Treatment as Prevention for Hepatitis C in Iceland (National program)
Health outcomes additional info
- Incidence: 80% reduction in incidence of domestic new cases of HCV by year end 2020 M
- ortality: >65% reduction in mortality due to HCV cirrhosis and HCC by 2025
Performance target additional info
- Harm reduction. WHO target of 300 needles/syringes/year/person already achieved
- Care cascade: HCV testing. Estimated >90% of people who inject drugs are tested for HCV.
- Care cascade: HCV diagnosis. As of November 2018 90% of estimated total number of infected diagnosed
- Care cascade: Referred for treatment. As of November 2018 97% of diagnosed linked to care and referred for treatment
- Care cascade: HCV treatment. As of November 2018 98% of linked to care initiated on treatment
Summary and objectives
A nationwide program for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. The project was named “Treatment as Prevention for Hepatitis C in Iceland“ or “TraP HepC“ - to underline the fact that active people who inject drugs (PWID), who are most likely to spread the virus, would be the focus of the treatment effort. Iceland, with a population of 340.000 had a low estimated HCV prevalence of 0.3% in 2016 (estimated total number of infected 800-1000).
By providing universal access to direct acting antiviral agents (DAA´s) to the entire patient population, the two key aims of the project are to 1) offer a cure to patients and thus reduce the long-term sequelae of chronic hepatitis C, and 2) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. The goal of TraP Hep C was to treat vast majority of patients within 36-months from the launch of the project. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, i.e. PWID, inmates of the penitentiary system as well as patients with advanced liver disease. In addition to treatment scale up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection, and improve linkage to care. Landspitali University Hospital serves as a project center.
The main collaborator is Vogur Hospital, SAA - National Center of Addiction Medicine (Society of Alcoholism and other Addiction, SAA). The Chief Epidemiologist, on behalf of the Ministry of Health, supervises the project. The pharmaceutical company Gilead, provides DAAs free of charge for the project in an epidemiological study setting. To measure the short-term and long-term effects of TraP Hep C the incidence of HCV infection acquired in Iceland and the incidence rates of cirrhosis and HCC due to HCV will be monitored for up to 15 years (Clinical trial number: NCT02647879). Additional factors, such as virological response rates, compliance, and prevalence among PWID are monitored as well. Use of health care services and costs of treatment will be tracked. These data as well as the data generated during the project will be used to assess the effect of the intervention on the future burden of illness for patients and society.
As of November 2018 it was estimated, on the basis of extensive screening among risk groups that >90% of domestic HCV infections had been diagnosed. A total of 720 patients (97% of those diagnosed) were linked to care and DAAs were initiated for 703 patients (98% of linked to care). The mean age is 42 years and 34% of the patients reported intravenous drug use in the past 6 months. Despite a high overall treatment success there is a small group of people who remain difficult to engage in care, mostly people who are actively injecting drugs. Visitors from abroad, asylum seekers and immigrants with preexisting HCV infection are also a challenge.
References: Olafsson S., Tyrfingsson T., Runarsdottir V., et al. Treatment as Prevention for Hepatitis C (TraP Hep C) – a nationwide elimination programme in Iceland using direct‐acting antiviral agents. Journal of Internal Medicine. 2018; 283:500-7. Scott N, Olafsson S, Gottfredsson M, et al. Modelling the elimination of hepatitis C as a public health threat in Iceland: A goal attainable by 2020. J Hepatol. 2018; 68:932-9.