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Background Info

In October 2017, the Scottish Government Hepatitis C Treatment and Therapies Group, an advisory group made up of experts, made a series of recommendations to the Scottish Government on revised targets contributing towards the Scottish Government’s commitment to eliminate hepatitis C. The following recommendation was made: “The annual number of people initiated onto anti-viral therapy: 1,800/year, during 2017/18, rising to 3,000 during 2018/19; of the 3,000, 1,500, or as near to that figure as possible, should belong to the F2-F4 liver fibrosis category at time of treatment, to ensure that the 2020 target associated with morbidity reduction is met.” This recommendation was made unanimously by members of the group.

In January 2018, the Scottish Government rejected the recommendation of the Treatment and Therapies Group, opting instead to increase the target of new treatment initiations from 1,800 in 2017/18, to just 2,000 in 2018/19, with a stepped approach to a treatment target of 3,000 in 2020/21 and subsequent years.

This is despite the fact that the Treatment and Therapies Group stated in the justification for its recommendation that “even taking into account any net additional non-drug related costs, the overall cost of treating 3,000 individuals in 2018/19 will be considerably less than the cost of treating just over 1,700 individuals in 2016/17” due to a significant decrease in treatment costs.

Scotland has long been regarded as a world leader in tackling hepatitis C. The Sexual Health and Blood Borne Virus Framework 2015-2020, published in September 2015, contains an explicit commitment to the elimination of hepatitis C. The World Health Organization defines elimination as a minimum 90% reduction in incidence of chronic hepatitis C infections and a 65% reduction in mortality from hepatitis C by 2030. The UK is one of 194 countries signed up to the World Health Organization Global Health Sector Strategy on Viral Hepatitis, which commits participating countries to the elimination of hepatitis C as a major public health threat by 2030.

The Hepatitis C Action Plan (2006-2011) and the current Sexual Health and Blood Borne Virus Framework (2015-2020) are considered to be models of international good practice and have led to significant increases in the numbers of people diagnosed and treated in Scotland over the past decade.

However, Scotland is in danger of falling behind without further action. During the inquiry preceding The Hepatitis C Trust’s January 2018 report, there was general agreement from experts that elimination will not be achieved by 2030 with current treatment numbers. The report found that some clinicians were being asked to slow down the numbers of patients being treated in order to treat patients in line with targets, rather than in line with the allocated budget (with treatment cost reductions not resulting in increased access). A key recommendation in The Hepatitis C Trust’s report was for “treatment cost reductions to be reinvested into additional treatments or services to ensure access to treatment is available immediately to all who need it”.

Given the confirmation of vast reductions in treatment cost by the Treatment and Therapies Group, the Scottish Government’s decision to be decidedly unambitious in its treatment target revision amounts to a significant reduction in overall spend on hepatitis C treatment, and an abandonment of the previously strong commitment to elimination. This was a disappointing decision for many former patients and campaigners. Now that we have a full cure for this deadly virus, it seems clear that it should be a national objective to get significantly greater numbers of people tested and treated.

The Government’s current hepatitis C treatment target numbers - 2,000 people treated in 2018/19, 2,500 for 2019/20 and 3,000 for 2020/21 onwards - do not reflect the current treatment environment or treatment cost reductions in recent years.

Savings made due to treatment cost reductions should be re-invested in finding the undiagnosed and treating additional numbers of people, in line with the recommendation in The Hepatitis C Trust’s recent report for “treatment cost reductions to be reinvested into additional treatments or services to ensure access to treatment is available immediately to all who need it”. There should be universal access to hepatitis C treatment across Scotland, and every health board should be conducting active outreach to diagnose additional numbers of people.

To encourage health boards to find and diagnose additional numbers of people, and to avoid the perception that this target is a cap, the Government should set an additional, aspirational upper target for treatment initiations in each year.

Background on hepatitis C

Hepatitis C is a blood-borne virus that primarily affects the liver, and can cause fatal cirrhosis and liver cancer if left untreated. Hepatitis C can also have a much broader impact and has been linked to cardiovascular disease, mental health issues, kidney problems, and musculoskeletal pain. It is transmitted through blood-to-blood contact, and disproportionately affects marginalised and disadvantaged groups, such as people who inject drugs (PWID), homeless people, men who have sex with men (MSM), and migrant communities from endemic countries. These groups are not the only ones at risk: significant numbers were infected by the NHS through infected blood and blood products.

People infected with hepatitis C often experience few or no obvious symptoms, which can result in them living with the virus for many years without being diagnosed, increasing the risk of severe liver damage. Crucially, hepatitis C is preventable, treatable and curable for the vast majority of people. New treatments are now available, with short treatment durations, limited side-effects and cure rates upwards of 95%.

Recent estimates suggest that around 34,500 people are chronically infected with hepatitis C in Scotland, with more than 40% remaining undiagnosed. Of those diagnosed, many are not in touch with services and need to be reconnected to the service pathway. In 2016/17, 1,739 people commenced treatment for hepatitis C, slightly lower than the total for 2015/16. Worryingly, the incidence of hepatitis C infections among people who inject drugs in 2015/16 was reported by Health Protection Scotland as almost double that of 2011/12.

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