Hepatitis C screening programmes targeting the homeless,
people who inject drugs and prisoners achieved linkage to specialist care in
over 80% of people diagnosed with hepatitis C, a four-country European study
The study findings are published in a special supplement of
the Journal of Antimicrobial
The HepCheck study was carried out in Ireland, Romania,
Spain and the United Kingdom on various dates between 2016 and 2018. The pilot
study was designed to investigate the feasibility of intensified hepatitis C
screening and linkage to care for people who inject drugs. HepCheck was part of a larger project funded by a grant from the
European Commission to investigate models of care that can link primary, secondary
and community care and outreach services for populations at risk of hepatitis
A non-invasive test, used instead of a biopsy, to measure the stiffness
or elasticity of the liver using an ultrasound probe.
The study was designed to enhance screening activities in a
variety of specialised settings – prisons, drug and alcohol clinics and
homeless outreach services – by providing multidisciplinary support to the
services. Point-of-care testing was used at all sites to offer rapid diagnosis,
either oral swab or fingerprick blood sampling.
People diagnosed with hepatitis C received confirmatory
testing for chronic hepatitis C infection and wherever possible,
community-level Fibroscan screening to assess liver fibrosis. All people
diagnosed with hepatitis C were referred for specialist care. Treatment was
prescribed according to national guidelines.
The main prison screening programme took place in Dublin, Ireland,
where an on-site methadone clinic in one of the city’s prisons served as the
venue for a mass screening programme publicised within the prison by a volunteer
organisation that provides peer support to prisoners. A total of 425 people volunteered
Screening was also carried out in a drug and alcohol clinic
and two services for homeless people in Cork where medical services and
methadone clinics are provided by a visiting multidisciplinary team. A single
screening day was publicised by staff and outreach workers; 193 people
volunteered for testing. Overall, 10% of people tested had chronic hepatitis C
infection and just over half had not been diagnosed previously.
In London, screening was offered at 61 sites providing
health care for homeless people across the city, including drug treatment centres
and drop-in centres. Screening was publicised at the participating sites; 461
volunteered for testing. Overall, 43% had chronic hepatitis C infection but only 19 out
of 197 were new diagnoses.
In Bucharest, Romania, screening was offered at addiction
clinics, homeless shelters and two prisons. Screening was publicised by doctors
and by non-governmental organisations working with vulnerable populations in
Bucharest. A total of 513 people volunteered for screening. 9.2% had chronic hepatitis C infection
and almost all (41 of 47) were new diagnoses.
In Seville, Spain, screening was offered through a variety
of services where service users were at high risk of acquiring hepatitis C. Four hundred and ninety
people volunteered for screening, 19% had chronic hepatitis C infection and just under
half (39 of 91) were new diagnoses.
Overall, 74% of service users accepted screening. The high
frequency of previous hepatitis C diagnosis recorded in this study (79%,
strongly influenced by outcomes in London) “shows the importance of screening
not only to identify new cases but also to identify previously known cases and
link them into the cascade of care,” the study investigators concluded.
The investigators suggest that previously diagnosed people
may have been lost from care because of the need for further clinic visits to
diagnose chronic hepatitis C infection.
“To be able to go to the patient, diagnose them in the
community, give them a timely diagnosis and immediately offer them treatment,
eliminates the lost-to-follow up problem encountered historically in these
patients,” the investigators conclude, looking forward to the wider availability
of point-of care tests that can diagnose chronic hepatitis C infection within two hours
and pan-genotypic direct-acting antivirals that can be dispensed to all.
Eighty per cent of people diagnosed with chronic hepatitis C infection
(including previously diagnosed people) were successfully linked to care,
defined as Fibroscan screening for liver fibrosis and referral for specialist
care. Further data on treatment uptake will be described in a separate article.