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Global targets for reducing deaths from viral hepatitis will not be met without massively accelerating universal access to testing and treatment, the World Health Organization (WHO) said yesterday in a review of progress towards elimination of hepatitis B and C.

The Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021 provides a snapshot of recent statistics on viral hepatitis testing and treatment, as well as recommendations for actions to accelerate progress towards elimination of viral hepatitis.

Around 1.4 million people died from viral hepatitis in 2016, 1.75 million people were newly infected with hepatitis C in 2015 and 1.1 million people were newly infected with hepatitis B in 2017, the most recent years for which WHO has collated data.

The report reveals that rates of viral hepatitis diagnosis remain low in all regions of the world. Less than 1% of people with hepatitis B in Africa and 2.3% of people with hepatitis B in the Western Pacific region have been diagnosed. Although hepatitis C diagnosis rates are higher in some regions – 36% in the Americas and 21% in the Western Pacific – WHO estimated that only 19% of people with hepatitis C knew their status at the end of 2017.

WHO estimates that $6 billion a year needs to be spent on viral hepatitis testing to achieve the elimination targets by 2030. Innovations in point-of-care testing are also needed to improve access to testing and to simplify linkage to care.

The World Health Organization (WHO) is organising a series of briefings and consultations to inform the development of global health strategies on HIV, viral hepatitis and sexually transmitted infections for 2022-2030. A series of regional consultations will be held in May and June 2021 to hear from a broad range of stakeholders from every region. Parallel to the regional consultations, an online survey is available to broaden the scope for input from additional stakeholders.

WHO encourages all interested individuals and organisations to complete the online survey here.

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The COVID-19 pandemic severely reduced hepatitis C testing, diagnosis and treatment in the United States during 2020, a study by Quest Diagnostics and the US Centers for Disease Control and Prevention reports.

The findings are published in the American Journal of Preventive Medicine.

An estimated 2.4 million adults are living with hepatitis C in the United States, but a large proportion remain undiagnosed and unable to benefit from curative treatment with direct-acting antivirals.

The US Centers for Disease Control and Prevention recommends that all adults born between 1945 and 1965 – the baby boom generation – should be tested at least once for hepatitis C. The US Preventive Services Taskforce subsequently recommended that all adults aged 18 to 79 years should be screened for hepatitis C.

The study found a sharp decline in antibody testing and confirmatory HCV RNA testing from March 2020 to July 2020. HCV (hepatitis C virus) antibody testing volume decreased by 59% during April 2020 and rebounded to a 6% reduction in July 2020.

Positive diagnoses also fell by 56% in April 2020 as did positive HCV RNA results indicating chronic HCV infection (down 62% in April 2020). Positive HCV RNA tests remained 39% lower in July 2020 than the average for 2018 and 2019. Prescriptions for direct-acting antivirals were 38% lower in July 2020 compared with 2018 and 2019.

When analysed by age, testing and prescribing activity suggested that older people were avoiding face-to-face clinical encounters, reducing opportunities for hepatitis C diagnosis. In 2018, approximately two-thirds of tests were carried out in people aged 40 or over; in 2020, 52% of tests were carried out in the over-40s.

Dispensing of direct-acting antivirals – a 12-week or 8-week treatment course in most cases – fell in people aged 60-84 in 2020. The 60-84 age group accounted for 45% of prescriptions in 2018 and 37% of prescriptions in 2020. Prescriptions to people aged 20-39 years increased from 14% of all prescriptions in 2018 to 24% of all prescriptions in 2020.

The shift towards prescribing more treatment courses to younger people may not be a consequence of COVID-19 alone, the study authors say. Greater awareness of risk factors for hepatitis C among younger people and the rise in opioid injecting may also explain greater testing activity and more prescriptions.

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Most people with hepatitis C and liver cirrhosis experience improvement in liver function after direct-acting antiviral treatment, but a small minority – mainly those with a history of liver decompensation – may suffer further deterioration in liver function after being cured of hepatitis C, a large Italian cohort study has reported.

Direct-acting antiviral treatment cures hepatitis C and leads to improvement of liver function in people with less advanced liver disease. What has been less clear is whether people with advanced liver disease experience improvements in liver function, or if severe liver damage in the form of decompensated cirrhosis is irreversible despite hepatitis C cure.

The Italian Platform for the study of viral hepatitis therapy (PITER) is a multicentre cohort that follows previously untreated people with hepatitis C. The cohort includes people co-infected with hepatitis C and HIV.

To assess outcomes of people with cirrhosis, PITER researchers identified all cohort members recruited between 2015 and 2019 who had cirrhosis prior to treatment and who were cured of hepatitis C after direct-acting antiviral treatment (defined as sustained virological response 12 weeks after completion of treatment).

The study compared outcomes in people with hepatitis C alone or hepatitis C and HIV co-infection after approximately two years of follow-up.

Eighty-five per cent of co-infected people and 64% of monoinfected people experienced an improvement in cirrhosis, defined as a change in Child-Pugh class (from C to B or from B to A) during the follow-up period.

In most cases, cohort members experienced improvement from Child-Pugh stage B to stage A (16 out of 20 co-infected people and all monoinfected people who experienced improvement).

Approximately 10% of each group of patients experienced a decompensating event after completing direct-acting antiviral treatment, most commonly ascites, hepatic encephalopathy or gastrointestinal bleeding. Just under half of those who experienced decompensation (46%) had a previous history of liver decompensation, showing that people with decompensated cirrhosis remain at higher risk of liver disease progression after being cured of hepatitis C.

Worsening of cirrhosis, measured by change in Child-Pugh status, was associated with male sex, platelet count below 100,000ul or increased International Normalised Ratio (INR measures blood clotting; people with a higher INR are at increased risk of haemorrhage).

The study investigators say, “Our findings confirm the existence of a point of no return after which antiviral treatment may be too late to influence the natural history of HCV-related liver disease.”

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Australia’s model of universal access to direct-acting antiviral treatment for hepatitis C has been especially successful in treating recent drug users, the group most critical to reach for the elimination of the virus, an analysis of treatment uptake in New South Wales shows.

The findings are published in the Journal of Hepatology.

Australia made direct-acting antivirals available through general practitioners and specialist clinics for all people with hepatitis C from March 2016. To assess how well direct-acting antiviral treatment had reached people who inject drugs – a key group for hepatitis C elimination in Australia – researchers carried out an analysis of treatment uptake among people with a history of injecting drug use in the state of New South Wales.

To identify people with hepatitis C and a history of injecting drug use, the researchers linked recorded hepatitis C diagnoses since 1993 to death records and records of hospitalisation for a drug-related cause such as overdose since 2001, as well as registrations for opioid substitution therapy since 1985 or imprisonment for a drug-related offence since 1994.

They compared treatment uptake in people who were recent drug users with uptake in people who had no history of drug use or who used drugs prior to 2016. They found that 47% of recent drug users started treatment, compared with 38% of those with distant drug use (prior to 2016) or no history of drug use (33%).

People with HIV who were recent drug users and co-infected with hepatitis C were around 70% more likely to start direct-acting antiviral treatment compared to other recent drug users.

The researchers say that differences in uptake of treatment may be explained by engagement with healthcare services. Whereas people with hepatitis C and HIV co-infection had higher uptake of treatment, women and indigenous Australians had lower treatment uptake.

The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) and the National Viral Hepatitis Roundtable (NVHR) has released a new progress report detailing the changes to hepatitis C treatment access in Medicaid programmes since first publishing an analysis in 2017. The Hepatitis C: State of Medicaid Access May 2021 National Progress Report demonstrates that while there is better access to hepatitis C virus (HCV) treatment today, discriminatory practices persist in some state Medicaid programmes. In particular, sobriety restrictions – required periods of abstinence from alcohol and/or substance use – continue to undermine public health efforts to eliminate hepatitis C in the US.  

“State Medicaid programs have made tremendous progress in five years in removing barriers to treatment, particularly with fibrosis restrictions. However, discriminatory restrictions remain in several states, and continue to undermine our collective efforts to address both hepatitis C and the growing opioid epidemic,” said Phil Waters, Staff Attorney at CHLPI.

“The sobriety restrictions remain the most pressing and widespread barrier to accessing HCV treatment at a time when the opioid crisis has fostered a new wave of HCV infections among younger people who inject drugs and whose needs are ill-served by sobriety restrictions,” said Adrienne Simmons, Director of Programs at NVHR. “A generation struggling to survive the overdose crisis will face long-term health consequences from HCV if Medicaid policies are not revised to facilitate access to treatment now.”

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