Liver-related deaths and liver transplants due to hepatitis C are continuing to decline in England as the number of people treated with direct-acting antivirals (DAAs) rises, according to Public Health England’s annual hepatitis C report, released last week.
Public Health England estimates that deaths from hepatitis C-related end-stage liver disease or hepatocellular carcinoma fell by 3% between 2014 and 2016. During the same period, liver transplant registrations fell by 43% and transplants fell by 25% in people with cirrhosis of the liver as a consequence of hepatitis C.
In comparison, deaths from hepatitis C-related end-stage liver disease almost doubled between 2005 and 2014 in England and transplant registrations and operations remained stable between 2008 and 2014.
Public Health England says that year-by-year increases in the number of people treated with DAAs to cure hepatitis C may be starting to have an impact on mortality and transplant demand. Furthermore, prioritisation of people with cirrhosis for DAA treatment together with expanded access to treatment is likely to lead to a sharp decline in the number of people with cirrhosis due to hepatitis C in the next decade, according to modelling published in 2016.
NHS England set a target of treating 10,000 people for hepatitis C using DAAs in 2016/17, 12,500 in 2017/18, 13,000 in 2018/19, 14,000 in 2019/20 and 15,000 in 2020/21.
To achieve these rates of treatment, Public Health England says that diagnosis of hepatitis C needs to improve. In its report, Public Health England points to improvements in testing across all groups with a higher prevalence of hepatitis C. Overall, testing is estimated to have increased by 24% between 2012 and 2016. In people of South Asian or Eastern European origin, testing has risen by 27% and 52% respectively between 2012 and 2016. (Of note, 3.2% of people of Eastern European origin tested positive for hepatitis C virus (HCV) antibodies during this period, although Public Health England is unable to determine whether this represents evidence of higher prevalence or better targeting of test offers.) Testing has also increased among new entrants to English prisons.
Despite an increase in testing activity, a national anonymised surveillance survey conducted in 2016 found that only half of people with HCV infection who had ever injected drugs were aware of their HCV infection. The same survey found that 54% of people currently injecting drugs had hepatitis C antibodies in 2016. Public Health England recommends that testing should be extended in drug prevention services, including through the use of dried blood spot testing, and that service commissioners and providers should consider introducing opt-out testing for bloodborne viruses in drugs services.
Educating professionals and the public about hepatitis C and guidance for HCV testing will continue to be important measures for ensuring diagnosis and access to treatment, but there may also be a pool of people already diagnosed who are unaware of the availability of well-tolerated DAA treatment. Public Health England will be providing details of everyone previously diagnosed with hepatitis C so that NHS England can offer assessments for treatment.
Reducing new infections remains a significant challenge, says Public Health England. New HCV diagnoses in young adults are a proxy measure of new infections. Surveillance in England shows a slight increase in the proportion of new injectors (less than three years injecting history) with HCV antibodies since 2005 and only a modest reduction in the proportion of young adults (24 and under) testing positive for HCV antibodies since 2012.
Improving needle and syringe programme coverage, reducing the sharing of injecting equipment, increasing drug treatment rates and increasing awareness of HCV status among people who inject drugs will all be necessary in order to reduce HCV incidence.