Is the UK set to be hepatitis C free?

KEYWORDS:

• Hepatitis C
• operational delivery networks (ODN)
• HCV elimination
• National Health Service England
• WHO targets

Hepatitis C virus (HCV) infection still represents a significant global health burden and is associated with progression to cirrhosis with the development of hepatocellular carcinoma. It is estimated that approximately 58 million people are living with chronic HCV worldwide [1].

In December 2022, the National Health Service (NHS) England reported that it was on track to eliminate HCV by 2025 and attributed this to its pioneering elimination program (improved testing and greater access to treatment) [2]. This targeted program is in partnership with 23 operational delivery networks (ODNs) across the UK and is in line with the World Health Organization’s (WHO) goal of eliminating the hepatitis virus by 2030.

The UK Health Security Agency (UKHSA) and Office for Health Improvement and Disparities (previously called Public Health England-PHE) estimate that the number of people living with chronic HCV infections has fallen dramatically from 2015 to 2021, with a reduction of over 47% [2]. This reduction in HCV infections has also shown an impressive reduction in mortality, with a fall of more than 10% (another WHO target).

This is despite the COVID-19 pandemic, which had a negative impact on HCV testing and treatment, decreasing treatment numbers by 40.2% in 2020/21 [3]. Despite the impressive reduction in the rate of HCV infections, UKHSA report in 2023 suggests that it is likely that almost three-quarters of those who are still living with chronic HCV remain unaware of their infection [4]. However, multiple initiatives through the national HCV team, ODNs, and pharmaceutical companies, working collaboratively, have continued providing services to those at risk of infection.

Despite the disparity of data collection across UK health providers and the lack of a national HCV screening program and registry, six main strategic pillars provide the foundation for HCV elimination.

1. The spectacular success of direct-acting antivirals, dramatically transforming HCV therapy and shifting the focus of HCV elimination programs from ‘controlling’ to ‘curing’ the infection.

These anti-viral treatments currently ensure cure rates of more than 95% with short courses of treatment lasting between 8 and 12 weeks and with minimal side effects. A great example of a successful HCV screening program using these new therapies was carried out by the Egyptian Government. The 100 Million Healthy Lives campaign screened more than 50 million residents and treated more than 4 million HCV-infected residents, decreasing the HCV prevalence from 3.5% to 0.5% [5].

In 2015, National Institute for Health and Care Excellence approved these interferon-free regimens in the UK. By 2020, 67.2% of patients diagnosed with chronic HCV initiated treatment with 72.2% ascertaining a sustained virological response at follow-up in England [2].

2. The efficient allocation of financial and logistical resources for HCV, such as reduced drug costs, and the availability of comprehensive, affordable, and validated point-of-care tests and nucleic acid tests.

The NHS signed a ground-breaking national contract with pharmaceutical companies, which decreased unit drug cost and embedded a partnership ‘invest to save’ model of treatment access with long-term savings for the NHS [2]. Additionally, pharmaceutical companies, in partnership with various ODNs, have supported several educational and testing programs across the UK.

Furthermore, in 2017, the UK Standards for Microbiology Investigations (UK SMIs) published their recommendations for HCV testing across the UK to try to standardize this and create a common practice. Reflex testing was suggested as the standard care for those with a positive HCV antibody with shortened ‘time to treatment’ pathways, which is carried out by the central laboratory or by using point of care (POC) testing [6]. Following the WHO recommendations, POC HCV testing has been widely used in prisons, harm reduction centers, and pharmacies across the UK, with excellent results [6].

3. Successful interventions for people who inject drugs (PWID) with a focus on education, decentralized testing and treatment, and creating safe needle and syringe environments.

For example, in December 2013, a community-based ‘one-stop’ nurse-led HCV service was set up in a large substance misuse area. This integrated community-based test – stage – treat project (ITTREAT) showed that delivering treatment outside the hospital is feasible and access to HCV care can be facilitated by mitigating previous negative hospital-based experiences [7].

Unlinked Anonymous Monitoring survey has been crucial in monitoring the prevalence and incidence of HCV alongside other blood-borne viruses (BBV) but may be limited in assessing progress to elimination [8]. The Needs Assessment program conducted in late 2022, which initially focused on people who actively or recently injected drugs, showed a dramatic decrease in HCV infections (from 13–40% to 6.8%) in those who are engaged in drug services. These results reflect the success of ‘Test and Treat’ projects carried out by ODNs.

There is also no doubt that the inclusion of community peer-to-peer support via the Hepatitis C Trust has been essential in the success of these projects. Data from NHS England’s treatment registry, which included 30,729 patients, demonstrated an increase in treatment initiation and treatment completion in those ODNs with peer network support [9].

4. The integration of services in the available health care systems to serve socially marginalized groups, such as prison populations, and disadvantaged individuals who may not be catered to by routine health care, or who have lost their follow-up, with the additional benefit of providing more generalized health inclusion.

Since 2019, testing and treating HCV programs in prisons have increased across England. Some partnerships between Practice Plus Groups (PPG), Gilead Sciences, and the Hepatitis C Trust have shown excellent results in high-intensity test and treat programs. By April 2022, 14 of 48 PPG partnership prisons had achieved their HCV micro-elimination targets. HCV screening in PPG prisons increased remarkably from 41% in May 2019 to 87% in April 2022 [4]. This increase in testing was maintained despite the COVID-19 lockdown. Unfortunately, complete data from across UK are missing as PPG (the independent provider for the NHS) only covers 40% of the 118 English prisons.

People who have experienced homelessness often do not have regular contact with health services. To improve their access to HCV testing and treatment, NHS England have funded several community vans. These vans (as well as others independently funded by other partnerships) have been placed in areas with high health inequality with extraordinary results [10]. Additionally, in 2020, as a response to the COVID-19 pandemic, nearly 15,000 people who were sleeping rough or at risk of doing so were placed in temporary accommodation. Data from the national report suggest that there was still a high rate of HCV testing and treatment in and outside London during the pandemic.

Importantly, the NHS is working with third parties, such as St Mungo’s charity, to ensure that access to education, testing, and treatment in high-risk groups, who are difficult to engage with standard health care, are still available.

5. The inclusion of primary health care and local pharmacies has been key in decentralizing HCV testing and treatment across the UK.

International and local data support that the adoption of decentralization and task-shifting to non-specialists in national HCV programs improves testing, links to care and treatment in low- and high-income countries [11,12].

Moreover, in the UK, there has been key educational investment to improve the awareness of this infection in primary care. For example, the Project Extension for Community Health Outcomes (ECHO) uses a tele‐mentoring system, which has allowed primary care providers (PCPs) and nurse practitioners to be in contact with HCV specialists and share case‐based learning. As a result of this project, and multiple other projects targeting PCPs, an increase in HCV testing via GP surgeries of 43.3% between 2015 and 2019 has been noted [2].

What is more, GPs have been locating people who are not yet aware that they have an HCV infection, but have a positive test in their medical records, as well as offering HCV testing to those who are at an increased risk of being infected, or who are newly registered with the practice. The Patient Search Identification Tool, supported by Merck, which utilizes the NHS General Practice health records, has been another useful strategy across the UK to identify patients with HCV [2].

Finally since 2020, pharmacies across the UK have been able to provide a ‘Community Pharmacy Hepatitis C Antibody Testing Service,’ offering testing to PWID who are older than 18 years and who were not engaged with another services [13].

6. Beyond state‐run public health programs, several civil-society-led initiatives, screening programs, and health awareness campaigns have helped to reduce the stigma around HCV whilst also raising awareness of the disease.

As part of the newer initiatives for hepatitis C elimination, NHS emergency departments (ED) in high areas of prevalence implemented BBV ‘opt-out’ testing in 2022. Preliminary data from over 250,000 HIV tests and over 100,000 HCV antibody tests, delivered between April 2022 to July 2022, have identified over 500 people with previously unknown BBVs. By June 2023, more than 33 EDs have implemented this testing program and it is likely to be expanded in the coming years.

Since May 2023, NHS England’s dedicated Hepatitis C Elimination program has introduced self-hepatitis C testing online service, which allows people who have not been engaged with other initiatives to obtain a free home testing kit. This pioneering remote diagnostic project aims to increase the rate of testing across England. Even though currently there is no universal screening program, this new initiative will allow the majority of the UK adult population to be tested for free for hepatitis C.

In conclusion, national data support the tenet that the UK will achieve interim targets by 2025, and remain on track toward the WHO’s target of eliminating hepatitis C by 2030. The UK’s targeted hepatitis C test and treat program supported by UKHSA, pharmaceutical companies, charities, as well as civil and patient’s societies has showed a 35% reduction in mortality, which means the NHS has exceeded the WHO’s target of 10% by more than three-fold.

However, the lack of a national HCV screening program, standard data collection process, and national HCV registry makes it difficult to definitively know whether or not this goal will actually be achieved across the whole of the UK. Undoubtedly, this impressive elimination program has already shown a decrease in HCV prevalence and HCV-related mortality, but if HCV elimination is to become a reality, it is essential that there is continuing national investment, accurate modeling, further investment in local resources and networks, as well as maintaining a strong partnership with pharmaceutical companies and civil societies.

It is also critical to improve and expand the resources available to underserved groups and those who have been difficult to engage with the current strategies. Simplification, treatment decentralization with scaled-up same-day testing and treatment, as well as self-home/hostel testing could help to eliminate the current barriers to HCV screening and treatment.

Declaration of interest

Kosh Agarwal is an advisor for Aligos, Arbutas, Assembly, Abbvie, Biotest, GLC, Gilead, Immnucore, Merck, Springbank, Shinoigi, Sobi, and VIR. Kosh Agarwal has also received research grants from Gilead, Roche, and MSD. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they have received research grant support from Gilead Sciences, Abbvie, and Merck and consulting fees from Theratechnologies and Gilead Sciences. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.