What is the evidence for the effectiveness of interventions to reduce hepatitis C infection and the associated morbidity?

Summary

The issue

Hepatitis C infection has been declared a global health problem. Prevalence is most common among injecting drug user populations, where up to 98% can be infected despite a low HIV prevalence. Up to 20% of those infected with hepatitis C can clear the virus, though chronic infection can lead to significant hepatic morbidity and death.

Findings

While needle exchange programmes reduce the prevalence of hepatitis C (HCV), prevalence remains high. Therefore, other interventions are required to complement exchange programmes. Whereas opiate maintenance treatment, most commonly with methadone, has significantly reduced the incidence of HIV, it is only marginally effective at reducing the incidence of HCV. In part this could be due to underdosing. There is a paucity of research evaluating the effectiveness of either behavioural interventions or bleach disinfectants in reducing the transmission of hepatitis C infection among injecting drug user populations. The research that has been conducted would suggest that these interventions warrant implementation and evaluation. There is an emerging evidence-base for the effectiveness of supervised injecting centres at reducing the prevalence.

The transmission of hepatitis C infection from mother to child can be reduced by offering elective caesarean section in those co-infected with HIV. Optimal management of the intrapartum period can also reduce hepatitis C incidence. Breast feeding should only be avoided in those co-infected with HIV.

PEG interferon-ribavirin dual antiviral therapy is currently the most effective treatment at achieving a sustained virological response in those who are hepatitis C-RNA positive. Such treatment reduces the risk of developing chronic hepatic cirrhosis, or hepatocellular cancer. Dual therapy is also indicated in cases of co-infection, as long as HIV status is stable. Interferon monotherapy is indicated for those who develop acute infection after needle-stick injury.

Blood screening with NAT-technology is highly effective at reducing the transmission of HCV. However, NAT technology does not render careful donor selection unnecessary, nor does it allow blood or blood products to be used outside of pre-existing guidelines or in place of alternative manufactured infusions.

Policy considerations

Interventions are needed, particularly among injecting drug user populations. Behavioural interventions, distribution of bleach disinfectant and other injecting devices alongside clean needles and syringes, and supervised injecting centres are all promising interventions that merit further piloting and evaluation. Where opiate replacement therapy is provided for drug users, adequate dosing regimes should be used to minimize the risk of injecting practice. Cost–effectiveness analysis of current interventions aimed at primary prevention of hepatitis C infection shows additional benefits in reducing the prevalence of HIV.