France switches to simplified pangenotypic hepatitis C treatment

French health authorities have recommended that everyone diagnosed with hepatitis C should be treated with a pangenotypic direct-acting antiviral combination by a general practitioner unless they have severe liver disease, co-infection or kidney disease and need to be referred to a liver specialist.

The new guidance is intended to simplify testing and treatment initiation and speed progress towards the target of eliminating hepatitis C in France by 2030. The guidance has been issued by the Haute Autorité de Santé, the French national authority for health technology assessment and development of healthcare guidelines.

The guidance recommends that everyone who has been at risk of hepatitis C exposure should be tested for hepatitis C.

The Haute Autorité de Santé says that recommendations for testing are likely to change after a heath economic assessment is completed. A cost-effectiveness study by Sylvie Deuffic-Burban and colleagues found that universal screening was the most cost-effective strategy for France if everyone was treated immediately, regardless of liver disease stage.

Everyone who tests positive for hepatitis C antibodies should be tested for chronic HCV infection using an RNA test. Everyone diagnosed with chronic infection should be assessed for:

• liver fibrosis (using blood tests or Fibroscan)
• alcohol consumption
• overweight or obesity, diabetes, metabolic syndrome
• HBV and/or HIV co-infection
• severe renal insufficiency.

All patients with high alcohol consumption, obesity, metabolic syndrome or diabetes, severe renal insufficiency (estimated glomerular filtration rate eGFR < 30 ml / min / 1.73 m²), a prior history of hepatitis C treatment or co-infection with hepatitis B or HIV, or with severe liver disease should be referred for specialist management.

All other patients should be managed by the general practitioner. HCV genotyping is not necessary. Anyone diagnosed with hepatitis C who does not need specialist care can be treated with either:

• Epclusa (sofosbuvir / velpatasvir) for 12 weeks
• Maviret (glecaprevir / pibrentasvir) for 8 weeks.

HCV RNA testing is recommended only at the time of diagnosis and 12 weeks after the completion of treatment to check for sustained virologic response.

A study published in 2014 estimated that approximately 74,000 people with chronic hepatitis C infection were undiagnosed in 2014. In 2014, the French Viral Hepatitis Testing Experts group recommended a one-time test for HIV, hepatitis B and C for all men aged 18-60 and all pregnant women.