Spain has made significant progress on hepatitis C elimination after approval of the Strategic Plan for Hepatitis C in the Spanish National Health System (PEAHC) in 2015.1 From 2015 to mid-2020, more than 135,000 people have received direct-acting antiviral agents (DAAs) against the hepatitis C virus (HCV). Besides, improvement has been made in understanding the country HCV infection's epidemiology and reinforcing awareness and community participation to prevent infection.
As part of the objectives of PEAHC, the Spanish Ministry of Health has recently published the Guide for the screening of HCV infection.2 The guide has been developed by the Secretariat of the National Plan on AIDS and the Screening Programs Unit of the General Directorate of Public Health of the Ministry of Health. Collaborators include members from several institutions including the National Plan on Drugs, the National Epidemiology Center (Carlos III Health Institute), the Epidemiology Services of the autonomous regions, the General Secretariat of Penitentiary Institutions, the Scientific Advisory Council of the PEAHC, several Scientific Societies (SEIMC, SEISIDA, AEEH, AEHVE, SEMFyC, SEMG, SEMERGEN), and Patient Associations and NGOs (PLAFHC Madrid, PLAFHC, CESIDA, Apoyo Positivo, FNETH, gTt-HIV). The document has been endorsed by the Population Screening Conference, the Regional Office of the World Health Organization (WHO) for Europe, and the Barcelona Institute of Global Health (See supplementary material).
The decision on the best HCV screening strategy and the recommendations for adequate implementation in the guide has taken into consideration different criteria. Firstly, the results of the 2nd Seroprevalence Study that places Spain as a country with a low prevalence of HCV infection.3 According to this study, 0.22% of the country's population had active HCV infection, of whom 29.4% (approximately 22,478 people) were not diagnosed. Besides, approximately one in five of those diagnosed with active infection was not linked to care or receiving anti-HCV treatment, a situation primarily affecting the most vulnerable populations. The study results highlight the drastic decrease in the prevalence of active HCV infection in Spain over the last years and the improvement in some groups’ quality of life, such as people with HIV coinfection. Notwithstanding, in recent years, an increase in new HCV infections and reinfections has been observed in men who have sex with men with sexual practices with a high risk of transmission in the context of drug use (Chemsex).
The screening recommendations consider the country burden of infection, the fact that more than 80% of people with active HCV have risk factors for infection, the absence of reliable evidence on the efficacy and cost-effectiveness of population screening, and the fact that screening in the presence of risk factors for HCV is already included in the portfolio of services of the Spanish National Health Service. Based on these pieces of evidence, and in order to optimize the available resources, screening is recommended exclusively for individuals with exposures or situations of risk for the transmission of HCV, such as injected or inhaled drug use, risky sexual relations, co-infection with HIV or HBV, health or esthetic procedures performed without the proper safety precautions, admission to prisons, and origin from countries with a medium or high prevalence of HCV infection. Screening for HCV infection is not recommended in asymptomatic people without exposure or risk situations.
Of note, the guide's coordinators have requested a study of other screening strategies’ cost-effectiveness (population screening, screening of birth cohorts) to the Network of Health Technology Assessment Agencies and Benefits of the National Health System. The current recommendations will be reviewed based on the results of this study. Currently, and in light of the data described above, improving access to diagnosis and linkage to the follow-up and treatment of people with HCV infection is key.
The Guide includes other recommendations such as the one-step diagnosis of HCV infection following the recommendation of Clinical Microbiologists, Infectious Diseases specialists, and Hepatologists.4 Tailoring of care in those more vulnerable is also encouraged. For example, initiatives on multidisciplinary care in centers for people with drug addiction, carrying out the diagnosis and dispensing treatment under the same roof. It is advised to integrate prevention and screening measures for HCV, HBV, HIV, and other sexually transmitted infections in primary care, hospitals, and sexual health clinics. The Guide acknowledges community organizations for their work in prevention and linkage to screening and treatment services.
The authors wish to thank the Editorial Committee of Enfermedades Infecciosas y Microbiología Clínica for the opportunity to present this HCV infection screening guide. We encourage all professionals to read and disseminate it and contribute to eliminating hepatitis C in Spain.
The following are the supplementary data to this article:
