Roadmap to Zero- The Elimination of Hepatitis C by 2030

Hepatitis C is an infection of the liver caused by the Hepatitis C virus, if left untreated it can cause permanent damage to the liver over many years. One in five people with liver damage associated with the virus will go on to develop Cirrhosis, which increases their risk of developing liver cancer. 1 Most people become infected with the hepatitis C virus by sharing needles or other equipment used to prepare and inject drugs.

From 2004 to 2019, 15,700 people in Ireland have been diagnosed with Hepatitis C. Each year around 600 to 700 people find out they have Hepatitis C and there could be as many as 30,000 people in Ireland living with the virus. 2 To date, over 5,000 patients in Ireland have been treated with highly effective Direct Acting Antiviral DAA’s for hepatitis C. 3

In May 2016, the World Health Assembly adopted the first global health sector strategy on viral hepatitis, 2016-2021. Ireland is one of 194 Member States of the World Health Organisation committed to eliminating viral hepatitis as a public health threat by 2030. 4 This ambitious strategy was made possible largely due to the introduction of Direct Acting Antiviral (DAAs) drugs in 2011. With a cure rate of ~96% these highly effective drugs with minimal side effects transformed HCV care globally. These drugs provided an opportunity to scale treatment largely due to the reduced monitoring and the increased efficacy they afforded.

In Ireland the oversight of Hepatitis C treatment is carried out by the National Hepatitis C Treatment Programme (NHCTP), established in 2015. The programme specifics and structure is available on HseLand, and also in the NHCTP Community Treatment Guidelines, originally published in 2019. The document outlines preferred community DAA prescriptions as:

Sofosbuvir/Velpatasvir 400mgs/100mg (Epclusa ® ) one tablet daily with or without food. Patient should be advised to take the medication at the same time every day. Pangenotypic 12-week course Suitable in all stages of hepatic impairment renally excreted (requires creatinine clearance > 30mls/min) Headache, fatigue and nausea are the most common side effects (> 10% of patients). They tend to be mild to moderate in severity. They are most likely to occur in the first four weeks of treatment.

Glecaprevir/Pibrentasvir 100mgs/40mgs (Maviret ® ) three tablets once daily with or after food. Patient should be advised to take the medication at the same time every day. Pangenotypic 8-week course not suitable for Child Pugh’s stage B and C cirrhosis. Suitable in all stages of renal failure including dialysis Minimal side effects. Headache and fatigue most common. Also potential for GI symptoms particularly if patients do not take their medication with or after food.

These treatments have >95% cure rate, for most patients are taken with minimal side effects, the drug cost is covered in the NHCTP. So why in some quarters does it appear Ireland, along with other EU countries is not on track to achieve the elimination of Hepatitis C by 2030?

A recent study done by Liver International in 2021 found, that out of 45 high-income countries, only 11 (Australia, Canada, France, Germany, Iceland, Italy, Japan, Spain, Sweden, Switzerland, and United Kingdom) countries are on track to meet the WHO’s global elimination strategy. Ireland, like 27 other member states, are predicted to achieve elimination by 2050, 20 years after the target date. 5 Current data from the NHCTP suggests that Ireland has reached the 2020 targets and is on track to achieve 2030 WHO elimination targets. 6

This is disappointing given the known risks of communicable diseases and the availability of highly effective curative treatments. The reasons for this are of course complex but in the simplest of terms, endemic barriers in the care cascade have resulted in many patients being lost to care.

We at the Hepatitis C Partnership (HCP) undertook a national scoping exercise during 2021 to try to better understand the experiences of healthcare providers and people directly affected by Hepatitis C. We hoped to learn what was working well, what could be improved and what those at the centre of the Hep C cascade of care thought.

The result of this extensive undertaking is “The Roadmap to Zero”, launched by the HCP on the 1st June of June 2022. The launch coincided with the opportunity to present the recommendations to the Oireachtas Joint health Committee, to discuss the current experiences of healthcare providers and their patients. The report produced 7 key recommendations across three themes, they were:

1. Establish regional needs with regional experts

Understanding the burden of Hepatitis C on a regional basis is important. Not all areas will have the same needs and it is important to work with regional stakeholders to:

• Establish baseline prevalence and incidence data on as local a level as possible.
• Identify any specific challenges in different regional areas considering at-risk cohorts, likely burden of disease, accessibility, and resource needs across the Cascade of Care.
• Define agreed regional micro elimination targets, based on the current best evidence of the likely burden of disease in the region.

2. Set national and regional implementation plans

• Have an explicit focus on elimination as defined by the World Health Organisation, and use the regional micro elimination targets as metrics for success.
• Set out how capacity is to be built in each regional area, as well as what actions will be undertaken at both national and regional levels to drive elimination.
• Assign ownership to a named role for delivery, both regionally and nationally, and set SMART objectives for implementation.
• Ensure PAG has appropriate structure and resources to monitor and drive implementation, including regional subgroups with representation from people with lived experience, statutory sector, and civil society representation which is representative of the challenges in the region.

2. Build pathways to support elimination in a sustainable way

Rationale

Now, there is an inequality in access to Hepatitis C care in that the care that you receive is largely dependent on your location in the country and your characteristics as a patient. Every effort should be made to create a policy framework that is driven by the need to test and treat as flexibly and locally as possible, to realise the Slaintecare vision for equality in the context of liver care. There is also the potential for cross-policy engagement with the National Drug Strategy, and actions related to making services more accessible for people who use drugs.

Recommendations

3. Unblock existing policy barriers, and set policy to enable elimination

• Remove the requirement that patients need to be engaged with opioid substitution treatment to be treated in the community by their GP.
• Remove any barriers to community pharmacy management of Hepatitis C medications and ensure that community pharmacists can dispense medication where possible.
• Ensure an opt-out system for testing in all community-based addiction services, including section 39 agencies, is being implemented.
• Implement an opt-out system for testing and treatment in prison settings.
• Broaden the range of testing opportunities by enabling a diverse range of community testing initiatives, including mobile and outreach testing, dried blood spot testing, point of care testing, and at-home testing as appropriate.
• Provide training on Hepatitis C testing and care to staff – project and support workers, peers, care and case managers, and nurses – in all community services working with people who are part of a population with higher seroprevalence, and resource those services to provide testing.

4. Build a community based, nurse and peer-led system to drive elimination

• Utilise existing hospital-based consultant-led services in each regional area as hubs and existing community services (e.g., OST clinics, GP-led services) as spokes. Recognising the pressures that both hospital and community professionals are under, support should be flexible and ad hoc, and leverage online tools (teleconferencing, emails) as a preference.
• Include paid peer workers with relevant lived experience to provide community-based testing, and patient support across the cascade, learning from the positive experience of the model in place at the Mater Hospital, and extending the same to other regions. Peer workers are vital in addressing Hepatitis C in our communities and should be paid, well trained, embedded in clinical teams/ services and provide flexible support (outreach, access supports) to patients determined by patient need.
• Include enhanced nursing supports to ensure a nurseled community service model, including nurse prescribing.
• Include properly resourced GPs who can treat Hepatitis C among any community-based population who do not clinically require hospital-based treatment and who can support a nurseled model of community care.
• Include access to appropriate laboratory/testing facilities at each spoke, acknowledging the significant pressure on laboratories, including the National Virus Reference Laboratory arising from COVID, and supporting those services accordingly.
• Include access to community pharmacy dispensing at each spoke, and consider a strategic partnership with a suitable national pharmacy group to scale community access.

5. Ensure utility beyond Hepatitis C

• Ensure that the system has a role in addressing longer-term liver care in Ireland after the initial push to eliminate Hepatitis C.
• Consider whether the system can play a role in detecting / providing longer-term care around other liver care issues (such as Hepatitis B virus (HBV) / fatty liver disease (FLD) or around other healthcare issues that could be addressed primarily in the community.

Drive Hepatitis C Elimination Rationale

When a suitable system is in place to drive elimination, we need to help people access it. Some people who are treated for Hepatitis C will have ongoing liver care needs, and will continue to be exposed to risk factors post-treatment, or may have other issues in their lives around which they seek support. The drive to eliminate Hepatitis C should be seen as an opportunity to link people to other systems of care.

6. Find the ‘missing thousands’

• Ensure widespread and sustained public health promotion campaigns targeted at the ‘missing thousands’ who are currently living with undiagnosed Hepatitis C in our communities. These campaigns should include a strong peer-led outreach component and can focus on the positive impact of addressing Hepatitis C in the community as well as maximising opportunities for general hepatic health promotion.
• Ensure that frontline healthcare providers and, where needed, patients, are appropriately incentivized (if this is not already the case) through a staged incentivization approach and are recognized for reaching agreed targets around reaching, testing and treating people with Hepatitis C.

7. Focus on supporting good longer-term outcomes

• Support people who access treatment and require additional inputs, such as around housing, employment, education, or psychosocial support to access those supports as needed

Summary

There is no doubt of the drive and commitment present in the healthcare provider cohort working with Hepatitis C and broader hepatic issues. Due to the nature of the transmission of Hepatitis C and high prevalence among people who do, or have, used drugs they often have co-occurring health issues, mental health challenges and frequently have experienced stigma in statutory settings. Community based treatment, improvements to regional access and the use of trained peer support workers can help with the drive to elimination. Initiatives such as the NHCTPs planned roll out of the home testing kits for Hepatitis C, initially a 1000 kit pilot, should be implemented and evaluated in a timely manner and if proven successful, fully implemented. Systemic and policy blockages should be resolved to maintain a flow of patients eligible for treatment, this improving health outcomes, future burden and quality of life.

Finally, there is a need to strategically align with the WHO goals and ensure that there is a consistent, visible, and clearly articulated metrics-based strategy focused on elimination.

The Hepatitis C Partnership (HCP) is a national collaborative network of stakeholders from across the public and NGO sector who lobby, educate and support those impacted by hepatitis C. Please go to the website for more information on our work, and access to the full report.

References on request

Read the latest edition of Hospital Professional News: August HPN

Catch up on our Clinical Features