Hepatitis C in England 2019: Working to eliminate hepatitis C as a major public health threat
On 28 May 2016, the World Health Assembly adopted a Global Health Sector Strategy (GHSS) on viral hepatitis for the period 2016-2021. This strategy introduced the firstever global targets for viral hepatitis control, including a 30% reduction in new cases of hepatitis B and C by 2020 and a 10% reduction in mortality. (1) This report summarises UK progress towards meeting these targets, to help support focused action to eliminate hepatitis C as a major public health threat by 2030 at the latest.
Latest estimates suggest that in 2015 around 182,400 people (95% credible interval 162,300- 203,500) in the UK were living with chronic hepatitis C virus (HCV) infection, and that this figure has fallen by around 20% to 143,000 in 2018 (95% CI: 122,400, 164,500). Of these remaining 143,000 chronic infections, two-thirds (95,600; 95% CI 78,300, 113,800) are thought to be undiagnosed.
Injecting drug use continues to be the most important risk factor for HCV infection in the UK, with data from UK surveys of people who inject drugs (PWID) suggesting that in 2018, just over half of PWID (54% in England, Wales and Northern Ireland; 57% in Scotland in 2017-18) tested positive for HCV antibody, and just over one quarter had evidence of current infection (27% in the England, Wales and Northern Ireland; 31% in Scotland).
Latest data from surveys of PWID(2),(3) suggest that around two thirds of participating PWID in the UK were aware of their HCV antibody positive status (72% among those who had injected in the past 6 months in the Needle Exchange Surveillance Initiative (NESI) survey in Scotland in 2017-18; 63% among those who had injected in the past year in the Unlinked Anonymous Monitoring (UAM) survey in 2018 in the rest of the UK). In 2018, 48% of PWID sampled in the UAM survey and 60% of those sampled in the NESI survey (2017-18) were aware of their current persistent viraemic (HCV RNA positive) infection. These figures are higher than, but consistent with, modelled estimates of the proportion of prevalent chronic infection diagnosed in England, Northern Ireland and Wales in 2018 (33%) since the modelled estimates are based on those infections that are reported, and levels of awareness of infection are expected to be higher amongst those PWID who are in contact with services.
Although the WHO target of 50% of those ever infected in the WHO European region knowing their status by 2020 looks to have already been met in the UK, more needs to be done if we are to reach the 90% target by 2030.(1)
Mortality data suggest a fall in death registrations from HCV-related end-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) of 13% between 2015 and 2017, with provisional data suggesting a further fall of 6% in 2018. Thus with a fall in deaths of Hepatitis C in the UK 2019 9 around 19% by 2018, from the 2015 baseline, the WHO target of reducing HCV-related mortality by 10% by the year 2020(1) will have been exceeded 3 years early in the UK and hence a reduction of at least 65% by 2030(1) seems achievable.
The fall in mortality from HCV-related ESLD and HCC observed since 2015 is consistent with increased treatment and sustained virological response rates (SVR) achieved with new direct acting antiviral (DAA) drugs that have taken place over the past five years (an increase in treatment of 6% in 2018/19, and of 138% when compared to pre-2015 levels). Importantly the fall is largely the result of a reduction in HCV-related ESLD rather than HCV-related HCC. As observed elsewhere,(4),(5),(6),(7) this suggests that while DAA drugs may lead to a reduction in deaths from ESLD, and a reduction in the incidence of de novo HCC, the risk of HCC is not altogether obviated after successful clearance of HCV in those with cirrhosis before treatment.
Our ability to sustain the current increase in numbers accessing treatment will be limited by our capacity to find and treat the undiagnosed, and to help those who are diagnosed but untreated to engage with local treatment services. Throughout the UK, a variety of enterprising partnerships support this. In England, resources have been developed to help people recognise their risk for infection, and innovative procurement agreements with substantial investment from NHS England and the pharmaceutical industry have been secured to help improve the numbers diagnosed and accessing treatment. This increased testing and treatment activity will be supported by peer workers who will help vulnerable people to navigate the system to achieve cure. Re-engagement exercises have been launched in England, Northern Ireland and Wales to identify people who have been diagnosed with HCV in the past but who may not have accessed new HCV treatments. Point of care testing is also being piloted and rolled out in various settings throughout England and Wales, including the prison estate. In Wales, testing of clients of substance misuse services has become a key performance indicator for these services. In Scotland, new recommendations on HCV case-finding and access to care have been published(8) offering practical guidance to improve HCV testing, diagnosis, and treatment uptake. In Northern Ireland, there has been a focus on screening and harm reduction education amongst PWID; actions include raising awareness of the risks of blood-borne virus transmission among PWID and those working with these populations. There has been increased testing of PWID for blood-borne viruses including the introduction of dried blood spot testing, and work is underway to increase the ready availability of clean injecting equipment.
In contrast to the improvements in liver related mortality, data from UK surveys of PWID do not suggest any reduction in numbers of new HCV infections over recent years; prevalence of infection in recent initiates to drug use in the UK were similar in 2017 (22%) to those observed in 2008 (24%), and incidence of infection was higher in 2018 (17.6 per 100 person years) than in previous years (6.9% per 100 person years in 2011), although there is substantial uncertainty in the estimates and significant Hepatitis C in the UK 2019 10 variability between years. In 2017 and 2018, only an estimated 3 out of every 5 (63%) PWID in the UK reported having adequate needle/syringe provision for their needs. Taken together, these data suggest that the WHO GHSS call to reduce new cases of chronic HCV by 30% by 2020 and 80% by 2030, represents a significant challenge for UK HCV prevention and treatment services.
Overall, with unrestricted availability of new DAA drugs, and the expansion of initiatives to increase diagnosis and referral into care, the UK is well-placed to meet WHO GHSS goals to reduce HCV-related morbidity and mortality, provided case-finding and diagnosis can keep pace with planned treatment scale-up. At the other end of the spectrum, there is little evidence to support a fall in the number of new HCV infections; if GHSS goals to reduce these levels are to be reached, then a radical change in our response to tackling HCV acquisition in PWID is required