CHEARS

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). It can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.

Hepatitis C virus (HCV) infection is a major public health threat worldwide, with approximately 71 million people living with chronic infection and is a major cause of liver cancer.

New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The 2020 standard of HCV care has evolved toward universal screening and treatment.

The approval of direct-acting antivirals (DAAs) starting in 2014 revolutionized treatment and allows nearly all patients to be cured. The number of individuals initiating HCV treatment has increased from approximately 500,000 in 2014 to over 2 million in 2017. In 2016, the World Health Organization called for HCV to be eliminated as a global public health threat by 2030, setting a goal of reducing new infections by 90%, treating 80% of chronic infections, and reducing mortality by 65%

WHO has encouraged countries to pursue elimination of both viral hepatitis B and C together, however they may choose to apply separately for one of four certification options:

• Option A: Elimination of mother-to-child transmission (EMTCT) of HBV (as part of triple elimination of HIV, syphilis and HBV, or HIV/HBV).

• Option B: HCV as a public health problem;

• Option C: HBV as a public health problem (including HBV EMTCT); and

• Option D: Elimination of both HBV and HCV together as a public health problem.

“This guidance is intended to motivate countries to take rapid and appropriate action toward viral hepatitis elimination. It is also important that the validation process is country-led and driven.

To identify all cases of HCV and achieve full elimination, outreach programs designed to link high-risk patients to medical care and a more comprehensive screening strategy are needed.

WHO and EASL guidelines support general population testing in settings where the HCV antibody has at least a 2% to 5% seroprevalence.

Screening and Diagnosis Recommendations

· Screen all adults once using an HCV antibody test with reflex to HCV RNA by PCR.

· If universal screening is not feasible, screen all persons born from 1945 to 1965 and those with any identified risk factors.

· Continue annual screening for individuals with ongoing risk behaviours

Pre-treatment Recommendations

· Perform a physical examination and obtain a patient history, including HCV treatment history, stigmata of cirrhosis, extrahepatic manifestations, and all current medications

· Obtain blood tests, including CBC, AST, ALT, total bilirubin, albumin, and creatinine; test for HBsAg, anti-HBs, anti-HBc total, HIV antibody, anti-HAV, and eGFR

· Estimate fibrosis stage using platelet count and, if appropriate, detect advanced fibrosis/cirrhosis using APRI, FIB-4, serum-based biomarkers, elastography and/or imaging

· If advanced fibrosis/cirrhosis (F3 or F4) is detected, screen for HCC by ultrasound with optional AFP testing

· Consult with a specialist before managing a patient who has been previously treated for HCV or has active HBV or HIV coinfection, severe renal impairment, uncontrolled comorbidities, platelet count less than 100 × 109/L, or decompensated cirrhosis

Treatment Recommendations

· Treat HCV infection with one of the pan-genotypic regimens GLE/PIB or SOF/VEL (or SOF/DAC, if available)

· Before initiating treatment, assess for potential drug-drug interactions

Monitoring Recommendations

· Advise patients, particularly those with prior HBV infection, to contact their HCP if they experience unexpected or severe symptoms

· At least 12 weeks after treatment completion, confirm cure by assessing HCV RNA by PCR; refer patients with detectable HCV RNA to a specialist

· At least 12 weeks after treatment completion, obtain the ALT level; if ALT remains abnormal on repeated measure, refer the patient to a specialist

Post cure Recommendations

· Inform patients who are cured that they are susceptible to reinfection

· Provide patients with appropriate HCV harm-reduction resources to minimize the possibility of reinfection

· Continue HCC surveillance every 6 months in patients who had advanced fibrosis/cirrhosis before HCV treatment

The goal of simplifying HCV therapy is to enable expansion of treatment on a scale that will meaningfully contribute to HCV elimination. Together, these resources may facilitate diagnoses and lead to greater treatment access in the primary care setting, thus contributing to elimination of HCV infection.