The UK needs to “be doing so much more” in
response to hepatitis C, according to a new report. Supported by a consortium
of leading hepatitis C charities, Confronting
the silent epidemic: a critical review of hepatitis C management in the UK highlighted a 300% increase in hepatitis C
virus (HCV)-related deaths since 1996 and significant concerns about the future
of services within the reformed NHS.
“Diagnosis and treatment rates are
dishearteningly low when compared to other European countries and patients are
suffering unnecessarily as a result,” said Charles Gore of the Hepatitis C
Trust. “It is now more important than ever that hepatitis C is a priority for
commissioners and service providers throughout the UK.”
The report was funded by the drug company Roche
and endorsed by the Hepatitis C trust, the British Liver Trust and the European
Liver Patients Association, as part of the Hepatitis Awareness Leading Outcomes
(HALO). It combines a review of the literature looking at the management of HCV
in the UK with qualitative evidence providing case studies of best practice in
the crucial areas of diagnosis, treatment uptake and retention and adherence.
According to WHO estimates, there are
214,000 cases of chronic HCV infection in the UK. However, approximately half of
these infections are undiagnosed, and the Health Protection Agency (HPA)
estimated that there will be 370,000 HCV infections in the UK by 2035. However,
the HALO report showed there are serious deficiencies in HCV surveillance. A quarter
of NHS health commissioners have yet to estimate the number of local diagnoses.
Despite the availability of care and
treatment services across the UK, fewer than one in 30 people with HCV receive
therapy every year. Treatment rates in France are up to twelve times higher.
Moreover, in 2010 a report commissioned by the All-Party Parliamentary
Hepatology Group found “huge variations” in hospital treatment of HCV, with
many centres refusing therapy to drug users and those who had undergone a
previous course of treatment. Inadequacies in the recording of treatment
outcome rates were also highlighted.
The consequences of not treating HCV are
already apparent. The report shows that hospital admissions due HCV-related
disease increased from 612 in 1998 to 1979 in 2010, and deaths from 98 in 1996
to 323 in 2010, an increase of more than 300%.
Analysis of HCV diagnosis and treatment
rates in leading industrialised countries showed the UK’s record currently placed it 13th out of 14. In
2010, the All-Party Hepatology Group concluded: “it is unacceptable that the
number of deaths from liver disease and liver cancer is rising sharply in the
UK, while falling in the rest of Europe.”
The economic consequences of poor diagnosis
and treatment rates are also highlighted in the HALO report. The HPA estimates
that, if left untreated, 15,840 people will have HCV-related cirrhosis or
liver cancer by 2035. This would result in treatment and care costs of £11,000
and £12,500 per patient per year at current values. If current trends continue,
4200 liver transplants will be needed at a cost of £50,000 each.
The number of people receiving HCV
therapy in the UK needs to be quadrupled in order for the epidemic to be
controlled and the human cost of liver disease reduced. Although this will cost
an estimated £43.8 million per year, it would be highly cost effective, with gains in productivity of £73.3 million.
But data highlighted in the report suggest
this is an ambitious target. Only a third of the now defunct primary care trusts fully implemented the 2010 Hepatitis C Action Plan for England and the
situation does not look like improving. NHS changes introduced in April give
local authorities responsibility for public health. The HALO reports draws
attention to a survey conducted in March 2013 which found them “to be
unprepared for their new responsibilities, with only a fifth having a clinical
lead for hepatitis C in place, and even fewer with a strategy”. Moreover, gaps
have been identified throughout the HCV care pathway, with the “cumulative
effect…most notable in treatment”.
Two protease inhibitors were recently
approved for the treatment of genotype 1 infection, clinical trials showing
that they significantly improved treatment outcomes when used in combination
with the current standard of care, pegylated interferon and ribavirin.
Remarkably, the licensing of these agents was accompanied by a 6% fall in the
number of treated patients in England, though this may partly be because
clinicians and patients are awaiting even more effective and tolerable agents.
But the HALO report also highlights some
examples of best practice, showing what can be achieved in the most challenging
of circumstances when resources are made available to prepare people for
triple therapy and support their adherence.
“The trajectory of HCV therapeutic
advancement is stunning,” said Professor David Goldberg of Hepatitis Scotland.
“Islands of outstanding clinical and public health practice in the UK
demonstrate that, with adequate resources, imaginative leadership and major
input from the third sector...the seemingly tortuous patient journey for those
with lifestyle issues can be completed very successfully.”
The report concludes: “Maintaining the
current level of response is not an option if we are to interrupt the UK’s
relentless escalation of serious disease and death caused by hepatitis C.
Action plans without muscle had suboptimal impact. There is no time to lose.”