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London needs to step up the rate of testing for hepatitis C if it is to achieve elimination of hepatitis C, Professor Graham Foster of Queen Mary University London told the London Joint Working Group on Substance Use and Hepatitis C conference on hepatitis C elimination in London this week.

Although NHS England has exceeded its hepatitis C treatment target – "no other European country has achieved that", said Professor Foster – expanded testing is the key to elimination, he said.

"We need to find people who started using drugs 30 or 40 years ago and don’t know they have it and are in real trouble – we need to start doing general practitioner testing," he said. Professor Foster also endorsed greater promotion of online self-testing services as a way of reaching people with a history of injecting drug use.

London’s experience as it works towards elimination of hepatitis C may be relevant for other cities in several areas:

• Screening of migrants: 58% of people diagnosed with hepatitis C in west London were born abroad – but they come from 104 countries. Targeting screening efforts at people from specific countries may miss hepatitis C in many migrants.
• Peer outreach has been 'transformative' in engaging people who use drugs and homeless people in hepatitis C care, said Professor Foster. Peer outreach may require multiple contacts before people are ready to engage. Part of the work of peer outreach is to make hepatitis C a higher priority for clients. This takes time, said Rob Allan of the Hepatitis C Trust.
• Micro-elimination of hepatitis C in prison populations requires co-operation between prison health services, prison staff, peer support groups and health services outside prisons. NHS England aims to test and treat the populations in 30 prisons over the next year. At least eight prisons in England have already achieved elimination and are screening and treating all new inmates, Mark Gillyon-Powell of NHS England reported.

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 found.

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 C.

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.

Overall, 74% of service users accepted screening. The high frequency of previous hepatitis C diagnosis recorded in this study (66%, 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.

Intensive peer support during engagement with hepatitis C care was associated with a high level of engagement in care among vulnerable people including recently homeless people and people who inject drugs in London, HepCare Europe researchers report in the Journal of Antimicrobial Chemotherapy.

The evidence comes from the London arm of the HepCare study, which investigated screening methods to improve linkage to care for people diagnosed with hepatitis C. The London arm was designed to study the impact of specialist outreach to vulnerable groups including the homeless and people who use drugs. This outreach work included the use of peer support.

Four hundred and sixty-one people were screened in London between 2016 and 2018. Over half were recently homeless (59%), 78% were male and the median age was 45 years. More than half reported a previous positive antibody test but were disengaged from care, 92% had a previous history of injecting drug use, 33% were currently injecting and 73% were receiving opioid substitution therapy.

A high proportion of those tested had chronic hepatitis C infection (42%). Eighty-nine per cent were referred to specialist care (the remainder were either lost to follow-up or already in care). Just over half (104, 52%) attended two appointments, underwent Fibroscan and had blood tests to assess fibrosis.

Hepatitis C elimination among gay and bisexual men depends on diagnosing and treating the infection in two populations, HIV-positive and HIV-negative men. Whereas HIV-positive men should receive regular screening according to European or British HIV Association guidelines – and are covered by national targets for hepatitis C diagnosis and treatment designed to eliminate hepatitis C in people living with HIV by 2021 – screening in HIV-negative gay and bisexual men is not systematic and the optimum interval is not defined.

Increasing the frequency of hepatitis C screening in gay and bisexual men taking pre-exposure prophylaxis (PrEP) in the United Kingdom has the potential to reduce new hepatitis C infections in the UK by 2030, especially if the proportion of men taking PrEP increases to 25%, researchers report in the journal EClinical Medicine.

The University of Liverpool’s HEP Drug Interactions Checker website serves as a reference for clinicians and researchers, as well as a patient education tool. The website allows users to check interactions between direct-acting antivirals and numerous medications.

Filter, the harm reduction news website, reports that the HEP Drug Interactions Checker has added heroin, carfentanil, alcohol and cannabidiol (CBD) to the list of drugs that can now be checked against hepatitis C drugs, in response to requests from site users and in line with its mission to offer free, evidence-based drug information.

Hepatitis C is common among homeless people, who may have a history of injecting drug use or other risk factors for the infection. As the HepCare study in London has shown, it is possible to engage homeless people with hepatitis C in care through peer-led interventions, but adherence to direct-acting antiviral treatment may be difficult for people who have nowhere secure to store medication. In some settings, the lack of a secure place to store medication can make people ineligible for treatment.

CBS Miami reports that a University of Miami scheme is now providing secure medication lockers for people enrolled on hepatitis C treatment. The scheme is part of the University of Miami’s Infectious Disease Elimination Act (IDEA Exchange), the only needle and syringe programme in the state of Florida.

Patients who were transplanted with hearts from hepatitis C-positive donors had comparable outcomes after one year to patients who received hearts from donors that didn't have the disease, according to a Vanderbilt University Medical Center study published in JAMA Cardiology.

The Vanderbilt Transplant Center in Tennessee, US is believed to be the largest user of hepatitis C-positive donor organs in the world, the study notes. Vanderbilt University Medical Center has greatly expanded the use of such hearts to patients since 2016 because of the proven efficacy of direct-acting antiviral therapies, which can cure hepatitis C infection in patients after 12 weeks of treatment.

Between 2016 and 2018, 37% of Vanderbilt's heart transplants were from hepatitis C-positive donors, a factor in allowing Vanderbilt to double the number of heart transplants, from 130 between 2013 and 2015 to 260 between 2016 and 2018. Vanderbilt is now the second-largest heart transplant programme by volume in the country.

As more organs become available, time on waitlists decreases. In the cohort of patients described in Vanderbilt's study, mean wait time once patients agreed to receive a hepatitis C-positive heart was only four days, compared with national reported median wait times between 70 and 535 days.

Egypt Independent reports that 1.6 million school students and 389,000 university students have been screened for hepatitis C over the past year as part of the nation’s 100 Million Healthy Lives screening programme. The screening programme is also offering tests for other diseases, including breast cancer screening for women.

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