Hepatitis C: policy context

In 2016, WHO published their Global health sector strategy on viral hepatitis, 2016-2021, outlining the priorities and strategic directions to advance toward the elimination of viral hepatitis. This strategy aims to reduce new cases of hepatitis C by 90% and deaths by 65% by 2030, while increasing the percentage of people aware of their infection to 90%. In 2019 they published a progress report informing on the implementation of the strategy.

In 2019 the Scottish Government commited to eliminate hepatitis C as a public health threat in Scotland by 2024. The key aim of the strategy is to increase the HCV treatment target to 3,000 people starting treatment every year from 2020-21 onwards and to reduce the number of people living with chronic HCV infection in Scotland from 21,000 to less than 5,000. Health Protection Scotland published the strategy to achieve it, which described the impact of the Scottish Hepatitis C Action Plan, which since 2006 has helped to reduce by 45% the number of people infected by hepatitis C in Scotland. 

The Hepatitis C Elimination strategy is the culmination of a series of policies over the last two decades to tackle HCV in Scotland. In 2000, the Scottish Needs Assessment Programme (SNAP) published a report on hepatitis C that reviewed existing services and made recommendations on how prevention, diagnosis and treatment could be improved.

In 2005, the Scottish Executive released for consultation the hepatitis C proposed action plan in Scotland which was designed to promote further implementation of the SNAP recommendations and the key messages in the hepatitis C consensus statement that emerged from a Royal College of Physicians of Edinburgh conference in 2004.

The Scottish Government launched Scotland Action Plan for Hepatitis C in 2006; the aims of which are:

  • To prevent the spread of hepatitis C, particularly among Injecting Drug Users (IDUs)
  • To diagnose hepatitis C infected persons, particularly those who would most benefit from treatment
  • To ensure that those infected receive optimal treatment, care and support

Taking a two-phased approach, Phase 1 (undertaken during September 2006 to March 2008), comprised 41 actions spread across the areas of co-ordination, prevention, testing/treatment/care and support and education/training/awareness-raising. It involved increasing awareness about hepatitis C among professionals and undertaking extensive research and consultation to inform proposals for the development of hepatitis C services during Phase II. All but one of the 41 Phase I actions were delivered; the outstanding action – the piloting of an in-prison needle and syringe exchange scheme – was rescheduled to be implemented during Phase II.

Phase II launched in May 2008, saw an investment of approximately £43 million to tackle the hepatitis C challenge facing Scotland (the bulk of which was allocated to NHS boards), over the three years of the Plan. It aimed to deliver 34 actions designed to improve prevention, diagnosis, treatment, care and support services for hepatitis C throughout the country. In 2010, the second Phase II progress report was released. 

Following on from the hepatitis C Action Plan, the Scottish Government launched the Sexual Health and Blood Borne Virus (SHBBV) Framework in 2012. Focusing on an outcomes-based approach, the Framework is firmly anchored in shared ownership and joint working with a key focus on challenging inequalities. Multi-agency, partnership working is central and the Scottish Government, the NHS, councils and the third sector all have vital roles to play in delivering the outcomes.

The Framework outcomes are:

  1. Fewer newly acquired blood-borne viruses and sexually transmitted infections; fewer unintended pregnancies.
  2. A reduction in the health inequalities gap in sexual health and blood borne viruses.
  3. People affected by blood-borne viruses lead longer, healthier lives.
  4. Sexual relationships are free from coercion and harm.
  5. A society where the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood-borne viruses are positive, non-stigmatising and supportive.

The framework also details a number of specific indicators with associated accountabilities within NHS boards, councils and Scottish Government activity.

An updated SHBBV framework covering the 2015-20 period was published in September 2015. The update does not replace the 2011-2015 framework; instead it outlines the progress made since its publication and highlights areas that require additional focus in 2015-2020 in order to help meet the five outcomes originally identified in 2011.

Significant developments have occurred in both hepatitis C treatment and prevention practices since the original strategy was published. The updated framework highlights a number of developments, including:

  • An increase in hepatitis C testing, resulting in a rise in the estimated proportion of the total infected population who have been diagnosed (from 38% in 2007 to 55% in 2013).
  • An increase in the number of people commencing antiviral treatment (from 470 in 2007/8 to 1,270 in 2014/15), coupled with the development of new and more effective antiviral therapies. The first of these was approved (with restrictions) by the Scottish Medicines Consortium in 2014, and more followed in 2015 and 2016. These therapies are not only more tolerable for patients, but they also offer higher viral clearance rates - which is considered a cure (see more on this below).
  • Changes to the Misuse of Drugs Act that mean people who inject drugs can now be provided with foil via injecting equipment provision services (which can be used to smoke rather than inject drugs), further reducing the harm associated with injecting. 
  • New challenges associated with the rising use of new psychoactive substances (some of which are injected), and evidence from Public Health England that suggests men who inject performance and image enhancing drugs are at an increased risk of hepatitis C.
  • The completion of the Penrose Inquiry into the transmission of Hep C and HIV via infected blood and blood products in NHS settings. It highlighted the importance of continued case-finding efforts by the NHS in order to diagnose individuals who may have contracted hepatitis C many years ago.
  • The UK National Steering Committee’s updated review of screening for hepatitis B and C in individuals born outside the UK.

A target was set to initiate antiviral treatment in 1,500 people per year in the 2015-20 period in order to bring about 75% reduction in the number of people with hepatitis C developing liver failure and/or liver cancer by 2020 (from 200 to 50). The treatment initiation target of 1,500 people per year represented an almost 20% increase in the number treated in 2014.

Due to the COVID-19 pandemic, the next publication of the SHBBV Framework was postponed until 2022. Instead the Scottish Government published a Recovery Plan, to combat the effects of the COVID-19 pandemic on SHBBV services. It is a fluid framework with 4 key aims:

  • To re-establish a comprehensive range of SHBBV services across Scotland;
  • To understand the impact of the pandemic on people with SHBBV service needs, particularly those facing additional barriers accessing services, and to develop targeted responses where possible;
  • To assess and begin to mitigate the SHBBV inequalities that the pandemic will have exacerbated or created;
  • To ensure that the innovations and service redesigns in response to the pandemic are evaluated, that learning is shared, and local or pilot projects are scaled up where successful and appropriate.

For detailed information on how the COVID-19 pandemic has affected SHBBV services and the plans to address this see the Recovery Plan.