EXPLORING NEW FRONTIERS IN HCV CARE TOGETHER
The development of direct-acting antiviral (DAA) therapy has changed the treatment landscape for chronic hepatitis C virus (HCV) infection.1 But DAA therapy is only one part of the care continuum, and while significant progress towards elimination has been made on several fronts, there are many remaining challenges. Now is the time for all stakeholders to come together and work toward eliminating the burden of HCV.
Innovation for elimination
To meet the ambitious targets set by WHO to eliminate HCV as a public health threat by 20302, innovative strategies are required along the entire continuum of care. In countries that are on track to reach their elimination targets, several common themes are evident:
- There is engagement and commitment at the highest political level.
- There are well designed and executed national action plans.
- There is successful implementation of innovative strategies to address existing treatment barriers.3,4
Broadly speaking, strategies that have been implemented in the fight to eliminate HCV can be divided into three categories:
- Specific interventions are initiatives that seek to improve screening for HCV or link more patients to care.
- Models of care take a holistic approach, targeting all aspects of patient management, from identification and linkage to care through to follow-up and harm prevention services.
- Regional elimination strategies aim to provide greater treatment access and equity for all those affected by HCV.
Several examples of successful elimination strategies, supported from Gilead Sciences, are provided here and can be used to empower other countries and territories to take practical steps and prioritise activities that will help eliminate HCV.
There are significant opportunities to expand HCV awareness campaigns and improve diagnostic technologies in order to increase the volume of patients screened for HCV.
Easy-to-use assays (e.g. point-of-care testing) can facilitate screening and allow treatment monitoring in remote and primary care settings.5 Similarly, dried blood spots are a feasible and reliable test for viral hepatitis and are useful for assessing treatment response and reinfection rates.4 Several examples of specific interventions from France and Spain are listed in Box 1.
Toulouse mobile liver disease team.
A service offering onsite screening for HCV, liver disease assessment, pre-treatment counselling and follow-up.
Andalusia one-step diagnosis.
Reflex testing for HCV has been incorporated into all microbiology laboratories in Andalusia, Spain.
Models of care
In order to achieve elimination targets, the continued development of diverse models of care and broad prescriber involvement is necessary.1
The simplicity of current DAA regimens means that therapy is now possible in the community by non-specialists, rather than being limited to hospital settings.1,6,7 This more convenient, patient-centered approach removes the burden of HCV from specialist services, provides the ability to substantially upscale treatment rates to the desired level for reducing population burdens of HCV. Receiving treatment in familiar environments with their trusted, accessible, long-term doctors also removes an important barrier to treatment for people living with HCV.7
There are many emerging models of care that have embedded themselves within the community, operating by mobile street units and pop-up clinics.8-10 These models seek out and treat vulnerable populations who may otherwise have limited access to care: in places where they access drug and alcohol services, where they socialise (such as annual festivals), or where they live, including supportive housing services for the homeless and alternate housing such as squats.
Models implemented to date can serve as a guide for other countries and territories to build upon or adapt as necessary to suit local conditions. Box 2 contains several examples of country-specific models of care.
Caserta model of integrated HCV care.
A simplified care pathway between hospitals, addiction units and prisons in a high prevalence area.
Duffy Health Center shared medical appointments
A shared medical appointment model for vulnerable patients provided by non-specialist providers.
Treatment of people who inject drugs (PWID) and people detained in prisons is a high priority because of both the high burden of HCV infection and the potential to transmit to others.6 Globally, 23% of new HCV infections and one-in-three HCV deaths are attributable to injecting drug use.11 Moreover, available data demonstrate that one-in-four detainees are HCV positive.12
For PWID, experts emphasise the need for integrated care: providing HCV treatment, addiction services, and general medical care under one roof.13 Relocating healthcare from hospitals to low threshold settings allows patients to be tested and treated for HCV in an environment where they feel safe.
There are some good practice examples (Box 3) that show progress towards achieving the WHO targets, and demonstrate how to improve access to HCV testing and treatment for PWID and people in prisons.
Villa Maraini Foundation integrated HCV care
Collaboration between a low-threshold service and tertiary institution to facilitate linkage to care for hard-to-reach HCV patients.
SAFE remote HCV screening project
Increasing linkage to care for PWUD using remote methods of education and screening.
The Catalan model of hepatitis care, a special approach in prisons
An initiative to introduce systematic screening for HCV for all individuals admitted to prison.
HCV care in a low threshold setting in Oslo
A primary care, low-threshold HCV clinic with a network-based, flexible, ambulant model of care.
Kombi Clinic outreach model of GP care
A GP-led, mobile hepatitis clinic engaging with disenfranchised, disempowered and socially isolated populations.
ARISTOTLE HCV-HIV project: peer support
A community-based, peer-driven referral process to increase linkage to care and treatment among PWID.
Cool Aid Community Health Centre nurse-led model of HCV care
A nurse-led ‘seek and treat’ approach to identify high-risk patients in supportive housing centres.
From HCV testing to treatment in social relief centres in Amsterdam
HCV screening and linkage to care in social relief shelters and walk-in centres across Amsterdam.
Regional elimination strategies
Some countries (e.g. Australia, Brazil, Scotland, Rwanda, Egypt) have successfully used political commitment, country investment and the empowerment of community networks to implement regional elimination programs.14 These initiatives involve upscaling HCV screening and linkage to care networks across a single geographical area and developing programs that facilitate knowledge transfer from specialists to general practitioners, nurses, pharmacists, non-medical providers, and the public on a large scale.
To be effective, regional elimination strategies need the engagement of all relevant stakeholders, and a recognition of HCV as a public health threat that can and should be treated. In doing so, these programs can build capacity throughout a region, targeting all relevant settings, carrying out universal HCV test and treat strategies, and proving care to all affected populations.14
Regional HCV elimination plan in Veneto
A test and treat ‘point of care’ HCV strategy among addiction services and prisons.
Holistic HCV elimination in Tenerife
A local initiative with the collaboration of multiple stakeholders to improve linkage to care in Tenerife, Spain.
The Catalan model of hepatitis care
Broad multi-stakeholder engagement, with the aim of eliminating HCV as a public health threat.
In all countries, there are barriers to HCV elimination that need to be overcome, as well as best practices in HCV management that can be adopted. However, we also have the tools at our disposal to meet the WHO goal of elimination by 2030 - simple curative treatment, accurate diagnostics and knowledge about how transmission can be prevented. The question is, can we mobilise these tools rapidly enough and implement them widely and equitably?3
It is important that the hepatitis community continue to collaborate and build on the current momentum and positive examples implemented to date. Together, it is possible to re-define HCV care and provide greater access to treatment and equity of care for all patients, ensuring that no one is left behind.
Watch the exploring new frontiers in HCV care together best practice animation below to find out more.
- Dore GJ and Hajarizadeh Infect Dis Clin N Am 2018;32:269-79.
- World Health Organization. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. June 2016. Available at: http://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/ (accessed January 2019).
- Klein MB. Journal of the International AIDS Society 2019;22:e25360.
- Vazquez-Moron S, et al. Scientific Reports 2018;8:1858.
- Johannessen A. J Viral Hepat 2015;22:362–5
- Terrault NA. F1000Research 2019, 8(F1000 Faculty Rev):54 (https://doi.org/10.12688/f1000research.15892.1).
- Wade AJ, et al. J Viral Hepat. 2018;25:1089–1098.
- O’Loan J. INHSU 2019; 11-13 September 2019; Montreal, Canada.
- Midgard H, et al. J Hepatol 2019;70(Suppl):e41:PS-068.
- Sypsa V, et al. J Hepatol 2019;70(Suppl):e344-e345:Poster #THU-427.
- World Health Organization. Access to hepatitis C testing and treatment for people who inject drugs and people in prisons – a global perspective. Policy brief. Geneva: 2019.
- Larney S, et al. 2013;58:1215–24.
- Bruggmann P, Litwin AH. Clin Infect Dis. 2013;57 Suppl 2:S56–61.
- Pedrana A, et al. Eliminating Viral Hepatitis: The Investment Case. Doha, Qatar: World Innovation Summit for Health, 2018. Available at: http://www.optimamodel.com/pubs/HCV%202018.pdf (accessed Feb 2020).
IHQ/LVD/2020-02//0006 • Date of Preparation: March 2020