HCV Elimination in Spain: Overcoming Challenges in High-Risk Populations

Marta Torrens, MD

Associate Professor
Psychiatry and Forensic Medicine
Universitat Autonoma de Barcelona
Head of Addiction Program
Institute of Neuropsychiatry and Addiction
Barcelona, Spain

Marta Torrens, MD, has disclosed that she has received consulting fees and fees for non-CME/CE services from Gilead Sciences and Merck.

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Released: July 5, 2019

In 2015, amid discussions calling for the global elimination of viral hepatitis, Spain launched a national strategy to eradicate domestic HCV infection. The Plan Estratégico para el Abordaje de la Hepatitis C en el Sistema Nacional de Salud (PEAHC) aims to reduce HCV-related morbidity and mortality through efforts in prevention, diagnosis, treatment, and follow-up.

Although therapy was originally prioritized for patients with F2-F4 fibrosis, these restrictions were lifted in mid-2017 such that any person with HCV infection can now be treated with direct-acting antivirals (DAAs) through the national health system, regardless of disease stage. More than 117,000 Spanish people received HCV treatment between January 2015 and September 2018, and Spain had the highest HCV treatment rate of any European country from 2014 to 2016 (16.13/10,000 persons).

Identifying Priority Populations Critical to HCV Elimination
To make our goal of national HCV elimination possible, case-finding to identify individuals with HCV infection who are not currently engaged in hepatology services is an important first step. In Spain, high-risk populations principally consist of persons who inject drugs (PWID), men who have sex with men, those in prison, and migrants from regions with high HCV prevalence. Of particular importance is the PWID population because approximately 70% of these individuals are infected with HCV.

Adopting Policies That Address Implementation Barriers
There is a pressing need for better strategies to facilitate screening, diagnosis, and treatment of high-risk populations. Accordingly, the PEAHC set forth these objectives:

  • Quantify the domestic epidemiology of HCV infection
  • Promote early diagnosis in priority populations
  • Reduce the incidence of HCV infection through expanded training
    • Prepare and disseminate educational materials for the general public, healthcare professionals (both primary care and specialists), and nonhealthcare entities (eg, NGOs and patient support groups)
  • Prevent HCV-related morbidity and mortality, mitigating complications associated with chronic HCV infection such as cirrhosis and hepatocellular carcinoma

For these objectives to be successful, we must overcome several challenges. First, the link between screening and diagnosis must be strengthened. Current efforts are bringing one-step HCV diagnosis as close as possible to high-risk populations. Second, HCV treatment access must be expanded at the sites where high-risk populations are concentrated, such as drug abuse treatment centers, harm-reduction facilities, and prisons. Third, posttreatment follow-up must be improved by better sharing of medical records among healthcare providers. Finally, networking connections must be enhanced across multidisciplinary teams, including those from general healthcare, prisons, hepatology, pharmacy, and substance abuse and mental health services.

These challenges cannot be addressed with a “one-size-fits-all” model. Rather, solutions should be tailored to local characteristics and situations. These microelimination projects target a specific population (eg, PWID) while taking into account the different scenarios, actors, and resources in that geographic region. I believe that it is through successful implementation of these microelimination initiatives that Spain will achieve HCV elimination.

Your Thoughts?
What challenges do you anticipate in achieving national elimination of HCV infection by 2030? Please share your thoughts in the comments box.

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