If the mountain won't come to Mohammed, then Mohammed must go to the mountain: Decentralisation of hepatitis C care for people who use drugs.

Abstract

In 2016 the World Health Organisation (WHO) set ambitious goals for elimination of Hepatitis C (HCV) by 2030.1 In Europe, HCV prevalence is low in the general population, therefore treatment of high prevalence populations like people who use drugs (PWUD), is crucial to reach the WHO goals. Barriers on patient, provider and system level inhibit successful care delivery in PWUD, leading to low treatment uptake, early loss to follow-up, and a human reservoir for transmission.2 Worldwide, alternative health service delivery models with varying degrees of care decentralisation are developed with reassuring results.3 In their article, Mangia et al. report on the results of a local effort to improve linkage to care for PWUD. Their initiative consisted of a dedicated program of low-threshold screening, facilitated transportation to the hospital, and fast-track treatment at 15 addiction care centres in Puglia, Italy.4 During this program, 1470 people were tested, a chronic infection was present in 231 patients (15.7%). Pangenotypic treatment with sofosbuvir/velpatasvir was initiated in these patients. An impressive 95% of patients completed therapy and 98.6% achieved a sustained virological response (SVR) in this group. This study shows once again that adopting tailored models to improve the HCV care chain for PWUD yields high SVR rates, despite often anticipated barriers in this population. The authors are to be applauded for their success in implementing this tailored HCV care chain. They found that only 4.8% of patients did not initiate or complete treatment, thus stigma towards this population in terms of treatment non-adherence is unjustified. In order to increase impact at an (inter)national level, upscaling is key. However, implementation of these fast-track services requires substantial efforts and resources. Several other HCV care models tailored to PWUD have been developed and tested.3 They involve some degree of decentralisation and task-shifting toward general practitioners or addiction care. A recent meta-analysis collected all initiatives and categorised and compared according to level of decentralisation: no decentralisation; partial decentralisation, which included testing on a decentralised site and referral elsewhere for treatment; and full decentralisation, which included testing and treatment at the same site. Results showed linkage to care in full decentralisation was 72% versus partial 53% versus none 47%. Treatment uptake had comparable percentages. Similar SVR rates were achieved by decentralisation of care and treatment to a non-specialist compared to treatment delivered by specialists.3 Therefore we call for full integration of HCV care for PWUD within addiction care facilities, when locally available. As part of integrated addiction care PWUD can be screened, educated, counselled and treated for HCV. Treatment complexity is no longer an obstacle for care decentralisation, due to development of pangenotypic Direct Acting Antivirals (DAAs), which bypass genotyping and simplify therapy choice. Liver fibrosis evaluation can be done using non-invasive, inexpensive and reliable biomarker panels, as recommended by the recent guidelines.5, 6 Some relevant interactions with DAA drugs can occur, especially with proton pump inhibitors and anti-psychotics.6, 7 Media have already been developed, to intuitively identify and tackle potential interactions, for instance the Liverpool HCV drug interaction checker.8 We would like to emphasise that drugs of abuse do not cause interactions. For the majority of patients unchallenging HCV cure, carried out in primary care is possible. Remaining challenges requiring specialist care include patients with end-stage renal disease, concurrent HIV or hepatitis B infection. HCV management in patients with decompensated cirrhosis or who failed previous DAA therapy is also better left to hepatitis treatment specialists.9 Patients with advanced fibrosis or cirrhosis should also be screened for hepatocellular carcinoma every 6 months.5, 6 Mangia et al. mention that in Italy addiction care centres and general practitioners are not allowed to prescribe DAAs. This is a major obstacle for full decentralisation. The recent developments in HCV care as outlined above, no longer justify barriers for bringing HCV care closer to patients in first line facilities. We strongly believe these developments make it feasible to reach WHO HCV elimination goals by 2030, either by efforts to bring the patient to HCV care in the hospital, or to bring state-of-the-art HCV care to the patient. To conclude, the study by Mangia and colleagues has effectively met an urgent local need for HCV micro-elimination in PWUD. HCV treatment in PWUD is very well possible. To reach WHO HCV elimination goals, such initiatives need to be scaled up to (inter)national levels. Decentralisation of HCV care is an alternative model to be pursued. The PWUD population will benefit greatly from care decentralisation, with only a few sparse exceptions still requiring specialist care. Doing so, WHO HCV elimination goals can be achieved by 2030. Daan W. Von den Hoff declares receipt of funds from AbbVie and Gilead. All other authors declare no competing interests. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.