12 good practices that should be part of the hepatitis C standard of care

Hepatitis C programmes and health services should review whether they are using best practices in diagnosis, treatment and care of people with hepatitis C, and update service models to improve hepatitis C elimination efforts, according to a review published this month.

The review, carried out by a team at the Barcelona Institute for Global Health and colleagues at universities in Denmark, Italy, Sweden and the United Kingdom, identified 12 good practices that should be scaled up in order to improve diagnosis of hepatitis C, uptake of treatment and retention in care.

The research team scanned the scientific literature, conference abstracts and reports on best practice to identify evidence for innovations in screening and care that have led to improved outcomes.

The researchers say that most of the examples of good practice they identified are already being implemented in Australia, Spain and the United Kingdom, which are three of the nine countries on track to achieve hepatitis C elimination by 2030.

Reflex testing, the practice of automatically testing hepatitis C antibody-positive blood samples for hepatitis C virus (RNA testing), eliminates the need for a person who tests positive for antibodies to be recalled for further testing. Reflex testing increases the rate of diagnosis of chronic hepatitis C infection. Implementation of reflex testing is practiced widely in Spain.

Alternative diagnostic methods to help people move from hepatitis diagnosis to cure are also needed, especially point-of-care tests that can give results within 20 minutes or an hour. Again, these can eliminate the need for multiple visits and blood draws, for example through siting the Gene Xpert RNA testing platform in drugs services. Testing for hepatitis C core antigen can eliminate the need for confirmatory RNA testing, while dried blood spot sampling allows screening in people with poor venous access or where trained personnel are not available to carry out blood draws. Dried blood spot sampling has been used extensively for hepatitis C screening in the United Kingdom, France and the Netherlands.

Electronic medical record reminders to screen for hepatitis C can improve screening rates, using age cohort reminders to screen older patients in the United States or risk-based reminders to screen people with hepatitis C risk factors.

Decentralised and community-based testing in drugs services not only improves diagnosis but leads to increased engagement in treatment, the review found. Similarly, offering testing in migrant facilities and internment centres can enable engagement in treatment, Italian and Australian models show. Very large-scale community-based testing in Egypt resulted in testing of almost 80% of the population in 2018 and 2019, the reviewers note.

Testing in community pharmacies using dried blood spot testing has achieved high testing uptake among people who inject drugs in London and Scotland and was more likely to result in hepatitis C screening compared to the conventional testing pathway in a Scottish study in people receiving opioid substitution therapy. Mobile testing services, for example through vans which go to locations where they can reach homeless people, drug users and sex workers, have proved successful in Australia, Denmark, Spain and the United States.

Providing treatment in non-clinical locations, such as prisons and harm reduction facilities has the potential to increase the numbers treated and engage people who would otherwise be missed by conventional service patterns. Co-ordination between existing health services such as mental health services providing treatment for substance users and hepatitis C programmes can also increase treatment uptake, US research shows. Screening for hepatitis C in tuberculosis treatment programmes resulted in high rates of diagnosis and referral for treatment in Georgia, a country with a high burden of TB.

Task-shifting, when medical tasks are devolved to nurses or community health workers, increases capacity to screen for hepatitis C and start people on treatment. A US study found no difference in cure rates according to the medical personnel who were responsible for supervising treatment, showing that a broad range of healthcare workers can provide high-quality hepatitis C care.

Telemedicine can support primary care physicians to provide hepatitis C treatment, linking physicians to specialist support in hepatology, addiction medicine and psychiatry, as they manage hepatitis C patients with complex needs.

Loss to follow-up prior to treatment or during treatment is a major obstacle to hepatitis C elimination. Strategies to promote re-engagement in care are essential. Some studies find a high proportion of those screened for hepatitis C have a previous diagnosis. Re-engaging these people in care by identifying their current and previous barriers to care can result in high cure rates, research in the Netherlands shows.

Stigmatising attitudes among healthcare workers are often cited as the reason for avoidance of hepatitis C care. Stigma education programmes for healthcare workers have the potential to improve engagement in care. Peer support in healthcare settings, drugs services and the community is critical for engaging people from marginalised groups in care and overcoming stigma. Peer outreach proved successful in promoting engagement in care in a UK trial, for example.

The study authors say that without political will to eliminate hepatitis C and investment in elimination efforts, good practices will not be sufficient to drive the elimination of hepatitis C. Research into the implementation of a combination of good practices, such as point-of care testing, nurse-led treatment initiation and peer support, all delivered in non-clinical services, is needed to demonstrate how good practices can be combined to best effect.