* Research doctor at the Center for Global Health, Higher Institute of Health
The arrival of new antiviral drugs against the hepatitis C virus represented an epochal turning point, namely the possibility of healing from a viral infection and related diseases. The World Health Organization has defined the targets for the elimination of HCV infection by 2030, involving numerous States, including Italy, which in 2015 adopted the National Plan for the Prevention of Viral Hepatitis (PNEV).
What happened in Italy? Since April 2017, all patients with an HCV infection have access to treatment, regardless of the severity of the disease. The crucial point, however, is that most HCV infections are asymptomatic, therefore difficult to diagnose.
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Risk factors for the HCV virus
According to data from SEIEVA (Integrated Epidemiological System of Acute Viral Hepatitis), the main risk factors for the acquisition of the infection – i.e. the current and / or previous use of drugs, the use of tools for aesthetics , acupuncture, tattoos, body piercing or dental care, in premises without adequate hygienic conditions or managed by unqualified personnel – are mainly distributed among the population between 34 and 55 years. But in this population a very low perception of risk persists, almost always accompanied by the absence of symptoms and a risk of transmission of the infection.
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71 million for the first phase of free screening
In 2020, 71.5 million euros were allocated to the Regions for free screening activities intended – for now – for all subjects followed by the public drug addiction services (SerT), prisoners in prison and those born in the years since 1969 to 1989. With this intervention, Italy has taken an important step forward in the fight against HCV, and has shown itself to be implementing an avant-garde health policy strategy.
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The screening process for HCV infection in Italy must ensure fairness in diagnosis and treatment. Therefore, this first stage, which involves screening in the younger sections of the Italian population, must be promptly followed by an extension of screening to older ones, including the population of the 1948-1968 birth cohorts, as well as to individuals with risk factors. and comorbidities, regardless of their age, to achieve the goal of eliminating HCV by 2030.
The implementing decree, adopted last April by the Minister of Health and published – finally – in the Official Gazette on 8 July 2021, defined the procedures to be used in relation to each of the categories of eligible subjects, and provided for the implementation of training and information to be borne by the Regions.
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Strong differences between regions
But the Regions are now on the starting grid with strong unevenness. The figure that catches the eye is a strong delay with respect to the roadmap drawn, which should see the screening activities be completed – for this first phase – by 2022.
We are faced with the possibility of being able to eliminate Hepatitis C, but the confusion that arises in the implementation of the decree is singular. This is a serious delay, certainly the result of the COVID-19 pandemic which continues to absorb resources and energy, but which is also explained by a series of other critical issues.
There are difficulties in coordinating the various regional figures involved in the planning and organization of screening. It is difficult to manage, in times suited to the objectives, to define and implement a plan that knows how to find regional resources to be used for training, information, reporting, and to combine with the methods of using the funds made available by the State for screening test.
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What to do
What can the regions do? Urgently define how to guarantee the exercise of the right of access to free screening, in accordance with current legislation.
It is certainly essential to understand how and at what level to involve the health structures present in the area, especially considering the serious shortages of health personnel and planning in the SERDs and prisons.
It is also necessary to establish if and how to involve the general practitioner, strongly advised by the implementing decree, as well as the pharmacies and prevention offices in the area: which ones? And in what ways?
How to proceed operationally? Provide a unique code – or a similar tool on the basis of the chosen model – for the identification of the beneficiary population, in order to allow the first and second level tests to be carried out without additional costs to identify an infection in progress. Furthermore, the code would make it possible to ensure the necessary link between tests, diagnosis and treatment, and would also allow for the effective collection of information.
It will be essential to establish a clear path in all the Regions that colleague specialists, general practitioners, doctors of the SerD and of penitentiary medicine, in order to better implement screening and optimize the connection to treatment. Furthermore, it is necessary that the Regions provide an effective communication plan, to avoid a poor response by citizens to screening.
We can still do it
The stakes are high: hepatitis C and the associated social and economic consequences can be eliminated. Failing now would mean losing an important opportunity in the name of a problem that has been debated for some time, namely the difficult coordination between the State and the Regions, especially for interventions that are able to deploy their real effectiveness only if carried out in a uniform and equitable manner throughout the territory. national.
Therefore, guaranteeing equity and reducing inequalities in access to HCV screening remains a very important knot that must be resolved between the State and the Regions, including actions of this type in the PNEV (national plan for the prevention of viral hepatitis from viruses B and C) and in the Regional Prevention Plans. Let’s try to make the elimination of Hepatitis C a case of virtuous collaboration for the benefit of all. Let’s not wait any longer, we can still do it.
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