School of Medicine
University of Dundee
Christopher Byrne, BA (Hons), MSc, has no relevant conflicts of interest to report.
Professor of Hepatology and Gastroenterology
Division of Molecular and Cellular Medcine
School of Medicine, University of Dundee
Honorary Consultant Physician, Gastroenterologist & Hepatologist
Clinical Lead for Blood Borne Viruses
NHS Research Scotland National Lead for Hepatology
President of Scottish Society of Gastroenterology
Dundee, United Kingdom
John F. Dillon, MB BS, MRCP, MD, FRCP (Edin), FRCP (Lond), has disclosed that he has received funds for research support and fees for non-CME/CE services from AbbVie, Gilead Sciences, Janssen, Merck, and Roche.
The HCV treatment as prevention (TasP) model is an innovative and promising approach to eliminating HCV, yet it remains to be proven in real-world populations of persons who inject drugs (PWID). As of 2017, injection drug use accounted for 91% of HCV infections with a known cause in Scotland. The prevalence of HCV antibodies in PWID was estimated at 58% in 2013-2014, indicating a clear need for elimination efforts in this population. Here, we share our progress in evaluating a TasP model of HCV care in PWID administered through our regional health board in Tayside.
Testing the HCV TasP Model in PWID: Background, Approach, and Findings to Date
To provide some context for how HCV is routinely managed in Scotland, our devolved single-payer National Health Service (NHS) covers direct-acting antivirals (DAAs)—available since 2014—with prescriptions free at the point of delivery. HCV care is guided by the 2015-2020 update to the Scottish Sexual Health and Blood Borne Virus Framework and administered through managed care networks, which were set up following publication of the Hepatitis C Action Plan for Scotland in 2006. Because HCV is concentrated in major urban areas, these sites are the focus for most testing and treatment efforts; fortunately, the urban policy environment has been largely supportive of test-and-treat initiatives.
To achieve the high treatment levels needed to achieve HCV elimination in PWID, we have localized and intensified HCV testing and treatment, with a focus on keeping these efforts as simple and accessible as possible. Operationally, this includes community pharmacies; drug treatment centers, which reach PWID receiving opioid agonist therapy; injecting equipment provision centers, which reach active injectors; prisons; and finally, our standard secondary care–led hepatitis service. We have empowered nonspecialists (pharmacists and nurses) to prescribe DAA treatment, developed peer-referral and third-sector HCV testing initiatives, and removed DAA prescribing barriers based on illicit drug use, previous HCV infection, and/or requirements to genotype patients.
Reports from health boards indicate an increase in the number of HCV tests administered recently, peaking around 2016. Testing has been increasingly administered in drug treatment and harm reduction services, largely via dried blood spot. Prisons remain a difficult environment to effectively implement HCV initiatives, but we are hopeful that testing rates will improve as the Scottish Health Protection Network recommended national opt-out testing for incarcerated individuals in January 2019.
Ongoing Challenges to Eliminating HCV in Scotland
Our HCV TasP approach requires political will, the motivation to adopt new technologies, and the willingness to shift HCV care from secondary to community settings. Fortunately, our efforts are complemented by centralized surveillance of HCV testing and treatment linked to national clinical laboratory data to monitor infection and reinfection, allowing us to track progress toward national treatment targets.
However, to achieve HCV elimination, prison systems will require improvement in their transition between a reactive test and linkage to care and treatment. More than 40% of people infected with HCV in Scotland have not yet been diagnosed. Encouragingly, our efforts in NHS Tayside have improved the local HCV diagnosis rate to more than 80%. Because PWID represent the primary Scottish population with HCV infection, we hope that the results generated by our HCV TasP trial will influence national elimination policy and initiatives.
Of note, the Scottish government recently committed to HCV elimination by 2024, putting national plans 6 years ahead of the WHO goal of 2030. Treatment targets have been adjusted upward, with promises to treat at least 2500 in 2019-2020 and at least 3000 annually from 2020-2021.
What do you consider the greatest challenge to eliminating HCV? How has your clinic or institution been involved in related efforts? Please share your thoughts and experience in the comments box.