Hepatitis C elimination: Tailoring the approach to each country’s needs and realities
Authors: Loreta A. Kondili, Antonio Craxi
Journal: Hepatology (2024)

Health cannot be a question of income it is a fundamental human right.—Nelson Mandela Since the arrival of direct acting antiviral(s) in 2015, improving screening and access to treatment and optimizing the HCV care cascade have become a global priority to reduce and ultimately erase the burden of HCV-related liver disease. As for other infectious agents linked to cancer development, detection and breakage of transmission chains should be pursued at a population level independently of the prevalence of risk factor(s). To meet the ambitious World Health Organization (WHO) targets, high-income countries have been committed to reaching elimination by 2030. However, the elimination targets are debated in terms of absolute or relative ones in most countries of the world—regardless of income level.1 The biggest challenge with HCV elimination is not figuring out what to do but rather how to scale up what works to achieve a population-level impact.2 Tian et al.,3 in their modeling exercise in the Canadian setting, have explored some potentially helpful policy implications that could be extended to other high-income countries. In keeping with data from other high-income countries, Canada could meet the WHO goals for HCV elimination by 2030 by sustaining the current national HCV treatment rate during the next decade.4 Nonetheless, according to the study by Tian et al,3 the future incidence of HCV infection will be mainly related to HCV transmission, stressing the fact that harm reduction strategies, in addition to the highest treatment rate, are paramount to reducing the further HCV spread and reinfection risk, especially in marginalized populations. In high‐income countries, HCV treatment rates among people who use drugs remain inadequate due to a lack of simplified HCV testing, scale‐up of harm reduction‐based HCV treatment programs, and numerous additional barriers to HCV services, including limited transportation, poor geographic access to specialist care, social stigma and discrimination, homelessness, and negative clinicians attitudes toward treating people who use the drug.5 Harm reduction services are often insufficient or absent. European Union (EU) States and Norway had needle and syringe programs in place. Still, the actual coverage and access remain challenging, with only 5 of the 17 EU countries with available data reaching the WHO service provision targets in 2021.6 From a public health policy perspective, it is easier to describe the epidemiology of HCV infection in high-income countries than to generalize successful public health measures to reduce HCV transmission and eliminate infection. The existing models do not capture the significant heterogeneity, including differences in characteristics of the HCV epidemic, prevention, population groups, costs, and existing health systems. Some high-income regions, such as the Northern European countries and the United Kingdom, have low estimated prevalence rates and an HCV epidemic wave mainly affecting drug users and other key populations, as men who have sex with men could, in theory, confront elimination by a risk screening approach.7 However, some key populations may be left behind. Despite rapid scale-up in many settings and further treatment simplification, it is hard to know if the expanded treatment access and treatment as prevention will be sufficient to reach the elimination target. An example of a country where epidemiological knowledge of HCV has been crucial in shaping public health policies is Italy. Italy is a high-income country with the highest prevalence of chronic HCV infection and the most significant number of deaths due to HCV-related cirrhosis and HCC in the EU. A cohort effect of HCV infection, affecting old generations through nosocomial transmission since the early 50s, in addition to the spreading of infection by i.v. drug use, which peaked in the 90s, makes mass screening the only effective tool to achieve the elimination target. The Italian elimination programs have required strong political will and financial investment to have a population-level impact. A firm public health commitment delineating HCV treatment policy allowed Italy to cure the highest number of infected patients in Europe since 2015 (around 260,000 chronically infected subjects treated with direct-acting antivirals up to January 2024) with unrestricted treatment eligibility. Based on this action, HCV-related mortality in Italy is expected to decrease by 75% by 2030, allowing Italy to meet the WHO's mortality reduction goal. Furthermore, in 2020, a dedicated fund of 71.5 million euros was allocated for mass screening, addressing, in the first phase of the program, the key populations as people who are followed in addiction services and prisons and the cohort population born between 1969 and 1989, to be later extended in older cohorts. The aims were to reduce the prevalence of active HCV infection and to lessen the chance of its further spread among young carriers at high risk of transmission. Primary health care providers and clinicians working in prevention services, prison health services, and addiction services can reach out to individuals through active calls and/or opportunistic hospital screening. Reflex testing was recommended for the screening of general and key populations. Single-step HCV RNA point-of-care testing was recommended for people who inject drugs in specific epidemiological contexts of high prevalence rates to reduce the time from diagnosis to treatment in a population that has been traditionally difficult to reach. Still, counseling and harm reduction services have been recommended but not fully implemented.8 Even with this massive effort, somewhat hampered by the COVID pandemic, the screening coverage ranges from 6.6% of the 1969–1989 birth cohort of the general population to 30%–59% of the people who are followed in addiction services and prisons, respectively. It is not just a matter of time until high-income countries get rid of HCV infection. The ongoing mass screening campaign in Italy shows that having political will and financial coverage is insufficient to achieve the HCV elimination targets. In high-income countries, encouraging and convincing people to get tested is among the most challenging and underrated. When planning HCV screening, policymakers should consider that some population groups must be persuaded to undergo testing and treatment. Individuals may not be aware that they are at risk of infection, or they may be wary of the stigma associated with infection. They may also not be aware that effective treatment is available and thus not believe that it is even worth being tested. Strategies promoting active participation and generating behavioral change are essential for improving screening and treatment adherence, adopting harm reduction measures, and managing stigma and discrimination.8 In Egypt, the country with the highest HCV burden worldwide, the government expanded the efforts to introduce population-level screening to test over 45 million people in just 6 months, despite political instability and financial constraints. The extremely high prevalence of HCV, particularly in older populations, likely leads to greater acceptability of testing than is seen in regions where HCV testing may be more stigmatized due to its association with injection drug use and other acquisition risks. The remarkably successful follow-up in this program is attributed to the high level of community engagement. The education programs before the testing campaign and the close contact between villagers, the health promoters, and the clinic staff were likely key to ensuring no loss to follow-up.9 Regarding HCV infection in migrants, the study by Tian and colleagues reports no routine-targeted HCV screening programs for immigrants before, upon entry, or after arrival in Canada. Many European countries have guidelines on viral hepatitis testing and vaccination with a limited focus on migrants. Although HCV prevalence in new immigrants to the EU is seemingly lower than in the country of origin, migrants account for a large proportion of HCV cases in the EU countries. Migrants permanently living in the European region are older and more likely to have advanced liver disease and HCC compared with nonmigrants at the time of HCV diagnosis. The migrant infection burden is due to a combination of vulnerability factors as well as social and economic vulnerability in host countries, including exposure to infections, inadequate health care access, and poor living conditions. For migrants, any assessment would be incomplete and misleading if it does not consider social determinants of health and other important information such as the country of origin, migration status, length of stay in the country of arrival, and travel history.10 The integrated screening for infectious diseases (tuberculosis, HBV, and HIV) and a dedicated approach to overcoming cultural and socioeconomic barriers to linkage to care shall ensure that screening does not stigmatize or impact immigration opportunities. Ultimately, without an HCV vaccine, harm reduction measures and treatment-as-prevention are the most effective prevention strategies, regardless of the country's income level. In high-income countries, HCV elimination as a public health threat will not be reached if not supplemented by strategic communication tools adopted to specific populations' needs.