Icelandic HCV elimination program treats majority of viremic population
Since its launch in 2016, a hepatitis C elimination program in Iceland has treated approximately 56% to 70% of the estimated viremic population with direct-acting antivirals, according to a recently published update.
“The idea was to offer DAAs to all HCV-positive patients within an entire population within a relatively short time frame and simultaneously initiate an observational study with long-term follow-up,” Sigurdur Olafsson, MD, FACP, Landspitali University Hospital, and colleagues wrote. “Gilead would, in a study setting, provide DAAs free of charge for the project.”
The Treatment as Prevention for Hepatitis C in Iceland program, or TraP HepC, was designed to treat a majority of Icelanders with HCV, including injection drug users. The concept was initially discussed in 2014 and then put into action in 2016.
“With the TraP Hep C program, Iceland is taking a cohesive, multipronged approach that includes scale-up of prevention, testing and early treatment of hepatitis C in both hospital and community settings,” the researchers wrote. “It includes a multidisciplinary public health model of care and cooperation between government, health services, the penitentiary system and community organizations.”
According to Olafsson and colleagues, Iceland has seen 40 to 70 new cases of HCV each year over the last 20 years with an estimated viremic population of 1,100 (range, 880-1,300) in 2014 for a population prevalence of 0.3% (range, 0.3-0.4). Most individuals with HCV in Iceland also have a history of injection drug use.
During the initial phase from January to October 2016, all patients with HCV received treatment with Harvoni (ledipasvir/sofosbuvir, Gilead Sciences) for 8 weeks to 12 weeks. Patients with genotype 3 also received ribavirin. After November 2016, all patients received Epclusa (sofosbuvir/velpatasvir, Gilead Sciences).
The program also included an increased focus on screening efforts, especially among injection drug users, and improving harm reduction strategies in the country. The researchers estimated that an 80% reduction in domestic incidence is achievable by 2025 if a minimum of 75 out of 1,000 injection drug users are treated per year. If 188 of 1,000 injection drug users are treated per year, the same reduction rate may be achieved by 2020.
“It has been estimated that by offering treatment to up to 200 patients every 4 months, the majority will be treated within the first two years of the program,” the researchers wrote.
Additional goals of the project include measuring the short-term and long-term effects of the program regarding the incidence of HCV infection in Iceland, the incidence rates of cirrhosis and hepatocellular carcinoma related to HCV, virologic response rates, compliance to treatment, and prevalence among injection drug users over a 15-year span.
“These data as well as the data generated during the project will be used to assess the effect of the intervention on the future burden of illness for patients and society,” the researchers wrote.
Since its launch, 557 patients with HCV have been evaluated for an estimated range of 56% to 70% of the viremic population. Of those, 526 patients initiated treatment with DAAs, 37% of whom reported injection drug use within 6 months.
Patients who were homeless (74% vs. 94%; P = .0005) and those who reported current injection drug use (87% vs. 95%; P = .003) were less likely to achieve sustained virologic response compared with others.
“Although some parts of this program are empirical in nature and highly dependent on intangibles, such as vigilance and motivation amongst health care professionals and the public alike, it is hoped that treatment as prevention will lower the incidence and morbidity associated with HCV well in advance of the WHO targets,” the researchers wrote. “The results of Icelandic project will provide important data and inform others globally trying to achieve the WHO hepatitis C elimination goals.” – by Talitha Bennett
Disclosure: Olafsson reports he received speakers fees from Merck. Please see the full study for the other authors’ relevant financial disclosures.