Addressing the hepatitis C care continuum: towards viral eradication

Hepatitis C virus (HCV) infection is a chronic disease which left untreated leads to cirrhosis, end-stage liver disease or hepatocellular carcinoma. Today HCV infection can be cured thanks to the development of direct acting antiviral (DAA) therapy. This provoked the World Health Organization to define targets to eliminate HCV infection as a public health threat by 2030. In order to reach these targets, the care for HCV infection needs to improve globally. In this thesis, we focused on the care for HCV infection from a Belgian perspective. In part I, we studied the first step of the HCV care cascade in the general population: diagnosis. We performed a large seroprevalence study at the emergency department of a regional hospital (chapter 1). The prevalence of chronic HCV infection was 0.52%. People who used drugs, people who were ever imprisoned, and people immigrating from high-endemic countries should be screened in Belgium based on our findings. Furthermore, we assessed the current testing policy for viral hepatitis by general practitioners in Flanders, Belgium (chapter 2). This study clearly indicated the lack of an effective screening strategy. Only 1.8% and 1.6% of the total population were tested for hepatitis B surface antigen and HCV antibody, respectively. When screening was performed, this was mostly done in women of the reproductive age. Furthermore, only 7.9% and 9.9% of all patients with chronically elevated liver enzymes were tested for hepatitis B surface antigen and HCV antibody. Clearly more efforts are necessary to educate GPs on viral hepatitis and to stress the importance of screening for viral hepatitis in patients with elevated liver enzymes. In part II, we focused on the care for HCV infection in people who inject drugs (PWID) in Belgium. PWID are currently the group most at risk to acquire the infection in Belgium, and they are underserved by the general health care. Firstly, we studied the influence of HCV infection on mortality in PWID and compared this to a control population of non-PWID with chronic HCV infection (chapter 3). In both groups, mortality was higher in patients with a chronic HCV infection, and curing the disease by therapy led to better standardized mortality ratios. As such, the benefits of HCV therapy for PWID were clear, although our findings are limited due to potential confounders and the retrospective nature. Furthermore, we demonstrated that DAA therapy was both safe and effective in two retrospective multicentre studies in Belgium (chapter 5). However, the availability of DAA treatment in itself is not enough to improve treatment uptake in PWID. We studied the current treatment uptake in PWID on opiate agonist therapy in a multicentre prospective study (chapter 6). Treatment uptake was low, and remained stable despite the availability of new DAA therapy during the study period. This was mostly due to the strict reimbursement criteria in Belgium. As these have been lifted as of the beginning of 2019, this would be the ideal time to study factors impeding treatment uptake in PWID. We also organized the care for HCV infection for PWID on opiate agonist therapy in Limburg. This led to a high uptake for screening, linkage to care and treatment uptake, although the latter was impeded by the reimbursement restrictions. Finally, we demonstrated that there is still a long way to go to improve on prevention, diagnosis and treatment of HCV infection in the European prisons.

Publication year:2019

Keywords:Hepatitis C virus, prevalence, general population, people who inject drugs, screening, linkage to care, treatment, mortality, policy

Accessibility:Embargoed