Hepatitis C elimination in Australia: progress and challenges

Early empirical evidence provides grounds for optimism about eliminating HCV by 2030

Curative direct‐acting antiviral (DAA) therapy for people with chronic hepatitis C virus (HCV) infections1 has transformed clinical management and spurred ambitious World Health Organization elimination targets for 2030.2 WHO service targets encompass marked improvements in prevention, diagnosis, and treatment; impact targets include a 65% reduction in HCV‐related deaths and an 80% reduction in new HCV infections compared with 2015.2

In 2015, an estimated 71 million people were living with chronic HCV infection. Progress toward elimination since the launch of the WHO viral hepatitis strategy in 2016 has been patchy; globally, only 20% of people with chronic HCV infection are diagnosed, and an estimated 1.75 million people are infected with HCV each year: more than the number of those cured by DAA therapy.2 In 2018, only a small number of countries, including Australia, were on track to achieving the WHO HCV elimination targets by 2030.

In Australia, about 85 000 people with HCV infection had been treated with DAA therapy by the end of 2019. Importantly, DAA uptake appears higher among populations at risk of transmission, including people who inject drugs and HIV‐infected gay and bisexual men.3,4,5 The Australian government developed a unique model that provided unrestricted national access to DAA therapy over five years, with an annual expenditure cap.6 A return on this therapeutic investment can already be seen in terms of reduced numbers of people with complications of advanced liver disease and of liver disease‐related deaths,7 but sustained government funding and support will be crucial.

Satisfaction with the success of HCV elimination in Australia to date is tempered by consideration of the challenges that lie ahead. As outlined in the modelling study by Scott and colleagues,8 DAA treatment numbers have declined, and projected estimates of HCV RNA testing (required for confirming current infections) indicate that they will need to be raised to achieve the 2030 targets.

While acknowledging the importance of increased HCV testing and linkage to care, several factors justify greater optimism. First, our recent downward revision of the estimated number of people with chronic HCV infection in 2015, from 227 000 to 188 000 (largely because of duplicate HCV notifications), means that the starting point for HCV elimination is 17% lower.

Second, there is increasing evidence of higher DAA uptake among people at greater risk, including people who inject drugs or are imprisoned. The model reported by Scott and colleagues assumed comparable access to DAA therapy across populations at low and high risk of infection, with a sensitivity analysis evaluating the effect of reduced uptake by people who inject drugs. A sensitivity analysis evaluating higher uptake would be more appropriate, and would probably predict earlier HCV elimination.

Third, the authors’ model was based on absolute numbers of diagnostic (qualitative) HCV RNA tests. As the authors mention, it is likely that many quantitative HCV RNA tests coded as pre‐treatment assessments are actually confirmatory or diagnostic tests. There is also increasing use, particularly in New South Wales, of dried blood spot screening in prison and community settings (not covered by Medicare), which will bypass the rebated diagnostic HCV RNA test. Intensive screening in prisons has had the desired effect of increasing the number of new HCV notifications among young adults in New South Wales.9

Despite these caveats, the modelling study by Scott and colleagues highlights a renewed emphasis on HCV screening and linkage to care. Innovative screening methods with novel diagnostic tools (including point‐of‐care anti‐HCV antibody, point‐of‐care HCV RNA, and HCV core antigen tests) in different settings (including Aboriginal health services, drug health services, emergency departments, and prisons) facilitate testing and care in safe and culturally appropriate environments, free from stigma and discrimination.1 Evaluations of novel testing strategies with rapid (same day) DAA initiation among people who inject drugs in the community and prisons are underway, such as TEMPO (ClinicalTrials.gov, NCT03492112). Removing the remaining barriers to expedient DAA initiation, such as mandatory pre‐treatment HCV genotyping (given pan‐genotypic regimens), should further increase uptake.

To eliminate HCV at the regional and global levels, the common components of stories of successful elimination at the national level — political leadership, national strategy development, access to affordable DAA therapy — require emphasis. Further, implementing comprehensive HCV prevention strategies is critical. Among people who inject drugs, only 1% reside in countries with high coverage by needle syringe and opiate agonist therapy programs,10 while blood safety and health care‐related injection safety remain suboptimal in many low to middle income countries and regions. High levels of HCV screening and treatment will not control transmission among people who inject drugs in areas where harm reduction coverage is poor.11 Implementing models of care that take local epidemiology and the affected individuals into consideration is crucial. In Australia, this has involved considerable shifting of responsibility to primary care, drug health services, and prison health services: most people are now prescribed DAA therapy by non‐specialists.12

Finally, the stigma and discrimination experienced by most people with HCV infection remain barriers to accessing quality health care. Unlike DAA therapy, there is no miracle cure for these problems; concerted efforts to achieve health care equity will be needed at several levels, among health care professionals, policy makers, and the broader community.