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 Eliminating hep C in Scotland: what needs to be done

 

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The WHO hepatitis C elimination by 2030 strategy calls for a 90% decrease in hepatitis C incidence and a 65% reduction in related mortality through diagnosing 90% of those with chronic hepatitis C, and treating at least 80% of them 1. This e-bulletin looks at how this applies to Scotland.

Internationally, hospital rates related to hepatitis C are increasing as the population affected by the initial epidemic ages 2. In terms of long term costs, treating before 3 4 significant liver disease greatly reduces mortality and morbidity, although there is still significant benefit to treating whenever you can 5 6 7 8. Hill and colleagues indicate that Hepatitis C can only be eliminated if annual cure rates are consistently higher than new HCV infection rates and this requires high and sustained rates of both diagnosis and treatment 9.

In Scotland (Figure 1), after a decline in new infections related to the impact of the Hepatitis C Action Plan, the incidence rates are climbing again 10. Treatment rates in Scotland are still rising however 11, and the aim is that 2500 people are treated annually by 2020. In some NHS areas, though, there is a danger that the limit has been attained in accessing the easier to reach 12.

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Figure 1. Hepatitis C in Scotland for the year ending December 2016.

 

Treatments are now better than ever 13 14 15, getting cheaper and with more options available. Unfortunately as prices have come down the health board budgets for hepatitis C treatment have not always been retained, and so the opportunity to cure greater numbers has often been missed. The urgent need is to get more people diagnosed and/or into care. Only by identifying everyone with hepatitis C and helping them consider treatment can we make an impact on mortality from the illness. With just over half the estimated affected population formally diagnosed another issue is the many of those who have been lost to follow-up.

Initial extreme prices in higher-income countries have dominated discussion worldwide and made hepatitis C a key example of a broken drug development system 16 17 18. The impact of the very high prices of new treatments was effectively treatment rationing, contributing to people failing to engage in testing or care. Yet, as shown in countries with low-cost generics such as Australia, high prices are not the only problem. Stigma towards marginalised communities such as people who use drugs, prisoners, men who have sex with men, and some indigenous and BME communities can be a huge barrier where improved awareness is much needed. This effect can be demonstrated in countries regarded as making spectacular progress, such as Australia and, in Europe, Spain. The initial surge in treatment numbers is dropping off 19 and there is an urgent focus on getting more people to come forward. If this does not happen the cost of medications in these countries will become significantly higher.

Finding and diagnosing people is expensive and, except in a few places in Scotland, is poorly adapted to where the person with hepatitis C actually is. The knowledge of DAA treatments amongst people with hepatitis C is also lacking 20. If someone initially didn’t want treatment because they didn’t like the idea of interferon, would they come forward now if they didn’t think things had changed? In the poorest and most marginalised communities, where prevalence rates are high and expectations low, it is likely many expect they will always be at the back of the treatment queue, so why bother?

The question of where we treat is also very important. Moving to a “go to them” rather than “come to us” approach would decrease resistance from communities. To overcome many barriers there is a need to gain the trust and community engagement that enables proper information transfer by going to where people are. Structural and cultural inequalities hinder access to, as well as from, marginalised communities 21. Integrating treatment and testing with other community based services also enhances access 22 while using peers as educators and support can also overcome barriers 23.

The rolling out of testing and treatment from centralised services to community and outreach services 24 25 and primary care 26 27 28 generally 29 works, as is being shown in Tayside 30 and elsewhere (Figure 2), 31.

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Figure 2. Hepatitis C treatment uptake in Australia in 2016.


When looking at decreasing incidence, reducing the pool of those infected is very important. Work on the Eradicate programme in Dundee 32 and elsewhere 33 has demonstrated that extending hepatitis C treatment to injecting partners is just as crucial in minimising prevalence.

There has been a decrease in funding across public health as austerity continues to bite. It is vital that work continues to identify, test and help bring forward to treatment not only those most in need but anyone who has a chronic infection. In terms of long term costs treating early greatly reduces mortality and morbidity 34. Only by identifying everyone with hepatitis C and helping them consider treatment can there be a significant step towards elimination.

Thankfully more people are getting access to treatment, but worldwide the numbers being treated are still roughly the same as those being newly or re-infected 35. Prevention is still very important and frontline public health measures must continue to cover a wider population of those at risk. Vaccines still seem to be a way off but will be essential in stopping the virus entirely.

The newer treatments have brought great benefit but caution must still be exercised. Hepatitis B reactivation, although uncommon 36, and a greater than expected number of reports of liver failure and severe liver injury 37 show that, although there are great advantages over interferon-based regimens, the treatments are still very new.

As demonstrated by the surge and subsequent drop-off in treatment numbers in Australia, having open access to medication is not a total panacea. Deals with pharmaceutical companies based on treating large numbers must ensure that large numbers of untreated people will continue to come forward. The gift horse must have its mouth fully examined or budgets may get a nasty bite.

Elimination of hepatitis C as a public health threat is possible but in Scotland, as elsewhere, much work remains.

We at Hepatitis Scotland will continue to advocate for the best solutions to prevention, testing, treatment and care to ensure that people affected by hepatitis C live long and healthy lives.

 

 

1. [WHO Global Hepatitis Report 2017]
2. [HCV hospitalizations increasing among baby boomers, men, drug users]
3. [Increased Mortality Among Persons With Chronic Hepatitis C With Moderate or Severe Liver Disease: A Cohort Study]
4. [Direct-Acting Antiviral Sustained Virologic Response: Impact on Mortality in Patients without Advanced Liver Disease]
5. [SVR in HCV genotype 1 improves insulin resistance]
6. [Improvement of liver stiffness in patients with hepatitis C virus infection who received direct-acting antiviral therapy and achieved sustained virological response]
7. [Viral eradication reduces all-cause mortality, including non–liver-related disease, in patients with progressive hepatitis C virus-related fibrosis]
8. [Liver-related morbidity and mortality in patients with chronic hepatitis C and cirrhosis with and without sustained virologic response]
9. [High prices of DAAs mean there's been little progress towards achieving WHO target of eliminating HCV by 2030]
10. [Needle Exchange Surveillance Initiative, 2008-09 to 2015-16]
11. [Blood borne viruses and sexually transmitted infections. Scotland 2017]
12. [UK elimination of hepatitis C in jeopardy unless more patients found]
13. [VIDEO: Expert reviews promising treatment data from The Liver Meeting 2017]
14. [New three-drug HCV regimen shows nearly 100% response in 6, 8 weeks]
15. [Most patients with HCV genotypes 2, 4, 5, 6 achieve SVR with Mavyret]
16. [Nonprofit challenges Gilead’s patents on sofosbuvir]
17. [Generic HCV treatments could cost $50, as effective as branded drugs]
18. [Pills and profits: How drug companies make a killing out of public research]
19. [Hepatitis C drugs not being accessed by thousands of Australians with the disease]
20. [Injection drug users with HCV lack awareness of DAA efficacy]
21. [Barriers of poverty and inequality]
22. [Treatment for Hard-to-Reach Hepatitis C Patients May Improve with Integrated Care]
23. [Perceived benefits of the hepatitis C peer educators: a qualitative investigation]
24. [Hep C Cases Discovered in Public Services Screening]
25. [Addiction clinics need physician education, lifted restrictions to treat HCV]
26. [Community pharmacies ideally placed to help the global fight against hepatitis C]
27. [Primary care pharmacists successfully manage uncomplicated HCV cases]
28. [Hep C Treatment Increasingly Feasible in Primary Care]
29. [Best Practice Testing Failed to ID Hidden HCV Infections]
30. [VIDEO: Pharmacy-delivered HCV therapy reached more injection drugs users]
31. [In the Northland region of New Zealand, the local health board provided 300 New Zealand dollars to general practices for each patient successfully diagnosed and treated for HCV.]
32. [Prioritize Injection Drug Users for Hepatitis C Treatment]
33. [HCV treatment cures patients despite injection drug use]
34. [Direct-Acting Antiviral Sustained Virologic Response: Impact on Mortality in Patients without Advanced Liver Disease]
35. [High prices of DAAs mean there's been little progress towards achieving WHO target of eliminating HCV by 2030]
36. [HBV reactivation uncommon in patients treated with DAA therapies]
37. [Report raises questions about long-term effects of DAAs for HCV ]

Contact

Hepatitis Scotland
91 Mitchell Street
Glasgow
G1 3LN

Telephone: 0141 225 0419
Fax: 0141 248 6414

 

Email:

enquiries@hepatitisscotland.org.uk 

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