Hepatitis C virus (HCV) infection is a significant public health issue in England, but one which the World Health Organization (WHO) has announced can be eliminated within a generation. New direct-acting antiviral curative treatments have been available in the UK since 2015, which means that theoretically it is possible to meet the WHO target and eliminate a disease which currently is a heavy burden on patients, carers and the health system. However, although England has pledged support for the WHO initiative, without a formal elimination strategy in place it is going to be difficult to meet this aim.
There are a few challenges we face. In England, around 160,000 people are reported to be infected with hepatitis C, although approximately 50 percent of patients remain undiagnosed. Hepatitis C is a disease that can affect anyone; the most common routes of transmission are through blood-to-blood, for example the sharing of needles, having unsafe dental or other procedures abroad, and blood transfusions. It can also be transmitted sexually. As well as the difficulty of finding people who are unaware that they have been infected, a large proportion of those with hepatitis C come from stigmatised populations – such as people who inject drugs – and therefore they are more difficult to access, and are less likely to engage with care.
As it currently stands, NHS England has rationed access to treatments to only 12,500 patients a year, but modelling indicates that it would need to treat 17,500 per year in order to deliver on the Public Health England pledge to eliminate the disease by 2030. In addition, access to these treatments across the country is patchy: in some areas, there aren’t sufficient patients engaged with services to meet current quotas, while in others patients wait for many months to access treatment.
Underlying all of this, and another large part of the problem, is the fact that England has no current formal plan in place to trace, test and treat people living with the disease, and while the WHO target is a good directive and is starting to mobilise people, it isn’t binding. That of course doesn’t mean we don’t have a moral and ethical responsibility to deliver on it, but right now we are behind the curve.
On a European level England is one of the few countries without a formal strategy, and is among the lowest-ranking in terms of the numbers of hep C patients treated related to prevalence. If we look at hepatitis C care from a global perspective, countries like France, Germany, Scotland and Australia have successful treatment models. Australia is widely considered a model country in terms of its hepatitis C strategy and is leading the way thanks to a slightly different approach; the Australian Government brokered a pioneering risk-sharing agreement with pharmaceutical companies and now has unrestricted access to medication, meaning every adult in the country is eligible for treatment as soon as diagnosed.
However, I remain optimistic about the future of hepatitis C care in this country. For me, it comes down to diagnosing the undiagnosed and engaging the disengaged, proactively bringing them to treatment – tactics that we’ve already seen being effectively deployed in pockets of the county. For this approach to be realised on a larger scale, health authorities and organisations need to learn from the success stories, and do two things: firstly, set the example from the top down, by instigating and incentivising a formal elimination framework to direct the operational delivery networks (that are responsible for regional implementation) and treatment centres; secondly, remove caps, so that we have unlimited access to medication.
Assuming measures were in place, the onus would then fall to each individual treatment centre to successfully engage, diagnose and treat on a local level. Here, the involvement of pharmaceutical companies and other stakeholders would be key; a collaborative, compliant and ethical joint-working activity, which focuses on reaching those populations that are traditionally recognised as being more difficult to engage. Without question, services should be user-friendly and geographically spread, so that physical accessibility doesn’t continue to be a barrier that prevents people engaging with care.
In my role working out of North Manchester General Hospital, I see the strides that can be made at a grassroot level across a region; strides that give me the confidence to say that regional treatment networks and centres have the enthusiasm and ability to deliver. However, to achieve the aim of elimination across the country a national hepatitis C framework is needed, as well as better directives from bodies such as Public Health England and NHS England.
Dr Andrew Ustianowski currently serves as a consultant in infectious diseases at North Manchester General Hospital/Pennine Acute Hospitals NHS Trust. He is the ex-chair of British Viral Hepatitis Group and the clinical lead for Greater Manchester HCV Elimination Programme. This article was authored in partnership with Gilead Sciences.