How Iceland Slashed Hepatitis C Infections

A treatment-as-prevention approach helped Iceland become the first high-income country to achieve World Health Organization (WHO) targets for diagnosis and treatment of hepatitis C, according to a population-based study.

From 2016 to 2019, 95.3% of participants diagnosed with hepatitis C virus (HCV) infections were linked to healthcare and 96.5% of participants started treatment, reported Sigurdur Olafsson, MD, from the National University Hospital of Iceland in Reykjavik, and colleagues.

In addition, 90.2% of participants who started treatment reportedly achieved a cure for HCV, the group wrote in The Lancet Gastroenterology & Hepatology.

"This great achievement is a milestone in the effort towards global HCV elimination," said Olav Dalgard, MD, PhD, of Akershus University Hospital in Norway, and colleagues, writing in an accompanying editorial.

The editorialists noted that the WHO service targets mean 90% of cases are being diagnosed and 80% of diagnosed cases are being treated. Hepatitis C elimination, which no country has achieved, is defined as 80% reduction in incidence and 65% reduction in HCV-related mortality compared to a 2015 baseline, they said.

Hepatitis C has been a growing concern worldwide, affecting over 71 million people, causing cirrhosis and even liver cancer. The study authors noted that among high-income countries in 2019, only 11 were progressing towards WHO elimination targets. Georgia was the first country to start the program, but has yet to meet the necessary goals. Olafsson's group added that the U.S. has also yet to meet the goals due to its socioeconomic barriers, health insurance requirements, a lack of diagnosed cases, and overall fragmented healthcare system.

They characterized Iceland as an "ideal setting" for epidemiological research, citing its central registries for infectious diseases, its low threshold for treating addiction, and its national healthcare system.

From February 2016 to February 2019, the Treatment as Prevention for Hepatitis C (TraP HepC) program took place in Iceland and included adults who had chronic HCV infection. Another focus of the program was providing sterile needles as a means of harm reduction for injection drug users.

HCV infections were confirmed by lab testing with PCR, and patients were started on direct-acting antiviral therapy consisting of ledipasvir-sofosbuvir (Harvoni) through October 2016, and velpatasvir-sofosbuvir (Epclusa) thereafter. As early as January 2017, the researchers estimated that over 90% of all HCV infections were diagnosed.

Participants were identified through a registry and injection drug users were prioritized for treatment. Prisoners were also treated. Cure was defined as testing negative for RNA HCV at 12 weeks or more after treatment ended.

When the program started, researchers estimated that 760 people had HCV infections (95% CI 690-851), including an estimated 75 who were undiagnosed (95% CI 6-166).

Among the 703 patients with demographic data who initiated a first treatment course, the median age was 45 years and two-thirds were men.

During the program, there were 183 new infections diagnosed, with 42 being reinfections. Therefore, among a total of 823 individuals, 865 infections were reported.

A little over half of participants had HCV genotype 3a and about 5% had an HIV coinfection. Injection drug use was reported in 84.1% of participants (mostly cocaine or stimulants) with 33% having recently injected drugs within 6 months.

In their editorial, Dalgard and colleagues proposed targeting drug users who inject drugs, since in many countries, they are the ones driving the HCV epidemics.

"It is likely that few countries will be able to provide data to show that the WHO elimination targets have been achieved even when the disease actually has been eliminated. This is mainly because reduction in incidence is difficult to measure, requiring repeated surveillance in large cohorts of people who inject drugs," wrote Dalgard and colleagues.

"In our view, each country should define HCV elimination pragmatically and in a way that is possible to document," they added. "HCV-related hepatocellular carcinoma is usually notified, and therefore a 65% reduction in this complication should be documented to strengthen the claim of HCV elimination."

Olafsson told MedPage Today separately that he was surprised by the large number of participants who had been actively or recently injecting drugs and that this should be accounted for in future research.

"It will be important to investigate different approaches to reduce the risk of reinfection and [analyze] the challenges when you have cured most patients and are left with a relatively small group of HCV infected patients who are actively injecting drugs and are difficult to engage in care," he said.

Limitations included the estimated quantity of HCV infections by using a population screening method. HCV infections may have also been underrepresented, since this study excluded temporary visitors or all others not given permanent residence. Iceland also has a small population.

"Our work shows that using multidisciplinary and public health approaches and focusing on people who inject drugs, the care cascade can be greatly improved, and the large majority of patients with HCV infection can be diagnosed and treated with direct-acting antiviral agents," Olafsson and co-authors concluded.

Comment