The World Health Organization (WHO) has called for greater commitments to scale up hepatitis C virus (HCV) testing and treatment services to people who inject drugs and people in prisons.

In an analysis released to coincide with the Harm Reduction International conference in Porto, Portugal, WHO reported that people who inject drugs are still overlooked in more than a third of national hepatitis plans, and the needs of people in prisons are overlooked in two-thirds of national plans.

Furthermore, even when services are planned, they may still impose restrictions such as abstinence from drug use to be eligible for treatment or may require health insurance coverage to obtain treatment.

WHO says that approximately 400,000 people who inject drugs acquire hepatitis C each year, out of an estimated global total of 1.75 million new infections per year.

Scale-up of harm reduction services proven to reduce the risk of acquiring hepatitis C – needle and syringe programmes and opioid substitution therapy – must form a major part of hepatitis C prevention among people who inject drugs, says WHO.

The WHO policy brief stresses the importance of addressing structural barriers such as criminalisation of drug use to improve access to treatment.

WHO also highlights several examples of national plans that have prioritised testing and treatment for people who inject drugs:

• Australia recently published its fifth national strategy (2018-2022) on the path to hepatitis elimination by 2030. The country used a simplified approach to service delivery, integrating hepatitis testing, treatment and harm reduction for people who inject drugs at decentralised sites, and engaging peer workers and general doctors. Concerted implementation of HCV testing and treatment in several prisons shows elimination in these settings is possible.

• India launched a national action plan to combat viral hepatitis in February 2019, targeting people who inject drugs as a priority population, aiming to provide 1,000,000 direct-acting antiviral treatment courses annually over the next 3 years.

• The Islamic Republic of Iran has a 3-year national hepatitis plan that proposes interventions for people who inject drugs and people in prisons. Direct-acting antivirals can be obtained for as little as US $81, but only for people with health insurance. Many people who inject drugs and people in prisons without insurance face a higher cost of US$ 2200.

• Ukraine is developing a national strategy to contain tuberculosis, HIV and viral hepatitis. Generic direct-acting antivirals are now available for less than US$ 100. Effective collaboration with the Ministry of Justice enabled HCV testing for 1000 people in prisons living with HIV in 2018. Of these people, 50 were treated with direct-acting antivirals achieving a 98% completion rate.

Bulevirtide, formerly known as Myrcludex B, led to suppression of hepatitis delta virus (HDV) and a functional cure of hepatitis B virus (HBV) in some people with both viruses when combined with pegylated interferon-alfa-2a, according to a presentation at the 2019 International Liver Congress held in April in Vienna.

Hepatitis delta is a defective virus that can only replicate in the presence of HBV. Over years or decades, chronic hepatitis B can lead to advanced liver disease including cirrhosis, liver cancer and end-stage liver failure. Liver disease progression is more aggressive in people with HBV/HDV co-infection than in those with HBV alone.

There is currently no approved therapy for HDV, though it is sometimes treated with pegylated-IFN-alfa.

The phase 2b study compared bulevirtide alone or in combination with pegylated IFN-alfa, given for 48 weeks, in 60 participants. At the end of the treatment period 60% taking the 2mg bulevirtide combination and 40% taking the 5mg combination achieved undetectable HDV RNA compared to 13% in the bulevirtide-only arms.

At 72 weeks, eight (53%) and four (27%) people in the respective combination arms still had suppressed HDV, but no one in the monotherapy arms had sustained suppression. Looking at both combination arms together, 27% had HBsAg loss and 20% experienced seroconversion, considered a functional cure, according to Dr Heiner Wedemeyer. No one taking either monotherapy had HBsAg loss or seroconversion.

Testing rates for hepatitis C virus (HCV) in prisons in the United Kingdom remain far below the national minimum target of 50% and without radical change, prison testing rates will pose a major barrier to the elimination of hepatitis C in the UK, researchers from the University of Nottingham warn in a study published in the Journal of Viral Hepatitis.

The researchers say they found wide variations in how opt-out testing was presented to people in prison and substantial variation in understandings among prison staff of what an opt-out testing policy meant.

But the research group concludes that the biggest barrier to improved uptake of testing is prison infrastructure. “Most prisons are not equipped in terms of staff or space to deal with the increased workload that a 50% testing target would engender.”

The US Food and Drug Administration (FDA) has approved Mavyret (glecaprevir/pibrentasvir, marketed elsewhere as Maviret) as the first pangenotypic treatment for hepatitis C for children and adolescents aged 12 to 17 years. It is estimated that there are 23,000 to 46,000 children in the US with hepatitis.

NHS England has announced details of an agreement to purchase direct-acting antivirals to treat hepatitis C with three pharmaceutical companies.

According to PM Live, the tendering exercise has reduced the cost per hepatitis C treatment from approximately £35,000 per year to around £10,000 per year.

NHS England has also ranked the three companies bidding for contracts to supply drugs in terms of the value for money that they offered, not only on price but also on activities designed to improve rates of diagnosis. Gilead was ranked 'gold', Merck Sharp and Dohme was ranked 'silver' and AbbVie was ranked 'bronze'.

The three companies will work with local health authorities, local government and civil society organisations to promote hepatitis C testing and engagement in care.

NHS England aims to diagnose and treat everyone with hepatitis C by 2030 in line with World Health Organization targets for hepatitis C elimination. NHS England estimates that 113,000 people are living with hepatitis C in England and approximately 69% are undiagnosed.

NHS England has written to all general practitioners in England to encourage them to test more people for hepatitis C. The letter was issued as a result of the National Infected Blood Inquiry, which is investigating the circumstances in which people became exposed to blood products containing hepatitis C in the 1980s and early 1990s. Testing of blood products for hepatitis C began in the United Kingdom in 1991. NHS England says that 1% of all blood transfusions given to people in the United Kingdom prior to 1991 “could have contained an infected agent such as hepatitis C.”

The letter suggests that doctors “should consider asking patients who present with nonspecific symptoms whether they may have had blood or blood products prior to 1991.”

How many people will be aware they received blood products so long ago? The letter suggests childbirth or road traffic accidents may have led to the use of blood products but more detailed information for patients might prompt more people to request a test for hepatitis C.

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