Impact of the COVID-19 pandemic on HCV elimination in Spain.

To the Editor:

We read with great interest the article by Sarah Blach and coworkers investigating the impact of COVID-19 on global hepatitis C elimination efforts. The authors show that over the next 10 years a 1-year delay scenario related to COVID-19 would result in 44,800 excess hepatocellular carcinoma (HCC) cases globally and 72,300 excess liver-related deaths, relative to a no delay scenario. The excess HCC cases and deaths would be among high-income countries.

Spain is one of the 45 high-income countries on the right track to reach HCV elimination by 2030 if the current screening and therapy rates are maintained. However, COVID-19 strongly hit the country in March 2020 and continues to date. The first wave from March to June prompted a country-wide lockdown and the second wave has been ongoing since September. During this overall period, there has been a drop in HCV testing, linkage to care, harm reduction programs, and microelimination programs. We aimed to assess the impact of COVID-19 on hepatitis C elimination in Spain.

A previously validated Markov model was adapted to simulate the effect of pandemic-related delays in HCV diagnosis and treatment on future advanced liver-related disease and deaths in the next 10 years. We used the data obtained to evaluate repercussions on the WHO goals by 2030 and to calculate the economic impact regarding healthcare costs (€, 2020).

A cohort of 15,859 patients was analysed comparing two scenarios: the non-COVID-19 scenario, where all patients would be diagnosed and treated in the first year, 2020, and the COVID-19 scenario where there would be an 18-month delay from the beginning of 2020 to the end of June 2021 with a view to the expected vaccine availability in mid-2021. The simulation used clinical data from patients with HCV treated with direct-acting antivirals in Spain (January 2019 to August 2020). In the COVID-19 scenario, the number of monthly HCV treatments decreased by between 19% and 84% from early 2020 to June 2021. In addition, it was assumed that patients would be treated in the following year and a half (50% from July 2021 and 50% during 2022), based on the 2019 distribution of patients. Patients with a delay in diagnosis and treatment progressed according to the natural course of the disease. Cohort baseline characteristics (average age and fibrosis) and sustained virological response were taken from published real-world data in Spain.

Fig. 1 shows the results for both scenarios by 2030. An 18-month delay in HCV diagnosis and treatment due to the COVID pandemic in a cohort of 15,859 patients would increase the number of liver-related deaths, HCC, and HCV-related decompensated cirrhosis by 117, 73, and 118 cases, respectively. In economic terms this would translate into a 1.0 M€ cost increase due to decompensated cirrhosis and a 1.3 M€ increase due to HCC. Furthermore, a high number of patients (34 vs. 48) would need a liver transplant due to decompensated cirrhosis or HCC. The cost associated with liver transplantation would increase by 2.5 M€ (5.8 vs. 8.3) for the total cohort during this period.

Fig. 1

Impact of the COVID-19-related diagnostic and treatment delay on HCV burden (clinical and economic) over the next 10 years.

The data derived here are based on a simulation with 15,859 patients, but it is estimated that 76,839 people still have active HCV infection in Spain. Thus, if a larger number of patients is affected by the COVID-19 pandemic, the actual clinical and economic impact would be greater.

The data we report were estimated with a different methodology than that used by Blach in her study on the global impact of COVID-19 on hepatitis C elimination. Nonetheless, the findings are similar: delaying HCV elimination programs will be associated with an increase in HCV-related morbidity and mortality in the next 10 years.

Spain was on track for HCV elimination, but the COVID-19 pandemic has hindered efforts to maintain the cascade of care for HCV and many microelimination programs. The excess morbidity and mortality caused by this delay calls for the reinforcement of screening programs, particularly in vulnerable populations and those with more difficult access to primary care physicians. This will be possible if the EASL guidelines for hepatitis C are applied. In summary, hepatitis C elimination must continue to be a political goal and a priority of our health system. The implementation of telehealth, home-delivery services for drugs or HCV screening when COVID tests are performed could minimize the impact of the COVID pandemic on HCV patients and HCV elimination.

Financial support

MB none. PORIB has received unconditional funding from , Spain for this analysis.

Authors’ contributions

All authors contributed equally to the concept and design, to the preparation of the manuscript and read and approved the final manuscript. RDH performed the modelling analyses.

Conflicts of Interest

MB: Advisory Board participant for Gilead and Abbvie. RDH and MAC are employees of Pharmacoeconomics & Outcomes Research Iberia, a consultancy firm specialising in the economic evaluation of healthcare interventions that has received unconditional funding from .

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