For Viral Hepatitis Elimination One Size Does Not Fit All

The conference 'Striving towards the elimination of HCV infection' was the first major European conference specifically on hepatitis C virus elimination since the publication of the WHO strategy in 2016

“For elimination, one size does not fit all” was a refrain repeated in a number of different ways throughout the presentations and discussions at the European Association for the Study of the Liver (EASL) Monothematic conference on “Striving towards the elimination of HCV infection” that has just come to a close in Berlin.

Whether in discussions about prevention, interventions in drug users, improving linkage to care, or treatment itself, attendees agreed that there is no golden ticket for hepatitis C elimination. However, there are a number of evidence-based strategies for impact that were presented very effectively by over 30 speakers in the six thematic panel sessions.

The two-day conference (2-3 February 2018) was the first major European conference specifically on hepatitis C virus (HCV) elimination since the publication of the WHO viral hepatitis strategy in 2016 and the adoption of the goal to eliminate viral hepatitis as a public health threat by 2030. It engaged 275 representatives from over 35 countries and a variety of sectors for a range of talks spanning stakeholder groups and areas of expertise.

So how are we doing? Well, the conference may not have been intended to concretely conclude at this stage, but each presenter did do their part to fill in a piece of the ever-evolving puzzle.

Experts addressed improving health and systems in general, a more complex and impactful goal than simply a general reduction of hepatitis prevalence

The now classic viral hepatitis cascade-of-care, in many ways, served as the backdrop for the entire meeting as presenters addressed individual and groups of stages of care, as well as the gaps and barriers that have yet to be resolved. The approach at this meeting was broad and geared towards solutions to fit the multi-faceted reality, with the elimination agenda as a constant in the background. Experts addressed improving health and systems in general, a more complex and impactful goal than simply a general reduction of hepatitis prevalence.

Source: The continuum of viral hepatitis services and the retention cascade. (WHO Global health sector strategy on viral hepatitis, 2016-2021)

Andi Hüttenmoser, a Swiss former-patient, opened the conference by talking about part of his story of 35 years of HCV infection, injection drug history, and ultimately advanced fibrosis and struggle to access treatment. The session chair noted that “we don’t often hear from [patient groups] at conferences” and this is a true missed opportunity in most multi-stakeholder meetings. Indeed, much of the remaining programme was made up of clinicians and researchers. However, many attendees and speakers did remark on the fact that it is crucial to bring in a more representative variety of voices to bear on the issue of elimination, especially those stakeholders who can provide insight beyond the clinical.

A Swiss former-patient, opened the conference by talking about part of his story of 35 years of HCV infection

A number of conference presenters, including Matthew Hickman of the University of Bristol, Sharon Hutchinson of Glasgow Caledonian University, Jason Grebely of UNSW Australia, and Jean-Michel Pawlotsky of the French National Reference Center for Viral Hepatitis B, C and Delta remarked that many processes for prevention, diagnosis, linkage-to-care, and treatment were developed in the interferon-age and are now antiquated. They can and should be updated for the DAA-era.

It was widely noted that improved engagement of marginalised patients is key to increasing HCV treatment

It was widely noted that improved engagement of marginalised patients is key to increasing HCV treatment. We have already treated those who are easiest (aka typically diagnosed and in care) to treat.

This requires novel approaches such as those described in the work of conference presenter Magdalena Harris of the London School of Hygiene and Tropical Medicine on removing residual barriers which impact engagement. Dr Harris noted that for drug-injecting populations, very often hepatitis C infection is nowhere near the most pressing problem that they face in their everyday lives. She called for a “fundamental shift” in the approach to these groups and for us to address what is beyond the cure: the impact of multi-faceted therapeutic care tailored to specific populations. Otherwise, it is likely that we will never reach the most marginalised of these groups.

Ricardo Baptiste Leite of Portugal, Medical Doctor and elected Member of Parliament, gave a remarkable talk on the role of payers, but from an unusually forward-thinking perspective. He presented a vision for outcome-based care where public procurement is value- and patient-based rather than the current standard of an industrial “health factory” system.

Discussion on the role of patient organizations in getting the needed attention of the goverments. Author: EASL.

Micro-elimination including targeted geographic elimination was a theme in many presentations

Micro-elimination, including targeted geographic elimination, was a theme in many presentations beginning broadly with inspiring presentations on national experiences in Australia and the United Kingdom by Gregory Dore and Graham Foster, respectively. Marieta Simonova presented on the clinical reality of the treatment landscape in Central and Eastern Europe. John Dillon spoke on elimination possibilities by moving care into the community and enhancing testing and treatment pathways to achieve micro-elimination of people who inject drugs and populations who use opioid substitution therapies. Martin Kåberg called for scaling up HCV treatment in drug, alcohol and psychiatry clinics. And Gregory Dore gave a compelling account of the potential for impact in the prison setting as a key to HCV elimination, specifically in Australia.

Nonetheless, due in part to the European and Western country focus of this meeting, presentations on strategies for HCV elimination in low- and middle-income countries were neglected. We must be careful, as Dr Antonio Craxi said on Saturday in his keynote talk “HCV: The Rise and Fall of a Virus”, to not necessarily extrapolate risk factors such as injection drug use and elimination strategies to all parts of the world.

One size does not fit all and in order to reach our ambitious goals of elimination as a public health threat by 2030

This is because, once again, one size does not fit all and in order to reach our ambitious goals of elimination as a public health threat by 2030, or in some parts of the world perhaps even sooner as I proposed in my own Saturday morning talk. In order to have a fighting chance to reach viral hepatitis elimination, we must consider the broader implications of the health system and change the provision of care for heterogeneous populations, which requires new and simpler models of care.