Professor and Chairman
Department of Gastroenterology and Hepatology
Essen University Hospital
University of Duisburg-Essen
Heiner Wedemeyer, MD, has disclosed that he has received consulting fees from Abbott, AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, MSD/Merck, and Roche and funds for research support from Abbott, AbbVie, and Gilead Sciences.
Since the introduction of HCV direct-acting antivirals (DAAs) in 2014 in Germany, we have observed a decrease in the number of patients undergoing liver transplantation due to HCV-related cirrhosis. Other encouraging developments include broader access to harm reduction programs for persons who inject drugs (PWID), the availability of DAAs without financial barriers or fibrosis-based restrictions, and the prevalence of clinicians in private practice prescribing DAAs. Nonetheless, challenges in eliminating HCV in Germany remain. In this commentary, I discuss those barriers and share how my colleagues and I are working toward implementing the HCV treatment as prevention model within the framework of national and state policies.
HCV Elimination in Germany: Challenges
We face multiple barriers to eliminating HCV in Germany. Here, approximately 8 of 10 HCV cases with a known transmission mode are associated with injection drug use. PWID—who are concentrated in prisons—thus represent a key population for HCV elimination efforts.
In 2016, Germany adopted a national strategy for reducing HCV that highlighted PWID as a priority population. However, implementation has generally involved a selective approach toward specific “hotspots” rather than a cohesive national effort. Although many harm reduction and treatment services are available in Germany, access to these services varies widely across our 16 states, particularly in the state-controlled prison systems responsible for care of incarcerated individuals with HCV infection. For instance, opioid substitution treatment is less common in the prisons of Bavaria but occurs quite frequently in Berlin.
Another challenge is a lack of familiarity with contemporary treatment options. Some of our colleagues—as well as some PWID—retain the perception from the interferon era that HCV therapy is ineffective, prolonged, and plagued by adverse events. Understandably, they hesitate when recommending or accessing therapy. Enhanced educational efforts are needed to reinforce that DAAs are highly effective, given for short durations, and safe.
Finally, there are other important populations needing HCV elimination efforts. Outbreaks of acute HCV infection via sexual transmission have occurred among HIV-positive men who have sex with men in multiple German cities.
Applying HCV Treatment as Prevention in Germany
Although I consider Germany to be on track to achieve HCV elimination, fully accomplishing this goal will require financial resources, time, and the efforts of dedicated, motivated clinicians and addiction specialists.
Proper training to identify and treat those at highest risk of acquiring or transmitting HCV infection will be critical and must extend past the healthcare team itself: Social workers, street outreach teams, prison staff, and politicians, such as the state ministers of justice, will require education on the benefits of both treatment as prevention and harm reduction services. Already, such initiatives are being provided through professional organizations, and we must continue in this tradition. By advocating for and improving access to DAA therapy in addiction clinics and prisons, we can meet patients where they are and work to dry the HCV reservoir in populations with a high prevalence of infection.
What do you consider to be the greatest barriers to providing HCV treatment in Germany or abroad? Please share your thoughts and experiences in the comments box or click here to read about progress in France.