Last Friday, the World Health Organization (WHO) launched updated guidelines for the treatment of hepatitis C, calling for testing and treatment to be delivered in peripheral and community-based facilities and integrating these with available care services.

While some countries are making progress in eliminating hepatitis C, many remain challenged in reaching those affected, Dr Philippa Easterbrook, Senior Scientist at WHO’s Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, tells Pharmaceutical Technology. The WHO made three new suggestions: simplification of service delivery, use of efficient point-of-care (POC) HCV ribonucleic acid (RNA) assays, and expansion of treatment guidelines to include adolescents and children with chronic hepatitis C infection. As such, treatment with direct-acting antivirals is now recommended for children aged three and older.  The international agency had previously set a target of eliminating viral hepatitis by 2030.

These guidelines were launched in a symposium held at this year’s International Liver Congress held by the European Association for the Study of the Liver (EASL), and was co-organized by the WHO, EASL and the US Centers for Disease Control and Prevention (CDC).

New guidelines aim to reach those who have not been reached before

According to the WHO, there are 354 million people with hepatitis B or C around the world, and 58 million people with chronic hepatitis C. But as per the World Hepatitis Alliance, a significant number of individuals  live with viral hepatitis without knowing about their condition. 

Given that some countries grapple with reaching all hepatitis C patients, Easterbrook called the guidelines a “radical simplification” of treatment and diagnosis.  For example, shifting access to the local level where testing and treatment can be done on the same site by non-specialist staff creates an opportunity to transform hepatitis C care. This approach previously worked well with the treatment of HIV, which marked a step forward, she explains. Indeed, in the 2022 guidelines, the adoption of a decentralized and simplified approach to HIV treatment is described as indirect evidence to reconsider the Hepatitis C guidelines.

As part of the symposium, Dr Graham Foster, who was appointed National Clinical Chair for the Hepatitis C Delivery Network in January 2016, shed light on hepatitis C care strategies in England. The country is divided into 24 operational delivery networks where medics focused on the testing and treatment.

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The new recommendations aimed at decentralization and integration are particularly important in reaching individuals with substance use disorder. According to Foster, this group is at the greatest risk, meaning every drug care facility needs to have a testing and treatment service. At the same time, he also stressed that it is impossible to know if the disease is being cleared from this particular population, given the evidence of re-infections. As such, a hepatitis C vaccine may yet be needed for elimination, since there are cohorts of patients who will not be reached, Foster said during the subsequent panel discussion.

Relatedly, Foster also discussed the National Health Service’s (NHS) efforts in addressing hepatitis C in English prisons.  At the moment, 33 out of 95 male prisons and 10 out of 12 female prisons have eliminated hepatitis C through intensive testing and treatment programs with patient partners.

A further expansion of treatment for children

The WHO’s third recommendation deals with broadening access to hepatitis C testing and treatment for the benefit of children and adolescents. Guidelines released in 2018 advised hepatitis C treatment from the age of 12. Based on WHO’s 2018 data, 3.26 million children and adolescents have chronic hepatitis C infections. The WHO’s decision to change the guidelines with respect to age and greater service simplification is a huge piece of advocacy for the early treatment of children and adolescents, Dr Manal El-Sayed, professor of Pediatrics at Ain Shams University in Cairo, tells Pharmaceutical Technology.  

While hepatologists previously said children and adolescents with chronic hepatitis C could wait for treatment until they are adults, El-Sayed says she noticed the disease having a neurocognitive impact. This includes fatigue and academic underperformance, she explains.

The new focus on decentralization and integration will also benefit the potential treatment of children and adolescents, says El-Sayed. She says this could involve using family health care facilities where children also receive their vaccines. According to El-Sayed’s presentation, almost around 12 million high school students have been screened as part of the 100 Million Healthy Lives initiative.

Low and middle-income countries still see multi-transfusion related hepatitis C infections, and the WHO’s new recommendations could be the step needed to further eliminate hepatitis C, and reach marginalized populations, says El-Sayed. Indeed, these changes are highly needed to test and treat groups such as adolescents with substance use disorders, orphans or refugees from conflict zones, explains El-Sayed.