Out of 36 invited C-EHRN focal points, all except one (from Estonia) responded (35/36, 97.2%).
The use of guidelines for hepatitis C treatment in people who inject drugs
Among respondents, six (17.1%) reported on still having no national guidelines for HCV treatment and seven (20.0%) reported on using the ones from EASL (Figure 1).
Figure 1. Reported use of most relevant guidelines for the treatment of hepatitis C from 35 European countries and their indications for treatment in different groups of people who inject drugs. #Scotland was treated separately from the rest of the United Kingdom. The countries in white did not participate in the study. ##The countries in blue use the national guidelines; the countries in grey use the guidelines of the European Association for the Study of the Liver (EASL); the countries in green reported no guidelines. ###The coloured circles represent permission for treatment in different groups of people who inject drugs: former injectors only (red), former injectors plus those on opioid substitution treatment (OST) (yellow), former injectors plus those on OST plus active injectors (dark blue). ####In North Macedonia treatment for hepatitis C is not available at all.
In only 23 of the responding countries (65.7%) the guidelines used include specific measures for PWID. In all but one of those 23 countries the guidelines somehow impact the accessibility to HCV testing and treatment of PWID, however they impact better access to harm reduction service in only 19/22 countries. Qualitative responses showed that several respondents were pessimistic about the impact of the guidelines used in their country on better access of PWID to the services such as testing and treatment and even by their own agencies. Responses received indicated that even if national guidelines exist, they have a limited relevance in practice. A range of challenges was reported, such as outdated guidelines and complicated testing and treatment systems, as well as lack of services and other kinds of disproportions between the formal guidelines and the real-life situation. However, as stated by some of the respondents, harm reduction agencies did not necessarily need official guidelines to start interventions on HCV.
According to the respondents, the DAAs were available in all reporting countries but North Macedonia (34/35, 97.1%). However, from 11/34 countries (32.4%) an official policy on restrictions for the use of DAAs was reported (Albania, Croatia, Finland, Latvia, Luxembourg, Montenegro, Romania, Russia, Serbia, Sweden, Ukraine). In 10 out of 34 countries (29.4%) DAAs were reported to be accessible only for people presenting liver fibrosis; in two countries (2/34, 5.9%) only advanced fibrosis or cirrhosis represented indications for DAA treatment (Albania, Serbia).
In 9/34 countries (26.4%) active drug users were still not applicable for DAA treatment (Figure 1). With the exception of Russia, PWID on OST were allowed to get HCV treatment in all other countries (33/34, 97.1%); former injectors were allowed DAA treatment in all of the included countries where DAAs were available (34/34, 100%).
All but six respondents (28/34, 82.3%) assessed that DAAs were being used in practice as stated in the official policy documents. DAA treatment was reimbursed by the health insurance or public health services in all countries except the UK; however, in a few countries the treatment was not automatically reimbursed for PWID (Hungary, Romania, and Serbia).
The functioning of a continuum-of-care for people who inject drugs
The C-EHRN monitoring data on a continuum-of-care including HCV testing and treatment showed that within Europe, a variety of service options existed for PWID, with some good and some bad practice examples (Table 1).
Respondents reported that screening tests for the detection of anti-HCV antibodies included either saliva testing (oral swabs) or blood testing (finger prick), whereas detection of HCV RNA was used as a confirmatory test. In the majority of countries the screening tests were a standard of care also outside the medical settings, such as harm reduction services or community centres (28/35, 80.0%) and prisons (21/35, 60.0%), as well as drug dependence clinics (22/35, 62.9%). The confirmatory testing was much more commonly performed at the infectious disease clinics (30/35, 85.7%) and gastroenterology clinics (18/35, 51.4%) compared to other settings, such as drug dependence clinics (12/35, 34.3%) and harm reduction services (9/35, 25.7%), however it was performed in prisons in 17/35 (48.6%) countries.
The prioritised settings for DAA treatment were the two clinical settings, infectious diseases and gastroenterology (29/35, 82.9% and 24/35, 68.6%, respectively). General practitioners (GPs) performed screening and confirmatory testing in 18/35 (51.4%) and 16/35 (45.7%) countries, respectively whereas they were allowed to prescribe DAA treatment in only 6/35 (17.1%) countries (the Czech Republic, Finland, France, Georgia, Germany, Scotland). DAA treatment was provided at the drug dependence clinics in 12/35 (34.3%) countries, and it was also provided in prisons in 15/35 (42.9%) countries. Since May 2019, all the physicians in France were allowed to prescribe DAAs.
Pharmacies were very rarely used as a setting for HCV testing (Italy, Scotland, and the UK) and DAA treatment (Scotland).
Scotland was reported to be the only country that offered HCV screening and confirmatory testing as well as DAA treatment at all the settings mentioned above.
Table 1. Settings for hepatitis C testing and treatment, as reported from 35 European countries. Scotland was treated separately from the rest of the United Kingdom.
Country
|
Gastro-enterology clinics
|
Infectious disease clinics
|
Drug dependence clinics
|
Harm reduction services or community centres
|
General practitioner
|
Pharmacy
|
Prison
|
Test
|
Treat
|
Test
|
Treat
|
Test
|
Treat
|
Test
|
Treat
|
Test
|
Treat
|
Test
|
Treat
|
Test
|
Treat
|
Albania
|
A R
|
Y
|
A R
|
Y
|
A
|
N
|
A
|
na
|
N
|
N
|
N
|
N
|
A
|
N
|
Austria
|
A R
|
Y
|
N
|
N
|
A R
|
N
|
A
|
na
|
A R
|
N
|
N
|
N
|
A R
|
N
|
Belgium
|
A R
|
Y
|
A R
|
N
|
A
|
N
|
A
|
na
|
A
|
N
|
N
|
N
|
A
|
Y
|
Bosnia and
Hercegovina
|
N
|
Y
|
A R
|
N
|
A
|
N
|
A
|
na
|
N
|
N
|
N
|
N
|
A
|
N
|
Bulgaria
|
R
|
Y
|
N
|
N
|
N
|
N
|
A R
|
na
|
N
|
N
|
N
|
N
|
N
|
N
|
Croatia
|
A R
|
Y
|
A R
|
Y
|
A
|
N
|
A
|
na
|
A R
|
N
|
N
|
N
|
(A)
|
N
|
Czech Republic
|
A R
|
Y
|
A R
|
Y
|
A
|
Y
|
A
|
na
|
R
|
Y
|
N
|
N
|
A R
|
Y
|
Denmark
|
N
|
N
|
A R
|
Y
|
A R
|
N
|
A
|
na
|
A R
|
N
|
N
|
N
|
N
|
N
|
Finland
|
R
|
Y
|
A R
|
Y
|
A R
|
Y
|
A R
|
na
|
A R
|
Y
|
N
|
N
|
A R
|
Y
|
France
|
A R
|
Y
|
A R
|
Y
|
A
|
Y
|
A
|
na
|
A R
|
Y
|
N
|
N
|
A R
|
Y
|
Georgia
|
A
|
Y
|
A R
|
Y
|
A
|
Y
|
A R
|
na
|
A
|
Y
|
N
|
N
|
A
|
Y
|
Germany
|
R
|
Y
|
A R
|
Y
|
N
|
Y
|
A R
|
na
|
A R
|
Y
|
N
|
N
|
A R
|
Y
|
Greece
|
N
|
N
|
R
|
N
|
N
|
N
|
A
|
na
|
N
|
N
|
N
|
Y
|
N
|
N
|
Hungary
|
N
|
Y
|
R
|
Y
|
N
|
N
|
A
|
na
|
N
|
N
|
N
|
N
|
A R
|
N
|
Ireland
|
R
|
Y
|
R
|
Y
|
R
|
Y
|
N
|
na
|
R
|
N
|
N
|
N
|
R
|
Y
|
Italy
|
N
|
N
|
R
|
Y
|
A
|
N
|
A
|
na
|
N
|
N
|
A
|
N
|
A R
|
Y
|
Latvia
|
N
|
N
|
R
|
Y
|
N
|
N
|
A
|
na
|
R
|
N
|
N
|
N
|
R
|
Y
|
Luxembourg
|
N
|
N
|
A R
|
Y
|
A
|
N
|
N
|
na
|
A
|
N
|
N
|
N
|
A
|
N
|
Montenegro
|
N
|
N
|
R
|
Y
|
N
|
N
|
N
|
na
|
N
|
N
|
N
|
N
|
N
|
N
|
Macedonia, North
|
N
|
Y
|
R
|
Y
|
N
|
N
|
N
|
na
|
N
|
N
|
N
|
N
|
N
|
N
|
Netherlands
|
A R
|
Y
|
A R
|
Y
|
A
|
N
|
N
|
na
|
A R
|
N
|
N
|
N
|
A R
|
N
|
Norway
|
A
|
Y
|
N
|
N
|
N
|
N
|
N
|
na
|
A R
|
N
|
N
|
N
|
N
|
N
|
Poland
|
N
|
N
|
R
|
Y
|
A
|
N
|
A
|
na
|
A
|
N
|
N
|
N
|
A
|
Y
|
Portugal
|
A R
|
Y
|
A R
|
Y
|
A R
|
Y
|
A R
|
na
|
R
|
N
|
N
|
N
|
A R
|
Y
|
Romania
|
R
|
Y
|
R
|
Y
|
A
|
N
|
A
|
na
|
A
|
N
|
N
|
N
|
A
|
N
|
Russia
|
N
|
N
|
A R
|
Y
|
A
|
N
|
A
|
na
|
N
|
N
|
N
|
N
|
N
|
N
|
Scotland
|
A R
|
Y
|
A R
|
Y
|
A R
|
Y
|
A R
|
na
|
A R
|
Y
|
A R
|
Y
|
A R
|
Y
|
Serbia
|
N
|
N
|
N
|
Y
|
N
|
N
|
A
|
na
|
N
|
N
|
N
|
N
|
N
|
N
|
Slovakia
|
R
|
Y
|
N
|
Y
|
R
|
N
|
A
|
na
|
N
|
N
|
N
|
N
|
R
|
N
|
Slovenia
|
N
|
Y
|
R
|
Y
|
R
|
N
|
R
|
na
|
R
|
N
|
N
|
N
|
R
|
N
|
Spain
|
R
|
Y
|
R
|
Y
|
A R
|
Y
|
A R
|
na
|
R
|
N
|
N
|
N
|
R
|
Y
|
Sweden
|
A
|
N
|
A R
|
Y
|
A R
|
Y
|
A R
|
na
|
A
|
N
|
N
|
N
|
A R
|
Y
|
Switzerland
|
A R
|
Y
|
A R
|
Y
|
A R
|
Y
|
A
|
na
|
A R
|
N
|
N
|
N
|
N
|
N
|
Ukraine
|
N
|
N
|
A R
|
Y
|
N
|
N
|
A
|
na
|
A
|
N
|
N
|
N
|
A
|
N
|
United Kingdom
|
A R
|
Y
|
A R
|
Y
|
A R
|
Y
|
A R
|
na
|
A
|
N
|
A
|
N
|
A R
|
Y
|
A antibody test, R RNA test, N no, Y yes, na not analysed
#Testing included either screening test for hepatitis C virus antibodies (A) or confirmatory test for hepatitis C virus RNA (R), or both (AR)
## Treatment in harm reduction services and community centres was not included in the questionnaire
Eighteen countries (18/35, 51.4%) reported having precise linkage-to-care protocols/guidelines for newly HCV diagnosed PWID to be referred for treatment. The government monitored the numbers/proportions of people who progress through each stage of the HCV continuum-of-care on the national level in 14/35 countries (40.0%); monitoring at the regional or local level was performed in five and seven countries, respectively whereas in the remaining countries monitoring was not performed at al.
Longitudinal evaluation of a continuum-of-care
The current C-EHRN survey revealed the dynamic of providers’, investment in various services of a continuum-of-care. Compared to the previous year, 15/35 countries (42.9%) reported on having more attention paid to HCV awareness campaigns, 18/35 (51.4%) to testing on the service providers’ own locations, and 15/35 (42.9%) to treatment on the service providers’ own locations; 9/35 (25.7%) countries reported on improvements made in all the three services (Belgium, Denmark, Italy, the Netherlands, Poland, Romania, Scotland, Switzerland, Ukraine) (Figure 2). In other countries the situation had remained the same as in the previous year or there had been even less activities but overall compared to the previous year the results on changes made in the continuum-of-care were positive.
Figure 2. Improvements in a continuum-of-care compared to the previous year and the role of harm reduction and non-governmental organisations of people who inject drugs reported from 35 European countries. NGO non-governmental organisation, PWID people who inject drugs. #Scotland was treated separately from the rest of the United Kingdom. The countries in white did not participate in the study. ##The coloured circles represent improvements in a continuum-of-care compared to the previous year with regard to awareness campaigns (yellow), testing (blue) and treatment (red). ###The countries in blue report on having active non-governmental organisations of people who inject drugs; the countries in green report on having no such active non-governmental organisations; for the countries in rose the data are missing.
Role of harm reduction and non-governmental organisations of people who inject drugs
Twenty-four European countries (24/35, 68.6%) reported on having NGOs of PWID that are working actively for political awareness in regard of HCV interventions whereas no such NGO support is reported from nine countries (9/35, 25.7%) (Austria, Bosnia and Herzegovina, the Czech Republic, Finland, Hungary, Luxembourg, Romania, Scotland, Serbia) (Figure 2). Finally, while trying to address HCV among PWID the barriers and limitations repeatedly mentioned by the harm reduction organisations were the lack of funding, political support and general recognition of harm reduction measures (Albania, Germany, France, Hungary, Ireland, North Macedonia, Romania, Serbia, and the UK). The shortage of knowledge and training on HCV infection, as well as a lack of skilful staff were mentioned by the Czech Republic, France, Germany, Ireland and Russia. Another reported barrier was the weakness of the CSO, whereas legal barriers, particularly those regarding the possibility of testing within the community were reported from Greece and Montenegro.