The elimination of HCV by 2030 requires an “intensification, a simplification” of care pathways



Easterbrook P. EASL-CDC-WHO Symposium: Innovations in Hepatitis Elimination and Launch of WHO HCV Guidelines on Simplified Service Delivery and Diagnosis. Presented at: International Liver Congress; June 22-26, 2022; London (hybrid meeting).

Disclosures: Easterbrook did not report any relevant financial information.

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LONDON – WHO presented updated guidelines on hepatitis C, calling for drastic simplification of care pathways to alleviate gaps in access to HCV testing and treatment, at a joint WHO-EASL-symposium CDC at the International Liver Congress.

“In 2016, when the 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, principal investigator of the global programs on HIV, hepatitis and STIs at WHO headquarters in Geneva, told participants. “These could be delivered through the scaling up of six synergistic interventions, including testing and treatment, to achieve elimination by 2030: 90% of those infected diagnosed and 80% of those diagnosed treated. ”

Panel ILC 2022
“If we are to achieve elimination goals, there needs to be a substantial intensification and simplification of care pathways,” Philippa Easterbrook, MD, told the participants. Photocredit: Steve Forrest/EASL

She added: “While excellent progress has been made in many champion countries and more than 10 million people have been treated, according to the WHO World Hepatitis Report a year ago , only 21% of those infected have been diagnosed and 13% treated.. If we are to achieve elimination goals, there needs to be a substantial intensification and simplification of care pathways.

Among its early recommendations, the updated WHO guidelines called for decentralization, integration and task shifting in HCV care. Specifically, WHO has recommended moving HCV treatment and care out of specialist clinics to more peripheral or community-based health facilities where trained non-specialist physicians and nurses can be tasked with patient care to expand outreach. access.

Philippa Easterbrook

“We recommend providing hepatitis C testing and treatment at peripheral or community health facilities, ideally at the same site to increase access to diagnosis, care and treatment,” Easterbrook said. “These facilities can include primary care, harm reduction sites, prisons, HIV clinics, as well as community organizations. We recommend the integration of hepatitis screening and treatment into the existing services of these health facilities. »

The WHO made this a strong recommendation, based on moderate certainty of evidence, other than for the general population where there was 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 versus partial or no decentralization or integration, as well as the distribution of tasks to non-specialists versus specialists.

In its second updated guidelines, WHO made several conditional recommendations on the use of point-of-care HCV viral load RNA testing, namely that it can be used as an alternative approach to testing of HCV RNA nucleic acid in the laboratory to diagnose HCV viraemic infection. . Additionally, point-of-care HCV RNA testing with a detection limit comparable to laboratory testing can be used as an alternative approach as a test for cure, according to WHO recommendations.

“The rationale for this was based on a review of the evidence from 45 studies involving 27,364 patients, in which 50% of the studies were from low- and middle-income countries, which compared point-of-care viral load with laboratory tests “, Easterbrook noted. “The main message here was that there were better outcomes with point-of-care testing, with a short turnaround time from antibody testing to the start of treatment, increased uptake of burden viral infection and an increase in the absorption of the treatment. The diagnostic performance in terms of sensitivity and specificity compared to laboratory tests was also very high.

Additional advantages of point-of-care HCV RNA testing include its use in lower-level healthcare facilities close to where patients receive care, as well as the ability to integrate with other molecular platforms. at the point of care for diseases such as HIV, TB and COVID-19[FEMININE

Enfin, les directives de l’OMS recommandaient fortement l’utilisation de schémas thérapeutiques antiviraux à action directe pangénotypiques pour tous les adultes, adolescents et enfants âgés de plus de 6 ans atteints de VHC chronique, quel que soit le stade de la maladie. Les enfants âgés de 3 à 5 ans ont reçu une recommandation conditionnelle, basée sur une très faible certitude des preuves.

De plus, pour les schémas thérapeutiques antiviraux à action directe, l’OMS a fortement recommandé l’utilisation du sofosbuvir/daclatasvir, du sofosbuvir/velpatasvir et du glécaprévir/pibrentasvir chez les adolescents et les enfants plus âgés, tandis que les enfants âgés de 3 à 5 ans ont de nouveau reçu une recommandation conditionnelle.

“La justification était basée sur une revue systématique de 49 études chez les adolescents, les enfants plus âgés et les enfants plus jeunes, avec [sustained virologic response] rate of at least 95% in all age groups in all plans,” Easterbrook said. “Serious adverse events and treatment discontinuations were rare and, of course, [the benefit of earlier treatment] is to achieve a cure before the onset of disease progression and in associated liver damage.

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