Elimination of Hepatitis C in Slovenia (National program)
Health outcomes additional info
Some micro-elimination goals have already been achieved: - zero HCV in haemiohilia patients, - zero HCV in current haemodialysis patients, - zero HCV in patients with decompensated cirrhosis, - zero HCV in organ transplant patients. WHO elimination goals for HCV are most probably going to be achieved before 2030. The modelling study for PWID projected elimination by 2026.
Summary and objectives
In a two million population of Slovenia the prevalence of hepatitis C virus (HCV) infection has been estimated to 0.3%. The majority of HCV-infected represent people who inject drugs (PWID) with HCV-seroprevalence between 23 and 27%. Co-infection with HIV is low (7.6%).
The national strategy to control HCV infection was set up and published in 1997 by the interdisciplinary National Viral Hepatitis Expert Board. In 1997 the first national guidelines for treatment of HCV infection in Slovenia were set up with consecutive updates. There are five hospital-based clinics for treatment of viral hepatitis regionally spread throughout the country. Historically all the currently recommended standard of care treatment options have been available, including the direct acting antivirals (DAAs), starting in 2014. Hepatitis C treatment is available and accessible for everyone. It is fully publicly funded by a national health insurance system and provided with no limitations except for one: it had to be prescribed by the nominated specialists for viral hepatitis (infectologists, hepatologists) according to the national guidelines. Restrictions to the use of DAAs were present according to the fibrosis stage only in the period 2014-2017 due to high prices. Since 1997, efficacy of HCV treatment has been analysed systematically for all Slovene patients treated for hepatitis C.
People who inject drugs (PWID) have never been deprived from HCV treatment. Of estimated 6-8 000 PWID, the vast majority is managed in various drug addiction programmes. In 1995 testing for HCV has been introduced in the Centers for the Prevention and Treatment of Drug Addiction (CPTDA). In 2007 a national healthcare network for the management of HCV infection in PWID was founded integrating already existing facilities of 18 CPTDA and five specialized clinics for HCV treatment into a multidisciplinary team providing a continuum of care for HCV-infected PWID with targeted interventions. In the recent years, a cascade-of-care including testing, liver elastography, linkage-to-care and treatment has been additionally stimulated and achieved excellent efficacy. In low-threshold services for PWID occasional HCV screening has been performed showing the need for mobile units. They are going to be introduced by the end of 2019 offering HCV testing, liver elastography and linkage-to-care in case of active HCV infection.
Even though incarcerated persons have so far been effectively treated for HCV and have the possibility of HCV testing within prisons, activities to improve HCV management towards micro-elimination in this high-risk group have started at the beginning of 2019 and an interdisciplinary project is going to be prepared by the end of the year.
Precise algorithms for HCV testing were introduced to GPs and HCV screening by risk-behaviour questionnaire is going to be implemented into routine medical checking of every Slovenian person. Besides, free anonymous HCV testing is possible within medical institutions as well as in particular NGO services.
The modelling study from 2014 that estimated 0.3% prevalence of HCV RNA positive persons in Slovenia has shown that by using DAAs with over 90% SVR for all HCV-infected patients and incrementally scaling up the number of annually treated patients to 590 in 2026 from a base of 150 in 2015, Slovenia could achieve a 90% reduction in HCV prevalence by 2030. Increasing treatment rates starting in 2016 would require the annual diagnosis rate to increase to 350 patients by 2019 since approximately half of the viremic cases in Slovenia have already been diagnosed. Another modelling study showed that the elimination of HCV in PWID is achievable by 2026.
However, by 2018 micro-elimination of HCV has been completed (zero infected) in haemophiliacs, patients on haemodialysis, patients with decompensated cirrhosis, organ transplanted patients and HIV co-infected. In all these subgroups active screening for HCV infection has been going on and immediate DAA treatment is indicated in case of active infection.
Recently accomplished prevalence studies and real-life data of DAA efficacy pointed out that at the beginning of 2019 the guestimation of HCV RNA prevalence in Slovenia has most probably been closer to 0.2% than 0.3% meaning that of estimated 4 400 HCV RNA positive persons approximately 80% have so far been diagnosed and 54% of all positives have so far been cured.