Union states are far from reaching the global targets towards hepatitis
C elimination, especially on harm reduction, testing and treatment, Dr
Erika Duffell of the European Centre for Disease Control (ECDC) told the
18th European AIDS Conference (EACS 2021) last week.
In 2016, the World Health Assembly agreed global targets
for elimination of viral hepatitis as a public health problem by 2030.
The targets aim to eliminate viral hepatitis by reducing new viral
hepatitis infections by 90% and reducing deaths due to viral hepatitis
by 65% by 2030.
Dr Duffell reviewed progress on elimination of hepatitis C, the predominant hepatitis virus in the European region.
- decompensated cirrhosis
The later stage of
cirrhosis, during which the liver cannot perform some vital functions and
complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.
ECDC estimates that 3.9 million people were living with hepatitis C
in the European Union, United Kingdom, Iceland, Liechtenstein and Norway
in 2015, around 6% of the global burden of hepatitis C (71 million).
Hepatitis C prevalence in the region is highly concentrated among
several key populations, notably people who inject drugs. Estimates of
prevalence among people who inject drugs range from 15 to 64% across
various countries of the region. High hepatitis C prevalence has also
been reported in people in prisons in some countries. Prevalence is also
high in men who have sex with men, especially those living with HIV
(1-5%), and in migrants (1-17%).
Measuring progress towards elimination in the region is challenging
due to lack of data collection or national targets for elimination in
some countries, Dr Duffell observed. In 2020, the majority of countries
in the region still lacked up-to-date estimates of how many people are
living with hepatitis C.
On blood safety, the region is making progress towards achieving
targets for not remunerating blood donors (21 countries have achieved
this target) and nucleic acid testing of blood donations (14 countries
have achieved this target). But eight countries in the region were
unable to report whether their blood donation systems had eliminated
paid blood donation in 2016, illustrating the information gap in
under-funded health systems.
Harm reduction coverage remains weak. By 2019, only three countries
had achieved the target of distributing 200 syringes per drug user per
year, while eleven countries had failed to achieve this level of
coverage. Only nine countries reported that they had hit the target of
providing opioid substitution therapy to 40% of high-risk opioid users.
Only two countries – Luxembourg and Norway – had reached both these
targets by 2019. Spain, Belgium and the Czech Republic were close to
achieving both targets.
Data on the cascade of care remains limited. Less than
half of countries in the region are able to report hepatitis C diagnoses
for 2020. Although slightly more countries are able to report how many
people were treated for hepatitis C in 2020, fewer than ten can report
how many treated people achieved a sustained virologic response after
Only four countries in the region – France, Ireland, Italy and Sweden
– were estimated to have diagnosed more than half of people living with
hepatitis C by 2020. The prevalence of undiagnosed cases is especially
high in Romania and Greece. Hepatitis C prevalence in Romania may be as
high as 3%.
“COVID has shown what can be done on testing at a large scale and we
need to channel some of that innovation into testing for hepatitis C,”
said Dr Duffell.
Although testing in harm reduction services and prisons
is now routine in most European countries, testing is still not offered
in prisons in several countries including Romania, Latvia and Greece.
Another site that could be critical for diagnosing new cases is also
being under-utilised; in 2019, only eight countries reported that more
than half of people entering drug treatment facilities were tested for
hepatitis C in the previous year.
Data are also lacking on late diagnosis. Only five countries were
able to supply data in 2020 on hepatitis C diagnosed at the stage of
decompensated cirrhosis or hepatocellular carcinoma. These estimates
varied from 5 to 27% of all diagnosed cases.
Data on changes in hepatitis C incidence and prevalence are also
lacking for most countries. Studies of incidence have been largely
confined to people who inject drugs and no country in the region has
evidence of a significant reduction in hepatitis C transmission among
people who inject drugs between 2015 and 2019. Greece and Italy are the
only countries to report marked reductions in hepatitis C antibody
prevalence among people who inject drugs. In most other countries,
prevalence has remained stable.
The European region is unlikely to achieve the elimination target of a
65% reduction in liver-related deaths by 2030 at the current rate of
progress, according to ECDC projections. In 2015, ECDC estimates that
64,000 people with hepatitis C died of liver-related causes. To reach
the 2020 target, deaths need to decline to 22,400 per year by 2030. But
deaths due to liver cancer are still increasing.
Countries in the region need to make substantial investments in
epidemiology and monitoring to understand their national epidemics, as
well as scaling up harm reduction, testing and treatment, she concluded.