Testing and treating HCV in marginalised populations
Dr Manuel Hernandez-Guerra is a Consultant Gastroenterologist at the Hospital Universitario de Canarias, La Laguna, Spain. Dr Hernandez-Guerra spoke with Hepatic Health in early 2019 about strategies to improve hepatitis C virus (HCV) testing and treatment for socially marginalised individuals, particularly people who inject drugs (PWID).
Of the estimated 3.2 million people with chronic HCV in the European Union (EU), nearly two-thirds are unaware of their status and need to be identified before treatment can be considered.1 Injecting drug use is the leading cause of HCV transmission in most western and northern European countries,2 and accounts for more than 40% of cases where complete information on transmission status is reported.3 According to Dr Hernandez-Guerra, PWID have usually been tested for HCV previously but are lost to follow-up due to poor referral patterns and/or a lack of appropriate support measures. “In the absence of a diagnosis and treatment, many patients are at risk of developing decompensated liver disease and hepatocellular carcinoma,”4 he said.
Given the prevalence of HCV infection among PWID, strategies to enhance HCV testing and treatment in this group remain a high priority.
Strategies to facilitate the diagnosis of HCV and linkage to care in PWID
The feasibility of HCV eradication rests heavily on the ability to achieve high screening and diagnosis rates of HCV infection among PWID and subsequently link infected individuals into care.5 On the issue of engaging PWID, Dr Hernandez-Guerra emphasised the need to distinguish between individuals receiving opioid substitution therapy (OST) and those on the fringes of society who are extremely difficult to access. “Those on OST are much easier to engage because they usually attend drug addiction centres which can be meeting points between the disease and the cure,” explained Dr Hernandez–Guerra but, “the latter population is stigmatized and, for many reasons, do not attend healthcare facilities,” he said.
Dr Hernandez-Guerra outlined a new model of care that has been introduced in the Canary Islands and is a referral programme in Spain, with the aim of reaching disengaged PWID at high risk for HCV infection. The initiative collaborates with drug addiction centres to understand the barriers faced by PWID and to promote networking amongst healthcare facilities. Dried blood spot (DBS) testing is then incorporated into centres, so it is decentralised, but still integrated into the public healthcare system as a routine diagnostic technique. To address the gap between regional and tertiary centres, a direct referral pathway is established from the addiction centre to the University Hospital. Several new measures have recently been added to the model to improve patient engagement (e.g. telemedicine; decentralised dispensing of medicines), and to address factors associated with patient drop out (e.g. low income, poor awareness of HCV and/or poor perceptions of treatment).
“Contact your local drug addiction clinics. Find out about their needs and how they can be of assistance.”
Dr Manuel Hernandez
According to Dr Hernandez-Guerra, drug addiction centres commonly use a psychosocial approach to facilitate patient follow-up and harm prevention measures: addressing personal issues such as social isolation, anxiety or discrimination. In addition, “DBS testing is useful for assessing sustained virological response and reinfection rates,” he said. But to really reduce HCV infection rates, Dr Hernandez-Guerra emphasised the need to promote educational strategies first. Not only is there a perceived futility among PWID in presenting for testing, there is also a lack of knowledge with regard to evolving treatment options.6
For healthcare professionals who find it difficult to engage PWID, Dr Hernandez-Guerra offered two suggestions for consideration:
• “Contact your local drug addiction clinics,” he said. “Find out about their needs and how they can be of assistance.”
• Second, “establish networks with other stakeholders such as staff at the [microbiologists] labs, pharmacists, regulators and policy makers. [We need] to ease the [testing and treatment] pathways, to make elimination of HCV in this setting possible,” he said.
This interview has been edited for clarity and brevity.
- The European Union HCV Collaborators. Lancet Gastroenterol Hepatol 2017;2:325–36.
- Hajarizadeh B, et al. Nat. Rev. Gastroenterol. Hepatol 2013;10:553–562.
- European Centre for Disease Prevention and Control. Hepatitis C. In: ECDC. Annual epidemiological report for 2017. Stockholm: ECDC; 2019.
- Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med 2001;345:41-52.
- Grebeley J, Dore GJ. Antiviral Research 2014;104:62–72.
- Roncero C, et al. Eur J Gastroenterol Hepatol 2017;29:629–633.
LID/IHQ/19-09//1076 • Date of Preparation: September 2019