, from that connection. The reason is people who inject drugs in Australia either have hep C, had hep C or know someone connected to them that has hep C – it is not a ‘past’ thing, it’s a ‘present’ thing… an everpresent thing.

Too often and for too long, we have spoken in euphemisms that have obscured (or tried to obscure) the reality – ‘people affected by hep C’ or ‘sub-groups of people with hep C’, etc. Representing the needs and issues of a highly criminalised, marginalised and relentlessly stigmatised group in the community is not an easy job – and a lack of plain speaking does not help this situation. People who inject drugs are forced into a hidden world; identified through rite of passage, word-of-mouth, by knowing who to trust and who to avoid. To be successful at hep C elimination is to connect successfully to the ‘world’ of people who inject drugs – a world in-between, traversing the illegal and disconnected due to the ongoing impact of discrimination and criminalisation.

Peer based organisations in Australia have been connecting successfully with their community for 3 decades and counting. As the W3 paper demonstrates, they constantly strive for change, fight to maintain their place in decision-making arenas, make visible the invisible and voice their outright opposition to shoddy thinking, but it remains difficult. But ‘difficult’ does not mean ‘impossible’  and one of the key benefits of the W3 Systems Map, is the way that it functions to provide signposts and encouragement for all ‘system players’ to utilise every opportunity and to think and act with purpose, understanding and direction. With this paper, each organisation or individual within the broader ‘system’ can see what they need to do, listen to those they need to listen to and act in the way they need to act – if they choose to do so…

Anything less means missing out on the (globally) unique opportunity that universal access to HCV treatment (regardless of acquisition, severity of progression or social/individual circumstance) affords us. And elimination as the goal.

Come one come all! HCV elimination is possible but only if we fund properly, trust fundamentally and focus our efforts in peer approaches and strategies embedded in the needs of people who inject drugs and driven by their representative, peer-based organisations. As the old adage says… “Instead of asking why, we should ask why not?”

If you do not have a subscription to the International Journal of Drug Policy, click here for a pre-press version of the article.


Charles Henderson is the Deputy CEO of the NSW Users and AIDS Association (NUAA). You can contact him here or follow him on Twitter here.

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Annie Madden is a PhD candidate at the Centre for Social Research in Health, UNSW and Peer Specialist Consultant at 2SqPegs. You can contact her here or follow her on Twitter here.

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[1] People Who Inject Drugs/People Who Use Drugs