Ten Steps to Eliminate Hepatitis C: Lessons from Spain on Accelerating Access to Testing and Treatment

Hepatitis C is curable, yet most countries are failing to find, test and cure tose living with it. To help address this, professional associations in Spain set out ten steps to eliminate hepatitis C in people accessing hospitals.

This case study highlights how hospitals can eliminate hepatitis C through practical approaches that strengthens the pathway from diagnosis to cure.

Spain has become a leading example of hepatitis C elimination by demonstrating how health systems can eliminate hepatitis C through integrating testing and treatment into routine care.

Since the introduction of Spain’s Strategic Plan for Addressing Hepatitis C in the National Health System (PEAHC) in 2015, the prevalence of hepatitis C decreased to 0.12% in 2022, with the number of liver cancer cases related to hepatitis C decreasing from 43% in 2008 to 17.5% in 2022.

However, despite the decline, the challenge of finding people who have not yet been diagnosed remained. Hepatitis C elimination initiatives focused on high prevalence populations or settings such as prisons and addiction centres as a way of reaching these populations. Hospitals were not commonly designated as settings for these initiatives. A 2022 study in Madrid, Spain, found that one in ten public hospital patients belonging to high prevelance populations, such as people in haemodialysis, people co-infected with HIV, people with advanced liver disease and people who inject drugs (PWID), had not been tested. Hospitals represented an untapped opportunity to find and treat people.

This finding prompted Asociación Española para el Estudio del Hígado, Grupo de Estudio de Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica and Sociedad Española de Patología Digestiva, professional associations in Spain, to consider how to accelerate testing and treatment within hospitals.

The following ten actions were proposed to eliminate hepatitis C in hospitals:

1.Implement reflex testing within all diagnostic services.

Reflex testing ensures that whenever a patient tests positive for hepatitis C antibodies, a confirmatory RNA test is automatically performed with the same blood sample. Reflex testing has shown benefits in linkage to care and is cost effective, even for mass screening strategies.

2. Adopt an effective system for notifications or alerts of positive cases, both to the requesting physician and to the service(s) responsible for hepatitis C treatment.

Service providers should be notified each time an active hepatitis C case is identified. This ensures that positive results are acted quickly upon and the person can be promptly linked to the next stage of care.

3. Establish direct referral to specialised care for any patient diagnosed with a chronic hepatitis C.

A simplified model avoids multiple referrals and proper coordination between services leads to better linkage to care and adherence to treatment.

4. Identify all patients lost in the system through a retrospective search for positive cases from at least 2015 onwards and periodically every 2 years after.

Searching for and finding patients who are positive for hepatitis C is essential to relink patients lost to follow up to care and treatment.

5. Simplify pre-treatment evaluation in patients with chronic hepatitis C, with or without compensated cirrhosis.

The only essential information needed to start treatment in patients with chronic hepatitis C is the presence of HCV RNA or HCV core antigen.

6. Simplify the dispensing of treatment, promoting complete delivery in a single visit, and facilitating its monitoring.

Where possible, treatment should be given in a single visit where the patient will be educated on the treatment and prevention. Techonology like mobile phones means that physical monitoring might not be necessary.

7. Implement universal screening in high-risk patients.

Universal screening is recommended for: people undergoing or who have undergone transplantation, people with chronic kidney disease and/or on haemodialysis, people living with HIV, People with liver cirrhosis, people with bleeding disorders who have or require blood transfusions, people with STI’s, PWID, people diagnosed with serious mental disorders and migrant people from countries with a high hepatitis C prevalence.

8. Establish screening in certain selected groups of patients by risk factors: pregnant people, patients admitted to the emergency department, during the pre-anaesthesia evaluation and/or those admitted to any hospital unit.

It is recommended that the protocols for emergency units, pre-anaesthetic evaluations and/or any hospital unit include the systematic search for risk factors for hepatotropic viruses and/or HIV.

9. Implement a decentralised and simplified diagnosis to facilitate approaching vulnerable populations.

Simplified diagnosis, including point of care testing and dried blood spot testing make hepatitis C testing accessible to vulnerable and underserved populations.

10. Implement coordination with harm reduction centres linked to hospitals.

Hospitals should work closely with harm reduction centres to improve testing and facilitate treatment for high risk populations.

Links to the NOhep Medical Visionaries Principles

Gather Allies

The recommended actions demonstrate the importance of multidisciplinary collaboration in accelerating hepatitis C elimination. It encourages healthcare professionals to work together to create seamless pathways from testing to treatment. Collaboration between healthcare professionals is essential to reducing missed diagnosis, improving linkage to care and making sure more people receive treatment.

Advocate to Governments

Building upon Spain’s Strategic Plan for Addressing Hepatitis C in the National Health System (PEAHC), the recommended actions encourage hospitals to prioritise and align with national elimination goals through investment and organisational change. Government commitment allows hospitals to innovate.

The proposed actions demonstrate that reaching hepatitis C elimination is not only about expanding treatment but also about creating healthcare systems where testing and treatment are seamlessly integrated. The actions model the TEST. TREAT. ELIMINATE approach in action.