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Tackling inequalities in hepatitis C testing and treatment

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The World Health Organisation estimate that a staggering 325 million people worldwide are infected with hepatitis B and C, leading to 1.4 million deaths a year.

In England, around 180,000 people are infected with hepatitis B and latest estimates indicate 113,000 people have chronic hepatitis C.

Treating hepatitis C

The major game-changer for hepatitis C elimination has been the NHS rollout of new very effective treatments for hepatitis C– oral treatments that can cure the vast majority of people, have fewer side effects and require a shorter treatment course than the traditional treatment options.

However, before treatment can be successful, these patients need to be identified, linked to care, and then helped to adhere to treatment until cure is achieved.

We estimate that around 113,000 people are living with hepatitis C in England, and we urgently need to find and treat these individuals to meet the WHO target of elimination by 2030.

Most people with hepatitis C infection in England acquired their infection via injecting drug use, and other under-served populations are at risk of infection, including those in prison and the homeless.

We also know that these groups often need additional support to help them access services and adhere to treatment.

New interventions

In recent years many new interventions for finding, testing and treating people have been explored. Recognising the need to support commissioners and providers in delivering evidence-based services, PHE has conducted an evidence review of interventions to increase case-finding and linkage to care for hepatitis C-infected patients.

This review is timely as the NHSE has reached a deal with three pharmaceutical companies to provide hepatitis C drugs to the NHS. As part of the deal the drug companies will also launch find and treat initiatives for the most under-served populations, working with local health services and stakeholders.

A scale-up of interventions is in progress and commissioners and providers need to know which ones are likely to have the highest yield, benefit most patients, and reduce inequalities.

Ensuring equitable access is particularly challenging for people who inject drugs, the main risk group for hepatitis C infection in England, since a PHE report on hepatitis C treatment identified that only 10% of those treated between 2015 and 2018 have been referred from drug services.

The review provides a summary of the evidence on the effectiveness and cost-effectiveness of interventions in different at-risk populations and settings, and makes recommendations for commissioners, providers and researchers.

The key recommendations for commissioners and providers are:

  1. Prioritise commissioning facilitator or nurse-led complex interventions for PWID, providing a multi-agency package of care to test patients and support them to access and complete treatment. This will require collaborative working across a range of organisations involved in the HCV treatment and care pathway.
  2. Fully implement the opt-out screening programme in prisons, prioritising linkage to care as the critical component of cost-effectiveness.
  3. Commission incentivised combined HCV and hepatitis B screening in primary care for migrants, particularly in areas of high migrant density.
  4. Improve recording of country of birth and risk factors on primary care and community drug service systems.
  5. Commission primary care HCV screening of those at risk of infection via electronic flagging using validated risk algorithms.
  6. For cost-effectiveness evidence, focus on the most recent models which have up to date assumptions about treatment efficacy, acceptability, uptake, duration and costs.
  7. Horizon scan to obtain evidence from ongoing and emerging research, and action research taking place as part of the national patient re-engagement exercise.

One recent UK study of a facilitator-led intervention in three drug treatment sites (The Hepatitis C Awareness Through to Treatment HepCATT study) reported a four-fold increase in testing uptake, and a 29-fold increase in treatment engagement compared to control sites.

Hepatitis C infection can have devastating consequences, so the fact that more people are accessing treatment and fewer people are dying from the disease, is a huge and very welcome step forward.

But we need to accelerate cohesive efforts across the health and social care sector to find and treat those individuals unaware they are living with this serious illness if we are to eliminate hepatitis C as a major public health threat in England.

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