WHO: HCV elimination by 2030 demands ‘scale-up, simplification’ of care pathways
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LONDON —WHO presented updated guidance on hepatitis C, calling for drastic simplification of care pathways to alleviate access gaps in HCV testing and treatment, during a joint WHO-EASL-CDC symposium at the International Liver Congress.
“In 2016, when WHO launched its global strategy, there were ambitious plans for elimination, defined as a 90% reduction in incidence and a 65% reduction in mortality,” Philippa Easterbrook, MD, senior scientist at the Global HIV, Hepatitis and STI Programs at WHO headquarters in Geneva, told attendees. “These could be delivered through the scale-up of six synergistic interventions, including testing and treatment, to achieve by 2030 towards elimination: 90% of those infected diagnosed, and 80% of those diagnosed treated.”
She added: “Although excellent progress has been made in many champion countries, and more than 10 million have been treated, based on the global hepatitis report from WHO a year ago, still only 21% of those infected have been diagnosed and 13% treated. If we are to reach the goals of elimination, there needs to be a substantial scale up and simplification of care pathways.”
Among its first recommendations, the updated WHO guidance urged decentralization, integration and task shifting in HCV care. Most notably, WHO recommended moving the treatment and care of HCV out of specialty clinics and into more peripheral health or community-based facilities where trained non-specialist physicians and nurses can be tasked with patient care to expand access.
“We are recommending delivery of hepatitis C testing and treatment at peripheral health or community-based facilities, ideally at the same site to increase access to diagnosis, care and treatment,” Easterbrook said. “These facilities may include primary care, harm reduction sites, prisons, HIV clinics, as well as community-based organizations. We recommend integration of the hepatitis testing and treatment within existing services at these health facilities.”
WHO made this a strong recommendation, based on moderate certainty of evidence, other than for the general population where there were less data. The rationale for these recommendations was based on a 2021 evidence review of 142 studies from 33 countries — 14% of which were low- or middle-income countries — that compared full decentralization or integration vs. partial or none, as well as task sharing to non-specialists compared with specialists.
In their second updated guidance, WHO made several conditional recommendations on the use of HCV point-of-care viral load RNA testing, namely that this can be used as an alternative approach to laboratory-based HCV RNA nucleic acid testing to diagnose HCV viremic infection. Additionally, point-of-care HCV RNA assays with comparable limit of detection to lab-based assays may be used an alternative approach as a test of cure, according to the WHO recommendations.
“The rationale for this was based on an evidence review of 45 studies of 27,364 patients, in which 50% of studies were from low- and middle-income countries, that compared point-of-care viral load with lab-based assays,” Easterbrook noted. “The main message here was that there were better outcomes with point-of-care assays, with a short turnaround time between antibody test and treatment initiation, increased viral load uptake and increased treatment uptake. Diagnostic performance in terms of sensitivity and specificity compared to lab-based assays was also very high.”
Additional benefits of point-of-care HCV RNA testing include its use in lower-level health facilities near where patients receive care, as well as the opportunity for integration with other point-of-care molecular platforms for diseases such as HIV, tuberculosis and COVID-19.
Lastly, WHO guidance strongly recommended the use of pangenotypic direct-acting antiviral regimens for all adults, adolescents and children aged older than 6 years with chronic HCV, regardless of stage of disease. Children aged 3 to 5 years were given a conditional recommendation, based on very low certainty of evidence.
In addition, for direct-acting antiviral regimens, WHO strongly recommended the use of sofosbuvir/daclatasvir, sofosbuvir/velpatasvir and glecaprevir/pibrentasvir among adolescents and older children, while children aged 3 to 5 years were again given a conditional recommendation.
“The rationale was based on a systematic review of 49 studies in adolescents, older children and younger children, with [sustained virologic response] rates at least 95% in all age groups across all regimens,” Easterbrook said. “Serious adverse events and treatment discontinuations were uncommon and, of course, [the benefit of earlier treatment] is to achieve a cure before the onset of disease progression and into the associated liver damage.”
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Easterbrook P. EASL-CDC-WHO symposium: Innovations in hepatitis elimination and launch of WHO HCV guidelines on simplified service delivery and diagnostics. Presented at: International Liver Congress; June 22-26, 2022; London (hybrid meeting).
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