Despite the huge disparities in care that were highlighted, last week's Standard of Care for HIV and Coinfections in Europe meeting in Bucharest featured discussions that could form the basis of a European-wide exercise to audit HIV centres to a common standard. As well as highlighting the difficulties facing clinicians tackling the needs of people co-infected with HIV and tuberculosis (TB), the meeting also looked at the needs of people with viral hepatitis and specifically hepatitis C.
Dr Jerzy Jaroszewicz of the Polish Association for the Study of the Liver said that given there is a World Health Organization (WHO) target that by 2030 90% of people with hepatitis C should know their status, we have a long way to go. It's currently estimated that 13% are aware of their status (globally), with one-third diagnosed in Europe as a whole.
The big gap in Europe is lack of treatment. Here the WHO target is for 80% of those diagnosed to receive direct-acting antivirals (DAAs) by 2030; last year it was estimated that 13% of those diagnosed received treatment (2.5% of all those with hepatitis C).
One of the problems is, as it is with TB, that most of the population that have co-infection with hepatitis C and HIV are former or current injecting drug users, especially in eastern Europe and central Asia.
Here, although the proportions are shifting, it is still the case that 45% of people currently living with HIV got it through injecting drugs. Because the vast majority of people who inject drugs and have HIV also have hepatitis C, 93% of those in the region who have hepatitis C/HIV co-infection are injecting drug users.
Although the mortality threat facing people with co-infection is not as acute as it is for people with HIV/TB co-infection in the region, longer-term outcomes for those co-infected with untreated hepatitis C are still worse than for those who only have HIV, even controlling for other health risks faced by injecting drug users. A long-term Polish study of people with HIV found that 20 years after diagnosis, 19% of people with HIV had died but 40% of those with hepatitis C co-infection had.
Dr Jaroszewicz said that population-wide screening for hepatitis C was not necessarily cost-effective, citing US studies that only found relatively small prevalences of hepatitis C in youth, and a lower acceptance rate and slow referral process in prisoners offered a hepatitis C test at reception.
There were countries and cities that had taken the decision to implement intensified hepatitis C screening and universal treatment. New York and Australia were examples outside Europe, and there is evidence from Australia, in particular, that this is resulting in falls in hepatitis C prevalence.
In Europe, Iceland is the first example of a country that has implemented a national hepatitis C elimination plan targeted at, though not exclusive to, injecting drug users. Its TraP Hep C elimination programme, started in January 2016, is a cohesive, multipronged approach that includes scale-up of prevention, testing and early treatment of hepatitis C in both hospital and community settings. By 2018 it was estimated that between 56 and 70% of Iceland’s hepatitis C-positive population had been treated with DAAs.
However, in order to implement this, a multidisciplinary public health model of care and co-operation between government, health services, the penitentiary system and community organisations was needed.
The barrier was not one of treatment guidelines, Dr Jaroszewicz said. The majority of European countries where DAAs were available at all now offered reimbursed DAAs at relatively low levels of liver fibrosis. It was lack of other measures to control hepatitis C and HIV infections in injecting drug users.
Modelling studies showed that DAAs in themselves would make little difference to the transmission of hepatitis C in eastern Europe and central Asia. A modelling study of hepatitis C prevention and treatment provision in five countries (Belarus, Georgia, Moldova, Kazakhstan and Tajikistan) found that, by themselves, adding DAA availability to current provision would only reduce new hepatitis C infections by 1 to 14%, depending on the country.
In contrast simply providing needle and syringe exchange would reduce infections by 10 to 25%, and adding opioid substitution therapy (OST) to that would reduce infections by 45 to 55%. Adding in DAAs to that would further reduce new infections, but not by all that much: about 5% more. Finally, if targeted screening programmes were also added, reductions could range from 55% in Tajikistan to 70% in Moldova.
One big problem is that there is an overall lack of co-ordination of agreement on programmes to test more people for hepatitis C in Europe. Dagmar Hedrich of the European Monitoring Centre for Drugs and Drug Addiction said that even now only 50% of people referred for opioid addiction treatment in Europe were tested for hepatitis C.
Dr Jürgen Rockstroh, currently EACS President, said that although in his clinic in Bonn, Germany 97% of people testing positive for hepatitis C had been treated, the problem was that even in Germany there was a lack of any coherent programme to diagnose people with hepatitis C.
One example of such a programme, he said, would be to include liver enzyme tests among the standard medical tests provided to anyone over 35 who gets a health checkup. However, this idea has faced opposition from the insurance companies that reimburse health costs in Germany because they feared a sudden increase in patients needing expensive DAAs – even though treating people early would in the longer run save money by reducing infections.
Dr Adrian Streinu-Cercel of Romania’s National Institute for Infectious Diseases said that there was an issue of “wide eligibility, but low accessibility” in many European countries of both hepatitis C testing and of treatment.
A lot of this was due to the continued lack of provision of other forms of harm reduction for injecting drug users, which means that many continued to use street drugs and dropped out of treatment. Dr Streinu-Cercel commented that although OST was available in Romania in theory, it was rationed in practice. When Romania had entered the EU it had promised to treat 12% of its injecting drug users with OST but was currently only treating 7%.
Issues like police harassment of injecting drug users was still a big problem, he said. “Although we provide needle and syringe exchange and the police say they will not harass people who come for them, in practice what happens is that after people leave, the police have secured the rooms our service users have occupied to find evidence of the drugs they have injected and will then charge them.”
WHO’s Elena Vovc said that part of the problem, as with TB, was that in parts of Europe treatment for drug dependency was the responsibility of non-HIV specialists who had a narrow focus on treating addiction rather than its health consequences. “You tend to get the narcologists taking over and wanting to treat people for addition, but infectious disease and public health get left out.” WHO’s own structure, which was led by the health policies of individual countries, was an issue here too.
Dr Michel Katzatchkine, the French HIV specialist who was director of the Global Fund from 2007 to 2014, and who is now the UN Special Envoy on HIV in central and eastern Europe, said that WHO guidelines needed to be updated too. The WHO guidelines on harm reduction dated from 2012. There were a few updates since then, but they had been “discreet," he said. "Where are the guidelines on safe injecting rooms? Naloxone provision for overdose? Heroin-assisted therapy?”
Dr Streinu-Cercel concurred, saying that this was a problem for monitoring and surveillance too: “The drug specialists do collect data on drug use and health outcomes – I have seen a paper linking benzodiazepine use to car crashes – but access to such data for research data tends to be restricted.”
Dr Kazatchkine commented: “We’re in a region where 1.9 million people who inject drugs have hepatitis C and 750,000 of those have HIV. One per cent of them are accessing OST, and the average annual allocation of clean syringes is 15 each. This is a health emergency.
“Physicians have to be more vocal about this. Where there is a conflict between legislation and public health, it is legislation that should be changed.”
Jaroszewicz J. HIV and HCV coinfection - Barriers in Central and Eastern Europe. EACS Standard of Care for HIV and Coinfections in Europe, Bucharest, January 2019.