The hepatitis C virus (HCV) is a blood-borne flavivirus causing liver infection in humans, which exhibits 55% to 85% chronicity after initial acute infection.1 Left untreated a significant percentage of those with chronic HCV will go on to develop liver cirrhosis and hepatocellular carcinoma (HCC).1 In the UK, HCV disproportionately affects marginalised populations, with past or present injecting drug use being the most important risk factor. Around half of people who inject, or have injected drugs (PWID) across the UK are estimated to be HCV antibody positive, with around a quarter having active infection.2,3 Sexual transmission of HCV is rare among heterosexual partners,4 but presents a growing concern in communities of HIV-positive men who have sex with men (MSM), and HIV-negative MSM using pre-exposure prophylaxis (PrEP) for HIV.5 Other under-served populations at increased risk of HCV include those in prison, the homeless, and communities who have close links to countries where HCV is endemic.
HCV is now a largely curable disease. The advent of direct acting antiviral (DAA) therapy in 2011 has progressively transformed the treatment of HCV beyond recognition. The pre-DAA treatment regimens involved prolonged and toxic treatment courses with limited success and the need for a high degree of monitoring. DAA therapies are short, safe, oral treatment courses achieving over 95% viral elimination rates.6 At the time of approval for use in the UK by the National Institute for Health and Care Excellence (NICE), DAAs for HCV were some of the most expensive drugs ever licenced; deemed to be cost effective due to the huge health and economic burden of chronic HCV-related liver cirrhosis, liver cancer, liver transplant, and liver mortality. DAA costs have decreased dramatically in recent years, and they are now the first-line treatment for HCV in the UK.
WORKING TO ELIMINATE HCV AS A PUBLIC HEALTH THREAT
The shift in framing HCV as a difficult to manage chronic disease towards a curable infection has transformed global health policy in this area. In May 2016 the World Health Organization (WHO) set an ambitious new global target towards the elimination of viral hepatitis as a major public health threat by 2030.7 The latest UK government report from Public Health England (PHE), although cognizant of the impact of COVID-19 on HCV care, still maintains the ambition to achieve this goal.8 Early signs of the impact of DAAs and the increased impetus to find and treat people living with HCV are promising. It is estimated that the number of people living with HCV in the UK has fallen from around 174 000 in 2015 to 118 000 in 2019.8 Preliminary data from all UK nations also shows a reduction in HCV-related deaths from end stage liver disease and HCC between 2015 and 2019 by an estimated 25%, particularly striking after a steady rise in HCV-related deaths for the preceding 10 years from 2005 to 2015.8
In the UK, achieving the WHO elimination target is now challenged by our capacity to find those who remain undiagnosed and offer treatment in an accessible and straightforward manner. National and local community screening initiatives are therefore vital, and strategies including health promotion materials, point-of-care testing, peer worker engagement, and reflex laboratory testing have all been employed to increase HCV diagnoses, with some success.8 Low-cost interventions to enhance HCV testing in GP surgeries have also demonstrated primary care can play a central role in identifying and diagnosing people living with HCV. The HepCATT study in South West England integrated an algorithm into primary care IT systems to identify individuals with high-risk markers of HCV, and rolled this out alongside educational and training packages for staff. While the increase in HCV testing was modest, the findings were sufficiently strong to recommend implementation of the system across the UK.9
IF PRIMARY CARE CAN DIAGNOSE, WHY NOT ALSO TREAT?
The ease of current DAA therapies has catalysed decentralisation of HCV treatment into the community in developed nations, with pathways demonstrating feasibility, increased treatment uptake, and similar cure rates to traditional models rooted in secondary care.10 Such treatment pathways are often located in drug services, prisons, and community pharmacies, but GP prescribing has also demonstrated its worth. For example, in Australia DAA prescribing restrictions were lifted in 2016 allowing GPs to initiate a course of therapy, contributing to an abrupt and substantial rise in treatment initiation over the following year.11 In the UK, there is evidence that such a move would necessitate significant barriers to be negotiated and overcome,12 with any expansion of GP responsibility in this area likely to be resisted in the current climate of unmanageable workloads. Such resistance must be balanced by the substantial benefits to person-centred care for some of the most vulnerable in our communities alongside potential benefits to GP job satisfaction, something in short supply for many! How often in primary care do you get to say ‘I’ve cured you’?
CURRENT GP RESOURCES AND ROLE
Although systematic screening and/or GP initiated treatment for HCV may be some time off for most working in primary care, a central element of the UK government policy to eliminate HCV is to raise awareness among GPs so they can recognise and ask about the risks for infection and offer testing. As a result, PHE have developed several up-to-date resources for GPs, which can be accessed at the Royal College of General Practitioners liver disease toolkit via the HCV quick consultation link.13
There is an additional drive by PHE via the operational delivery networks (ODNs) (who coordinate HCV treatment regionally in England), to engage people who have a laboratory record of testing positive for HCV historically but have not yet accessed the more modern, effective treatments. This makes use of primary care data to identify possible untreated patients. In some regions GP practices may be expected to communicate with their patients in collaboration with their regional ODN. PHE have also produced resources explaining this ‘patient re-engagement exercise’.14
We are in the privileged position as GPs of understanding the health needs of our patients and communities better than anyone. As we do for many others within our communities, it is up to us to advocate for people living with HCV as part of our fundamental role in reducing health inequalities and ensuring equitable access to evidence-based health care for all. The goal of HCV elimination will undoubtedly become more difficult to achieve in the UK over time as reducing cases become more difficult to identify and people living with HCV struggle to engage in traditional treatment avenues. Embedded within the neighbourhoods we serve, it is our unique position, insight, and the enduring therapeutic relationships we foster that will play a crucial role in the elimination of HCV as a public health threat moving forward.
Notes
Provenance
Commissioned; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2021
