New monitoring report for HCV published by Public Health England

Public Health England (PHE) last week published its annual “Hepatitis C in England” report, a key national monitoring document. The 2020 update shows good progress towards the elimination goals, particularly on diagnosis and reducing HCV-related deaths, and testifies to the relentless enthusiasm and determination of staff working in services. However, more must be done to reduce new infection rates and make improvements in harm reduction provision so that these gains are maintained.

PHE now estimates that 89,000 people have a chronic HCV infection in England, down from 99,000 last year. Injecting drug use continues to be the most important risk factor for HCV infection, this being cited in 93% of all lab reports. Over half (55%) of people who inject drugs participating in the Unlinked Anonymous Monitoring (UAM) survey were found to have antibodies for HCV (that is, they have had hepatitis C at some point), but an increasing proportion have now cleared the virus and no longer have an active infection (27% in 2018 compared to 19% in 2011).

One of the biggest achievements revealed in the report was that HCV-related liver transplantations have halved over the last decade, from 18% in 2009 to 9% in 2018. One of the World Health Organization’s (WHO) elimination targets was to have reduced HCV-related mortality from baseline levels recorded in 2015 by 10%. England has greatly exceeded this: death registrations for HCV-related end-stage liver disease and cancer fell by 20% between 2015 and 2018.

Another important target that was achieved was to have diagnosed half of those with the virus in 2015 by 2020. While this is a good milestone to have reached, too many people are still living with hepatitis C without knowing they have it: the latest estimates from the report suggest that around 47% of people who inject drugs are undiagnosed – though importantly the number of lab-confirmed cases of HCV has almost doubled over the last decade, indicating that patient engagement and testing initiatives are working.

A significant increase in testing rates in prisons will have contributed to this improved rate of diagnosis, with 32% of new receptions to prisons receiving testing in 2018/19 compared to 5% in 2010/11. The introduction of the blood-borne virus opt-out testing policy in 2015 is likely the main contributor to this boost. There is still much room for improvement, however, as uptake remains well below the 75% target set by NHS England and varies greatly between prisons.

Regarding treatment, small gains have been made since the introduction of direct-acting antiviral drugs (DAA) several years ago. 11,756 people accessed treatment in 2018/19, up 2% on the previous year and 131% on pre-2015 levels when the drugs were made widely available. This data was collected before the NHS hepatitis C elimination deal in April last year, after which point a host of patient finding and treating initiatives were launched. Next year’s report should demonstrate the impact that these initiatives have had on the number of hepatitis C-positive patients identified and accessing treatment.

Crucially, the report comments upon the impact of the coronavirus pandemic: “Overall, while COVID-19 may drive innovative models of service delivery, if services are not adequately re-instated, systematic under-diagnosis could lead to increased inequalities.” Its authors note the new opportunities to innovate in the current context, such as remote clinics, testing temporarily housed homeless populations, and medicine delivery, which may remain in place as services begin to recover.

 

Rachel Halford, Chief Executive of The Hepatitis C Trust, said:

“Public Health England’s latest report shows a welcome step forward in England’s progress towards eliminating hepatitis C. The hard work and resource invested in finding and treating people living with the virus are beginning to show results, as evidenced by the improved testing rates in both community and prison settings. We are pleased to see the work of the Hepatitis C Trust recognised within this report.

“As we move forward, it is vital that these efforts are not wasted by inadequate harm reduction provision. Preventing transmission is vital to reducing the health inequalities faced by people who inject drugs, stopping unnecessary deaths, and sustaining elimination.”

 

The full “Hepatitis C in England 2020” report can be read here.