To
eliminate hepatitis C in people with HIV in Scotland, healthcare
providers will need to reach people not on HIV treatment and step up
testing for hepatitis C in people who inject drugs, an analysis of
Scottish surveillance data published in HIV Medicine shows.
Scotland has a high prevalence of hepatitis C among people with HIV,
mainly due to sharing of injecting equipment. As in other European
countries, people with HIV are an important group for focused efforts to
eliminate hepatitis C – micro-elimination – because of the high rates
of HIV diagnosis and engagement in care.
In 2018, the British HIV Association (BHIVA) set the target to cure
hepatitis C in 80% of people with HIV by 2019 and all people with HIV by
2021.
However, few studies have looked systematically at
hepatitis C diagnosis and treatment in the entire population of people
with diagnosed HIV, including those not on treatment or disengaged from
care. Disengagement from HIV or hepatitis care and lack of screening are
major obstacles to curing hepatitis C in everyone with HIV.
Allan McLeod and Sharon Hutchinson of Health Protection Scotland,
working with hepatitis and HIV specialists in Scotland, carried out an
investigation of everyone diagnosed with HIV in Scotland to establish
whether they had been tested for hepatitis C, offered treatment or cured
of hepatitis C.
People with HIV were identified through the national HIV surveillance
database to the end of 2017 and matched with available hepatitis C
testing data reported since 2000 in the four major health regions of
Scotland. Five thousand and eighteen people had been diagnosed with HIV
and remained in Scotland.
The study population was 72% male and 76% White. People
who had acquired HIV through injecting drug use made up 11% of the
cohort, gay and bisexual men 45%, and heterosexual men and women 39%.
Over half the study population (56%) lived in the most socially deprived
districts in Scotland.
Twelve per cent had a recorded diagnosis of hepatitis C.
Information on hepatitis C testing history was available for 2939
people living in four regions where testing had been carried out
systematically since 2000. Twenty per cent had not been tested for
hepatitis C between 2000 and 2017 and people who were not on HIV
treatment were seven times more likely than those on treatment to be
untested for hepatitis C (adjusted odds ratio 7.21 [95% CI 5.15-10.10].
Never testing for hepatitis C was also associated with
HIV diagnosis in a GUM clinic (aOR 3.44, 2.68-4.40), with 'other'
ethnicity (aOR 3.46, 2-10-5.70) and living in the least deprived areas
(aOR 1.83, 1.33-2.52).
Based on these findings, the researchers estimate that 16% of the
full cohort had never been tested for hepatitis C and that approximately
100 people with hepatitis C remained undiagnosed, predominantly people
who inject drugs.
Of those who tested positive for hepatitis C (12% of the study
population), 79% had chronic hepatitis C infection and almost all (91%)
had attended a hepatitis C treatment clinic. Two-thirds had been treated
at least once for hepatitis C and of these, 85% had been cured.
However, one in three had never been treated for hepatitis C.
Again, those not on HIV treatment were more likely not to have been
treated for hepatitis C (aOR 3.60, 1.59-8.15), as were people who inject
drugs (aOR 2.09, 1.04-3.78) and people living in the most deprived
districts (aOR 2.64, 1.04-6.71).
Overall, the researchers estimate that 42% of those with hepatitis C
in the study population had been cured by the end of 2017, far short of
the BHIVA target of 80% cured by 2019.
The study authors emphasise the importance of following BHIVA
guidance to test people with HIV at highest risk of hepatitis C exposure
at least twice a year and to test everyone diagnosed with HIV for
hepatitis C at least once.
To achieve BHIVA's micro-elimination targets, uptake of hepatitis C
treatment needs to be improved, say the authors. Co-location of
hepatitis C treatment clinics within other specialist services such as
drugs services could improve uptake, as could streamlined referral
pathways between HIV services and hepatitis C treatment services.
But the finding that people not being treated for HIV were also much
more likely to be untreated for hepatitis C indicates that people more
likely to be disengaged from HIV care, including the homeless and people
who inject drugs in public places, need to be engaged in care by
services designed to reach them. Healthcare
workers in Glasgow have been engaged in intensive outreach to homeless
people and street drug users to tackle a major outbreak of HIV among
people who inject drugs in the city. Similar approaches tailored to the
local population may be needed in other regions of Scotland.