Viral hepatitis policies in Europe – topic overview
Viral hepatitis policies in Europe
Introduction
Hepatitis C virus (HCV) infection is the most common infectious disease in people who inject drugs, among whom it is usually transmitted through the sharing of syringes and other drug use equipment. Most of those who become infected go on to develop chronic HCV infection, which can lead to severe health problems in individuals and place a major burden on healthcare systems. Yet the infection is both preventable and treatable, and new medicines exist that can cure hepatitis C among nearly all of those infected.
In Europe, hepatitis C virus infection is highly prevalent among people who inject drugs, or have done so in the past, with national infection rates for this group ranging from 18 % to 80 %. However, infected individuals often show no noticeable symptoms, and many are unaware that they are carrying the virus, leading to it being referred to as a ‘hidden’ epidemic. Injecting opioid users in Europe constitute an ageing population, which includes many who have been living with hepatitis C for 20 or more years. The natural history of chronic HCV infection and the ageing cohort effect in this population mean that a large burden of advanced liver disease can be expected over the next decade.
Agenda 2030
Agenda 2030 for Sustainable Development: a global policy framework
At the United Nations Sustainable Development Summit on 25 September 2015, more than 150 world leaders adopted the 2030 Agenda for Sustainable Development, including 17 Sustainable Development Goals (SDGs) to end poverty, protect the planet and ensure prosperity for all.
SDG 3, 'Ensure healthy lives and promote wellbeing for all at all ages', addresses communicable diseases as follows:
'By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases (3.3).'
Contributing to the Agenda 2030, the elimination of viral hepatitis as a public health threat has been defined as a goal in the first Global health sector strategy on viral hepatitis, 2016–2021 (WHO, 2015). The strategy addresses all five hepatitis viruses (hepatitis A, B, C, D and E), with a particular focus on hepatitis B and C, owing to the relative public health burden they represent.
Global elimination targets for the year 2030 are twofold: a reduction in the incidence of chronic infections by 90 % and of associated mortality by 65 %; and ensuring equitable access to comprehensive prevention and recommended testing, care and treatment services for all.
To support the strategy as a global framework for action, an interactive website provides implementation tools, such as a manual for developing national viral hepatitis plans.
Europe
European overview
The regional action plan for Europe
An action plan for the health sector response to viral hepatitis in the World Health Organization (WHO) European Region adapts the global strategy to the European context. Resulting from a broad consultation process among European stakeholders, the plan guides the regional implementation of the global strategy. This regional plan was endorsed by the 53 Member States of the WHO European Region and recognises already existing prevention and control efforts in the European Region and the capacity of existing systems to further impact on the epidemics.
This regional action plan defines milestones for 2018 and sets intermediate European targets for the year 2020, including specific targets for people who inject drugs (PWID) as one of the populations most affected and at risk of infection with viral hepatitis.
In Europe, people who inject drugs are a main at-risk group and play a key role for HCV elimination. Latest evidence-based HCV treatment guidelines (WHO, EASL) recommend their prioritisation in order to maximise the reduction in incidence that can be reached through effective treatment.
Monitoring the elimination of HCV among PWID
The launch of a global strategy aimed at the elimination of viral hepatitis has created momentum and provides an opportunity to increase efforts and collaborations at all levels. In its Communication on next steps for a sustainable European future of November 2016, the European Commission committed itself to helping Member States to reach the global goals. The EMCDDA and ECDC collaborate with WHO Europe to support Member States in monitoring progress towards elimination goals. In November 2017, ECDC brought together stakeholders to define hepatitis B and C indicators to be monitored at the EU level, following the global framework and regional action plan targets. The EMCDDA contributes to this work by providing data on several core-indicators on prevention among people who inject drugs, available through its ongoing monitoring activities of this at-risk population. Complementing the monitoring framework geared towards the general European situation, the EMCDDA maintains a ‘barometer’ showing progress in HCV elimination among people who inject drugs. In order to strengthen Member States’ capacity in implementing evidence-based responses, the agency maintains a best practice database.
Existence of policies: a 2018 milestone for HCV elimination
Equitable access to hepatitis treatment is one of the progress indicators towards the global elimination goal, and the existence of a national hepatitis plan has been defined as an important 2018-milestone for countries in the European Region (1). In order to document progress made towards this milestone and to promote the exchange of good practices, the EMCDDA assessed national hepatitis policies in the 30 EMCDDA Member States with regard to whether they promote or limit access to HCV treatment and care for people who inject drugs. HCV policies were defined as national strategies, programmes and action plans addressing HCV and/or HCV among people who inject drugs – including those integrated in broader health strategies or plans. Between February and October 2017, a targeted search for policy documents was undertaken in the reports submitted by national focal points to the EMCDDA, in published and grey literature, and relevant national websites. Additional information was gathered through the EMCDDA expert network on drug-related infectious diseases. Where no national HCV strategies, programmes and action plans were identified, current clinical guidelines were considered. An assessment of whether and how national policies or clinical guidelines address the access of people who inject drugs to HCV care and treatment was made, and analytical summaries as well as lists of national policy-relevant documents were compiled. These were submitted to EMCDDA focal points in early 2018 for validation and, if necessary, update. The updated material was compiled by the EMCDDA and represents the status until March 2018. All countries except Turkey provided feedback.
The HCV policy landscape in Europe
Figure 1 — HCV policy landscape in Europe
By March 2018, 17 EU countries and Norway had official hepatitis policies. This includes the Maltese strategy, which was under consultation until 15 March. Eleven EU countries did not have a national hepatitis policy, but strategies were under preparation in Poland and Romania. No data were available from Turkey.
National HCV policies included an explicit reference to the importance of granting people who inject drugs access to care services. However, while responses of high relevance for people who inject drugs, such as community based infectious diseases testing and improved access to integrated prevention, harm reduction and care services, were mentioned in some strategic documents, clear national treatment targets for people who inject drugs as an important at-risk group had rarely been set. With the notable exceptions of Denmark, England, France, the Netherlands, Scotland and Slovenia, who developed their first hepatitis C policies between 1997 and 2007, most of the current national hepatitis policies in Europe are very recent (see Figures 2 and 3).
Agenda 2030 has had a major impact on national HCV policies in Europe. This is seen in the acceleration of policy development and adoption witnessed in recent years. It is also to be found in the content of policies adopted since 2015, which reflect countries’ commitment towards the Sustainable Development Goal on health, often embracing the HCV elimination goal. All new HCV policies consider people who inject drugs as an important risk-group. Nevertheless, in spring 2018, in 8 of the 11 EU Member States that had yet to adopt an explicit HCV policy, clinical guidelines restrict access to HCV treatment by people who inject drugs. Thus, systemic barriers to equitable access to HCV treatment continue to exist in a number of countries. Further information is provided in the Country summaries, below.
(1) 'A costed and funded national hepatitis plan with clear targets or a viral hepatitis response plan in a broader health strategy or action plan' (see Annex 1 of 'Action plan for the health sector response to viral hepatitis in the WHO European Region').
Country summaries
Hepatitis policy implementation by country
Note: the country summaries in this section are based on a study commissioned by the EMCDDA on viral hepatits policies in Europe, which also contains additional background information.
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Summary |
HCV policy key document |
Additional documents |
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Austria |
No national strategy or action plan addressing hepatitis is available and no specific guidelines addressing HCV treatment for PWID was identified. Locally, innovative options for the treatment of drug users with chronic HCV are being developed: HCV treatment is available both in hospitals in Vienna, Graz and Innsbruck – usually in cooperation with low- threshold centres – and also directly in the low-threshold setting of the Viennese ‘Ambulatorium’, as a directly observed therapy combined with opioid substitution treatment. Resulting from cooperation with a number of pharmacies, patients undergoing opioid substitution treatment at the ‘Ambulatorium’ can receive their hepatitis C medication at the pharmacy together with their substitution medicine. Nowadays, health insurance funds cover the costs of treatment with new direct-acting antivirals for all patients independent from degree of fibroses and genotype. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesGesundheit.gv.at (Öffentliches Gesundheitsportal Österreichs) (2017): Hepatitis C – Therapie & Nachsorge [HCV treatment information for general public] Research and practiceSchütz, A. et al. (2018): Directly observed therapy of chronic hepatitis C with ledipasvir/sofosbuvir in people who inject drugs at risk of nonadherence to direct-acting antivirals. Journal of Viral Hepatology, 2018 Jan 5. doi: 10.1111/jvh.12857. ClinicalTrials.gov number, NCT02638233 Haltmayer, H. et al (2016): Directly Observed Therapy of chronic Hepatitis C with Interferon-Free All-Oral Regimens at a Low-Threshold Drug Treatment Facility – A New Concept for Treatment of Patients with Borderline Compliance Receiving Opioid Agonist Therapy. Poster at the INHSU 2016, Oslo Haltmayer, H. et al (2015): Therapie der chronischen Hepatitis C bei Patienten unter Opioid-Substitutionstherapie im niedrigschwelligen Setting [Treatment of chronic HCV among patients in opioid substitution treatment in low-threshold settings], Suchtmedizin, Vol. 17, nr. 6, p 267-275. OtherGesundheit Österreich (2016): Datenanalyse zu Inzidenz und Prävalenz von Hepatitis-C-Erkrankungen in Österreich, [Analysis of prevalence and incidence of HCV-related illness in Austria] |
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Belgium |
A national strategic plan to tackle Hepatitis C (2014-2019) was prepared in 2012 and adopted by the Ministry of Health in May 2014. PWID are mentioned as a priority group in the strategic plan. There is no specific budget allocated to implement the action plan and no specific targets or concrete plan for monitoring progress towards the actions suggested in the plan. The plan includes three overall aims: 1) To reduce transmission of HCV; 2) Increase the proportion of HCV infected people who are diagnosed and 3) To improve care for and quality of life among people living with hepatitis C. Since the beginning of 2017, an inter-ministerial working group, representing all the Belgian communities and regions is evaluating the national strategic plan and is planning follow-up for those action points that have not been implemented yet. The clinical treatment guidelines were updated in 2017 and are based on the most recent EASL guidelines. PWID are not mentioned specifically and are treated with the same criteria used for non-PWID. |
Ministry of Health: Plan Hépatite C 2014-2019 [Hepatitis C plan 2014-2019], adopted on 5 May 2014. |
GuidelinesThe Belgian Association for the Study of the Liver (BASL): Treatment options and diagnostic cut-offs for HCV in Belgium (Updated January 2017) Bourgeois S et al (2016): Achieving WHO recommendations for Hepatitis C Elimination in Belgium. Acta Gastro-Enterologica Belgica. Vol LXXIX, April-June 2016. Research and practiceBelgian Health Care Knowledge Center KCE (2012): Health Technology Assessment Hépatite C: Dépistage et Prévention [Hepatitis C: Screening and Prevention] Literature review on the effectiveness and cost-effectiveness of HCV screening among PWID and of HCV prevention programs among PWID as well as application of a dynamic mathematical model to investigate the effectiveness of treating PWID (including active PWID) to prevent HCV transmission. Matheï C, Bourgeois S, Blach S, Brixko C, Mulkay JP, Razavi H, Robaeys G: Mitigating the burden of hepatitis C virus among people who inject drugs in Belgium. Acta Gastroenterol Belg 2016, vol.79, pp 227-232. OtherMuyldermans G , Van Gucht S, Van Baelen L: Jaarrapport 2016 Hepatitic C Virus. WIV-ISP, Brussels; 2016. |
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Bulgaria |
No national strategy or action plan addressing hepatitis is available. There is no specialised viral hepatitis treatment programme targeting people with addictions or other risk groups. The document defining the rules for treatment of viral hepatitis by the National Health Insurance Fund limits the access of people with current alcohol and drug abuse to treatment (see below). Clients in opioid substitution programmes are only eligible for HCV treatment if a psychiatric assessment determines that they are stable and meet certain inclusion criteria. The review of DAA restrictions criteria in Europe performed on behalf of the International Network on Hepatitis in Substance Users (INHSU) Network found that access to HCV treatment in Bulgaria required 12 month abstinence from drug and alcohol abuse (Marshall et al 2018). |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesNational Health Insurance Fund (March 2017): Изисквания на НЗОК за извънболнично лечение на Хроничен вирусен С хепатит при пациенти над 18 годишна възраст в сила [Requirements for the outpatient treatment of chronic viral hepatitis ] http://www.nhif.bg/web/guest/207 This document states: It is recommended that in patients who are expected to have a low level of adherence - especially patients with significant alcohol consumption and/or drug abuse, priority should be given to resolving the problems of abuse and postponing the treatment of hepatitis C until their stabilization. |
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Croatia |
No national strategy or action plan addressing hepatitis is available. Updated clinical guidelines for treatment of Hepatitis C were published in May 2017. These mention that the latest guidelines from EASL and WHO recommend that all patients with chronic hepatitis C who are willing to be treated and have no contraindication should be treated. However, they also mention that due to limited availability of DAAs it is currently necessary to identify priority groups who will be treated first. The clinical guidelines do not mention PWID. The costs of DAA treatment is covered by the national health insurance fund. The review of DAA restrictions criteria in Europe performed on behalf of the International Network on Hepatitis in Substance Users (INHSU) Network found that access to HCV treatment with DAAs in Croatia requires six months abstinence from drug and alcohol abuse and toxicological tests every 3 months while on HCV treatment (Marshall et al 2018). |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesMinistry of Health / Reference Centre for diagnosis and treatment of viral hepatitis (May 2017): Preporuke za liječenje hepatitisa C [Recommendations for treatment of hepatitis C] [Last update: 23 May 2017] |
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Cyprus |
No national strategy or action plan addressing hepatitis is available. No specific documents addressing HCV treatment for PWID are available. In the harm reduction pillar of the new Action Plan for Addressing Dependence on Illicit Substances and the Harmful Use of Alcohol (2017-2020) a specific action involving the Ministry of Health stipulates that people with substance dependence issues have free access to treatment for infectious diseases in public hospitals (Priority 7, Objective 1, Action 6). Free testing for HIV, HBV, HCV and tuberculosis for drugs users is available (Circular of Ministry of Health issued in 2011 and updated in 2017). HCV treatment guidelines: According to the Ministry of Health, the criteria for initiating the new antiviral treatment for Hepatitis C limit access to patients with rapid deterioration of liver disease. It is expected that no more than 20 cases will meet the access conditions every year. A Technical Mission on Viral Hepatitis B and C of ECDC and WHO experts took place in January 2018. A possible future extension of the new antiviral treatment for HCV by State Hospitals to specific high risk groups, such as intravenous drug users, may be discussed following the adoption of a National Hepatitis Strategic Plan. The review of restrictions for reimbursement of DAAs in Europe performed on behalf of the International Network on Hepatitis in Substance Users (INHSU) Network found that access to DAAs in Cyprus requires abstinence from drug and alcohol abuse (Marshall et al 2018). |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesMinistry of Health (2014) ΠΡΩΤΟΚΟΛΛΟ ΕΛΕΓΧΟΥ ΜΟΛΥΣΜΑΤΙΚΩΝ ΑΣΘΕΝΕΙΩΝ (HIV/AIDS, ΗΠΑΤΙΤΙΔΑ Β & C, ΦΥΜΑΤΙΩΣΗ, ΣΥΦΙΛΗ, ΣΑΛΜΟΝΕΛΛΑ ΚΑΙ ΠΑΡΑΣΙΤΑ) [Protocol for the control of infectious diseases – including hepatitis C]. OtherMinistry of Health (2017) Updated circular on free testing for infectious diseases for drug users. Cyprus National Addictions Authority (2017) Action Plan for Addressing Dependence on Illicit Substances and the Harmful Use of Alcohol 2017-2020. |
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Czech Republic |
No national strategy or action plan addressing hepatitis is available. The clinical guidelines on diagnosis and treatment for hepatitis C include the statement that HCV treatment must not be refused due to addiction. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesUrbánek et al 2017: STANDARDNÍ DIAGNOSTICKÝ A TERAPEUTICKÝ POSTUP CHRONICKÉ INFEKCE VIREM HEPATITIDY C (HCV) [National guidelines for HCV diagnostic and treatment] (From March 2017) OtherThe Czech National Monitoring Centre for Drugs and Addiction: National Drug Policy Strategy for the period 2010-2018 PWID access to HCV treatment and care not addressed specifically in this drug policy strategy, only the general objective to decrease and treat infections among PWID is mentioned. |
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Denmark |
In 2007, the national board of health published a national action plan for preventing hepatitis C among people who use drugs. This was followed up in 2013 with a general guidance on HIV, HBV and HCV for health care workers which included a section on ensuring testing, counselling and care (i.e. HBV vaccination) for people in drug treatment (e.g. in OST). |
GuidelinesWeis N et al 2017: Behandling af hepatitis B virus (HBV) og hepatitis C virus (HCV) infektion – En guideline (Dansk Selskab for Infektionsmedicin & Dansk Selskab for Gastroenterologi e Hepatologi); [Treatment guidelines for HBV and HCV] Research and practiceRADS (Rådet for Anvendelse af Dyr Sygehusmedicin) 2016: Baggrundsnotat for behandling af kronisk hepatitis C infektion [Background note on treatment of chronic hepatitis C] OtherSundhedsstyrrelsen 2007: National handlingsplan til forebyggelse af hepatitis C blandt stofmisbrugere [National action plan for preventing HCV among people who use drugs] |
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Estonia |
No official national hepatitis policy document (strategy or action plan) currently exists. However, despite current (2010) clinical treatment guidelines mentioning PWID as a non-priority group for HCV treatment, it was reported that in practice HCV treatment is available for PWID, but only if they have health insurance. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesEstonian Society of Gastroenterology and Estonian Society for Infectious Diseases, 2010: „Treatment guidelines for chronic Hepatitis C . PWID are currently mentioned as a non-priority patient group (which should not receive antiviral treatment for HCV). However, new clinical guidelines are in preparation in which access to HCV treatment for PWID will be adapted to reflect international recommendations. Estonian Society of sexually transmitted infections, 2015: Seksuaalsel Teel Levivate Infektsioonide Ravijuhis Eestis 2015 [Guidelines on sexually transmitted infections] . Includes a section on viral hepatitis in which the EASL 2014 guidelines on management of hepatitis C infection is referenced. OtherMaimets M et al. (2017): C-hepatiidi epideemia likvideerimisstrateegia eesmärgid ja tegevusplaan Eestis aastaiks 2018–2030. Eesti Gastroenteroloogide Seltsi ja Eesti Infektsioonhaiguste Seltsi visioon (Estonian Society of Gastroenterology and Estonian Society for Infectious Diseases) [Visions for an Estonian hepatitis C elimination strategy, 2018-2030] This paper has not yet been adopted as an official recommendation in Estonia. Ministry of Social Affairs: National Health Plan 2009-2020 The national drug strategy and all related activities are described in the National Health plan. The Plan does not mention specific activities regarding hepatitis among PWID. |
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Finland |
A national strategy for hepatitis C for Finland 2017-2019 was published by the Ministry of Social Affairs and Health in November 2016. The national strategy was produced by a multidisciplinary working group with members from the Ministry of Social Affairs and Health; the National Institute for Health and Welfare; Prison health authorities; NGOs; Clinicians and the Liver Patient organization. Finland’s strategy emphasizes that all people with hepatitis C infection should have equal access to treatment. The aims of the strategy are to: increase prevention of new infections, harmonize diagnostics and treatment practices, make a clear clinical pathway from testing to treatment evaluation and therapy, increase surveillance, and create a national treatment registry. Treatment guidelines included in the strategy specify that DAAs are to be used if the interferon therapy is not effective and liver damage is progressing or if there is a contraindication for interferon therapy and the liver damage is advanced (F2-F4). Patients who have a contraindication for interferon therapy (e.g PWID) must be referred to evaluation of the degree of liver damage and treated if the patient is motivated. In the long term all patients infected with hepatitis C virus would receive treatment regardless of the degree of liver damage. In March 2017, the Ministry of Social Affairs and Health set up a national HIV and Hepatitis Expert Group with the mandate to follow-up the implementation of the hepatitis C strategy. One of its working groups is elaborating recommendations on the pathway from testing to treatment evaluation and therapy, expected to be published during spring/autumn 2018. Work on HCV treatment registry is underway and centralised procurement for HCV DAA’s is taking place. A HCV prevalence study among general population (nested HCV study) is underway and hepatitis C awareness campaigns are scheduled to take place during 2018. |
GuidelinesSee strategy |
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France |
In 1999, France published its first national action plan for hepatitis C 1999-2002, which was followed by three further plans until 2012. Since 2013, based on an evaluation by the High Council for Public Health (HCSP), viral hepatitis is integrated in the National sexual health strategy (2017-2030) to achieve synergy, consistency and a global approach. It is also addressed in the 2013-2017 Government Plan for combatting drugs and addictive behaviours. France has globally been highlighted as a best practice example for ensuring universal access to hepatitis care and treatment also for direct treatment access of people who inject drugs. Since June 2016, the National Health Insurance Fund reimburses 100% of the cost of treatment with DAAs for current drug users in contact with low threshold who exchange their equipment, irrespective of the stage of fibrosis. |
GuidelinesAFEF (March 2017). Recommandations AFEF sur la prise en charge des hépatites virales C. AFEF (Association française pour l'étude du foie), Paris [Recommendations for the management of HCV infection] . ANRS and CNS (2016): Prise en charge thérapeutique et le suivi de l’ensemble des personnes infectées par le virus de l’hépatite C [2016 Treatment recommendations for hepatitis C infections] . Direction de l'Evaluation Médicale, Economique et de Santé Publique Haute Autorité de Santé. Antiviraux d’action directe. In : Commission de la transparence, ed. Saint-Denis : HAS, June 2016. Research and practiceHaute Autorité de santé (HAS) (2016). Commission de la Transparence. Rapport d’évaluation des antiviraux d’action directe dans le traitement de l’hépatite C. Delarocque-Astagneau et al (2010): The impact of the prevention programme of hepatitis C over more than a decade: the French experience. J Viral Hepat. 2010, 17: 435-443. OtherMILDECA (2013) Plan gouvernemental de lutte contre les drogues et les conduites addictives 2013-2017.Paris, Mission interministérielle de lutte contre les drogues et les conduites addictives. [Government Plan for Combating Drugs and Addictive Behaviours] CNS - Conseil national du SIDA et des hepatites virales (2016): Créer les conditions d’un accès universel aux nouveaux traitements contre le virus de l’hépatite C [Statement on creating conditions for universal access to the new hepatitis C treatments] . |
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Germany |
In 2016, an overall integrated strategy for HIV, hepatitis B/C and other sexually transmitted infections was published by the Ministry for Health. It is a general strategy without any specific targets. PWID and prisoners are specifically mentioned and the need for improved integration of hepatitis testing and treatment (including HBV vaccination) in addiction treatment services is highlighted. Recommendations to screen PWID for hepatitis C are included in clinical guidelines, but no national screening strategy exists. Access to DAA treatment is not restricted in Germany. The treatment costs are covered for all individuals with social health insurance, including PWID, if clinical guidelines are followed. Treatment is also available in prisons, however medical care of prisoners is funded by the Ministries of Justice of the federal German states, and great variation in access to HCV treatment between federal states and prisons is observed. |
Bundesministerium für Gesundheit (2016): Strategie zur Eindämmung von HIV, Hepatitis B und C und anderen sexuell übertragbaren Infektionen. BIS 2030 – Bedarfsorientiert · Integriert · Sektorübergreifend [Integrated strategy for HIV, hepatitis B and C and other sexually transmitted infections]. The document is available in both German and English. |
GuidelinesDGVS (2016): Aktuelle Empfehlungen zur Therapie der chronischen Hepatitis C [HCV treatment guidelines] OtherThe 2010 Guidelines on the management of HCV infection are currently under revision and expected to be published soon. |
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Greece |
On 28 July 2017, the Ministry of Health launched the first national Action Plan for responding to Hepatitis C among PWID, prisoners, sex workers, men who have sex with men, refugees and immigrants in Greece. The plan promotes early diagnosis and monitoring. The strategic goals are a) public awareness on Hepatitis C prevention and response, b) development / improvement of health services providing care and treatment for HCV infection, c) development of a network of competent health services which are going to cooperate with the ECDC and the EMCDDA for monitoring Hepatitis B and C, d) registering all HCV positive cases and mapping out all competent health and diagnostic services as a basis for the development of evidence-based health policy. The Action Plan will be coordinated by the Ministry of Health. The actions will be monitored by the National Coordination Committee which consists of: Hellenic Centre for Diseases Control and Prevention (HCDCP ), National Scholl of Public Health, General Secretariat for Gender Equality, General Secretariat for Young People, Universities, KETHEA, OKANA, 18 ANO, Alternative Therapeutic Programme for Drug-addicted Individuals ARGO, science associations (e.g. Hellenic Association for the Study and Control of AIDS) and NGOs supporting people living with HCV. |
Action Plan for responding to Hepatitis C among PWID, prisoners, sex workers, men who have sex with men, refugees and immigrants in Greece (no link available) |
GuidelinesHellenic Center for Disease Control and Prevention (February 2017) [Treatment Guidelines for Hepatitis C]. Athens: Hellenic Center for Disease Control and Prevention (29 pages). PWID should be tested for anti-HC and those tested anti-HCV-negative should be re-tested annually. Furthermore PWID who are HCV-positive should receive priority IFNa-free treatment. Research and practiceSouliotis K et al 2017: Access to treatment for Hepatitis C among injection drug users: results from the cross-sectional HOPE IV study. International Journal for Equity in Health (2017) 16:101. Gountas I et al 2017: Treatment and primary prevention in people who inject drugs for chronic hepatitis C infection: is elimination possible in a high-prevalence setting? Addiction, 112(7): 1290-1299. Greek Organization against Drugs (OKANA), Framework for the Operation of Treatment Facilities (2012). Recommends screening upon entry to treatment and referral to appropriate services. OtherA National Hepatitis Treatment Registry is operational since April 2017. Registration of patients is obligatory. Ministry of Justice (2014) The Greek Charter on the Rights of People addicted to Drugs. Makes references to HCV-positive drug users’ right for unhindered access to specialised treatment. |
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Hungary |
In Hungary there is no national HCV strategy. There is a so-called ’consensus paper’ on hepatitis C management which is updated yearly as well as a financing protocol – these are used in practice by the Health Insurance Fund and the clinicians (the official Gastroenterologists’ Association). A separate budget (of around 17 million EUR) has been established under the national health insurance fund. Currently, around 4000 people are initiating treatment each year and as waiting lists have been reduced, patients can enter treatment immediately. DAAs are the first line treatment and the cost per treatment is under 4000 EUR. The allocated budget is sufficient for all the patients seeking treatment. Screening efforts are emphasized as necessary to include more patients, risk groups including drug users are recommended to get screened. The official funding protocol in the hepatitis register requires from people with drug addiction a three-month period of abstinence before initiating treatment. Guidelines require that an addiction specialist’s (psychiatrist) opinion should be sought to assess comorbidities such as depression or other psychiatric disorders which may be contraindications for treatment. In practice, the decision regarding initiation of treatment lies with the hepatologist. An important remaining barrier for IDUs is their lack of health insurance rights. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesNational consensus guideline in Hungary from 22 September 2017 (abstract available in EN) OtherHepatitis Register (restricted access) A hepatitis C vírus okozta krónikus májgyulladás diagnosztikájának és kezelésének finanszírozási eljárásrendje (2017) [Funding procedure for the diagnosis and treatment of chronic hepatitis C] |
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Ireland |
The first national hepatitis C strategy 2011-2014 published in 2012 did not include any extra budget for implementation. After an expert advisory group had examined the feasibility of a multi-annual treatment plan for hepatitis C in their report: Public health plan for the pharmaceutical treatment of hepatitis C (2014), the Government approved the establishment of a National Hepatitis C Treatment Programme for 2016-2026 in the Health Service Executive (HSE) in line with the approach set out in the report. The National Hepatitis C Treatment Programme is managed by a fulltime Programme Manager and is led clinically by a Clinical Lead. In July 2017, comprehensive National Clinical Guidelines on Hepatitis C Screening were published. Access to HCV treatment is currently provided through specialist services based in the acute hospital setting. PWIDs are not restricted or excluded from treatment once clinically prioritised by their clinician. On a pilot basis, the HSE has started providing HCV treatment in the addiction services setting to patients in opioid substitution treatment. The HSE plans an expansion of HCV treatment across community and acute hospital settings in 2018. |
Health Service Executive (HSE): National Hepatitis C Treatment Programme 2016-2026 (website) – for an overview, see Tait (2018): National Hepatitis C Treatment Programme |
GuidelinesDepartment of Health (2017): Hepatitis C Screening (NCEC National Clinical Guideline No. 15) . Department of Health (2015): Public Health Plan for the Pharmaceutical treatment of Hepatitis C . OtherHealth Service Executive (HSE): National Hepatitis C Strategy 2011-2014 |
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Italy |
The latest national plan for prevention of hepatitis B and C was published in 2015. It does not include specific targets regarding PWID and no government body is in charge of monitoring its implementation. HCV treatment is provided regardless of individual history on drug use meaning that PWID are treated with the same criteria used for non-PWID. New guidelines for screening and diagnosis of infectious pathologies related to the use of substances at the dedicated Addiction care services were published in 2017. |
GuidelinesLuzi A.M. and Suligoi B. Nuove linee di indirizzo per lo screening e la diagnosi delle principali patologie infettive correlate all’uso di sostanze nei servizi per le dipendenze (New Guidelines for screening and diagnosis of the main drug-related infectious diseases at the Facilities for Addiction Care). OtherMinistry of Health (2017): Epatite C, uso terapeutico di farmaci interferon free |
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Latvia |
On 31 October 2017, a national action plan addressing HIV, STIs and viral hepatitis was adopted in Latvia and funding been allocated for its implementation: 22.7 mio Euro for activities in 2018 and 58 mio Euro for 2019-2020 – with most of the funding allocated to scale up access to HIV and HCV treatment. While the plan does not include a specific target regarding PWID, it addresses the group through several specific activities, including: the creation of new facilities; expansion of outreach staff; improved liaison between harm reduction and wider health care services; targeted vaccination of risk groups; scaling up of needle and syringe provision; introduction of new treatment options for opioid dependence; elaboration of information materials on HIV, STI, HBV, HCV prevention and treatment for PWID. The plan includes the elaboration of guidelines for primary care doctors regarding treatment of HCV and HIV; as well as the scaling up of treatment of HIV and HCV infection among people in prison. The 2017 national guidelines on diagnosis and treatment of chronic hepatitis C do not mention PWID specifically. A national HCV treatment registry was initiated in 2016 in paper format and since January 2017 it is operational electronically. |
Ministry of Health. Action Plan for the Elimination of HIV Infection, Sexually Transmitted Infections and Hepatitis B and C for 2018–2020 adopted by the government on 31.10.2017 |
GuidelinesMinistry of Health. The National Health Service. (Jan 2017) C VĪRUSHEPATĪTA RACIONĀLAS FARMAKOTERAPIJAS REKOMENDĀCIJAS ZĀĻU IEGĀDES KOMPENSĀCIJAS SISTĒMAS IETVAROS. [Hepatitis C treatment guidelines]. Document does not specifically address PWID access to HCV treatment and care. |
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Lithuania |
No national strategy or action plan addressing hepatitis is currently implemented, but a national hepatitis prevention strategy is in the planning stage. The national guidelines on diagnosis and treatment of chronic hepatitis C do not mention PWID specifically. HCV treatment is administered irrespective of whether the patient is a drug user or not – there are no specific restrictions for PWID, but it is unknown how many drug users are treated. Hepatitis C testing is foreseen in the framework of a health examination for people starting opioid maintenance treatment. The costs for one HCV test per patient prescribed by general practitioners or by medical doctors providing primary outpatient mental health care services is covered by the national health insurance funds. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesMinistry of Health (updated an consolidated),2016: DĖL LĖTINIO VIRUSINIO C HEPATITO DIAGNOSTIKOS IR AMBULATORINIO GYDYMO KOMPENSUOJAMAISIAIS VAISTAIS TVARKOS APRAŠO TVIRTINIMO [Guidelines for diagnosis and treatment of chronic hepatitis c] . OtherEurasian Harm Reduction Network (2013): Current situation regarding access to hepatitis C treatment in Eastern Europe and Central Asia [Lithuania is the only EU country included in this report] |
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Luxembourg |
A National Action Plan against Hepatitis (PANHEL), including access to HCV treatment and care for PWIDs (EASL guidelines), covering the period from 2018 to 2022 has been launched by the Ministry of Health in December 2017. Main five strategic axes of the national action plan against viral hepatitis are the following: Assessment of current situation and needs, Reduction of incidence of hepatitis, promotion of screening, access to health care, and surveillance, research and evaluation. National coordination will be put in place to ensure the implementation of the action plan and will be responsible for regularly reporting progress indicators and proposing potential improvements to the plan and its implementation. In addition to treatment costs, it is estimated that a total budget of 10 mio € is required to achieve the specific objectives and priority actions under five strategic axes during the 5-year period. |
GuidelinesArendt V 2017 Treatment guidelines for viral hepatitis in Luxembourg. VHPB meeting 8 November 2017 (ppt). OtherArendt V 2017 National action plan against viral hepatitis in Luxembourg. VHPB meeting 8 November 2017 (ppt). |
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Malta |
On 14 February 2018, a national strategy for the elimination of the hepatitis C virus was launched for a 30-day public consultation period by Health Minister Chris Fearne. People who use drugs are mentioned as key population to be specifically targeted; prevention measures are clearly specified, but no PWID specific targets are defined. The strategy document does not include information on budget allocation. Early diagnosis and screening for high-risk groups will be introduced; about 200 patients are expected to be treated for free annually, treating everyone eventually. Before then, no standard procedures, protocols, or documents were available which address diagnosis, referral to treatment and provision of treatment to patients (incl. PWID) with hepatitis C in Malta. Treatment for Hepatitis C included interferon treatment (alone and in combination with ribavirin). Current drug users with chronic Hepatitis C were not eligible for treatment as abstinence and termination of methadone treatment for at least one year were required. |
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Netherlands |
The national hepatitis plan screening and beyond officially launched in November 2016 was developed by a multidisciplinary commission representing all relevant stakeholders involved in research, treatment, prevention and control of hepatitis B and C. The plan focuses on five themes: 1) awareness and vaccination, 2) identification, 3) diagnostics and offering adequate treatment, 4) improved organization of the continuum of care and 5) improved surveillance including improved monitoring of the HBV and HCV cascade of care. HCV treatment is provided regardless of individual history on drug use meaning that PWID are treated with the same criteria as non-PWID. The implementation of the National Hepatitis Plan is being boosted by the installation of a steering committee with representatives from professionals in the field (hepatologists, infectiologist, addiction care doctors, GPs), members from the National Institute for Public Health and the Environment (RIVM), municipal health services and Trimbos Institute (and Focal Point). This steering committee described in 2017 the practical steps needed to implement the National Hepatitis Plan and the advice of the Health Council and will, during the coming years, follow up and coordinate joined efforts in the implementation of the care path for chronic hepatitis. |
GuidelinesNIV, NVHB, NVMDL, NVH, NVZA (2017): Richtsnoer behandeling hepatitis C infectie [Guidelines for treatment of hepatitis C – updated June 2017] RIVM (2016): Opsporing en herevaluatie van ooit gediagnosticeerden met chronische hepatitis B en C. Handreiking regionale aanpak [Guidance on detection and reassessment of chronic hepatitis B and C cases. A regional approach.] Health Council of the Netherlands. Screening risk groups for hepatitis B and C. The Hague: Health Council of the Netherlands, 2016; publication no.2016/16. RIVM (2012): LCI-richtlijn Hepatitis C [Hepatitis C guidelines. (General guideline on diagnosis, treatment and prevention)] OtherHealth Council of the Netherlands (1997): Committee on Hepatitis C. Detection and treatment of people with hepatitis C. Rijswijk: Health Council of the Netherlands, 1997; publication no. 1997/19. |
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Norway |
The national strategy plan against viral hepatitis was published by the Ministry of Health in June 2016. It is a brief (6 page) document which mentions three overall goals: 1) transmission of viral hepatitis should be kept at the current low level; 2) transmission among key populations should be reduced and 3) everyone with liver disease should have access to safe and effective treatment. The need for interventions and access to care for PWID is mentioned specifically in the plan. The national strategy plan is currently under revision, in order to reflect that since February 2018, following the price drop of direct-acting antiviral medication, all people who are infected with HCV, regardless of genotype, to receive this type of treatment. |
GuidelinesNorwegian Medical Association (2017): Faglig veileder for oppfølging og behandling av hepatitt C. [Guidelines for treatment of hepatitis C – updated March 2017] OtherForskrift om helseforetaksfinansierte reseptlegemidler til bruk utenfor sykehus [Regulations financing treatment of hepatitis C for patients outside hospitals – July 2015] Innstilling fra helse- og omsorgskomiteen om Opptrappingsplanen for rusfeltet (2016–2020) [From the committee on health and care: Plan of action for the area of addiction - Approved April 2016] |
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Poland |
No official strategy or action plan addressing viral hepatitis exists. The current National Plan for Drugs Prevention which is integrated into the National Health Plan 2016-2020 mentions the importance of access to harm reduction (substitution therapy and needle-syringe exchange) and increased uptake of infectious disease testing for PWID. There is no mention of access to HCV treatment for PWID. The work on a National strategy for viral hepatitis was initiated in 2006 but hampered by the lack of epidemiological evidence. The latest background documents were provided to the Ministry of Health by clinical experts in 2015 and by the National Institute of Public Health in mid-2017 and are now being processed in order to produce a National Strategy. In the current guidelines for the national HCV treatment programme it is mentioned that people who are actively dependent on a psychoactive substance are excluded from HCV treatment. Routinely offered HCV testing within harm reduction services is also not yet implemented at national level – under the national Drug Prevention Bureau two initiatives (both in Warsaw) have recently been launched to improve HCV testing among PWID. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
Research and practiceHalota et al 2016: Recommendations for the treatment of hepatitis C issued by the Polish Group of HCV Experts – 2016. Clinical and Experimental HEPATOLOGY 2016; 2: 27–33. This document does not specifically address PWID access to HCV treatment but mentions: All patients with chronic HCV infection should receive treatment. The sooner the therapy is initiated, the better the outcome and the lower the cost. OtherNational Health Programme (August 2016): National Health Plan 2016-2020 includes the National Plan for Drug Prevention. Ministry of Health website: Programy lekowe [Information on the national treatment programs] |
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Portugal |
Following intense advocacy efforts by civil society and the scientific community, the Portuguese Ministry of Health announced in February 2015 that the government would provide universal access to DAA treatment for all patients with chronic hepatitis C. An arrangement with a pharmaceutical company producing DAAs adopting a ‘risk sharing’ model together with a volume-based agreement was found. This meant that the Ministry pays per patient clinically cured (not per weeks of treatment, nor per patients treated), and that the price paid is inversely proportional to the number of patients treated. A national electronic HCV treatment registry has been setup and is used by all physicians prescribing DAAs. The latest national HCV treatment guidelines were updated in 2015. In July 2017, the Ministry of Health published the first report on the National programme for viral hepatitis 2017, the first national strategic plan of the health sector response to viral hepatitis. The document does not include specific targets and does not address resources for implementation. Also in July 2017, governmental order 6542/2017 determined that the design and implementation of prevention, diagnosis and treatment of infectious diseases, such as HIV and viral hepatitis among the prisoner population should be equivalent to other users of the national health system. Following this, a referral network for HIV and viral hepatitis care for the inmate population was established per governmental order 283/2018 in January 2018. |
GuidelinesMinistry of Health: Tratamento da Hepatite C Crónica no Adulto [Guidelines for treatment of hepatitis C] – regularly updated Research and practiceLeite RB (2014): Consensus for the integrated management of hepatitis C in Portugal. BMC Infectious Diseases 2014 14(Suppl 6):S9 EATG (2016) report: Access to highly effective hepatitis C treatment in Portugal A Community Perspective. Rodrigues et al (2016). Evidence of impressive real-world SVR from the Portuguese ledipasvir/sofosbuvir and sofosbuvir universal coverage programme to eradicate (eliminate) hepatitis C. J Hepatol. Vol.64 (2 Suppl):S224. Martins, J. et al. (2016) Long-Term Effect of the Portuguese Universal Access Program to New Generation Direct-Acting Antivirals for the Treatment of Hepatitis C. J Hepatol., Vol.64 (2 Suppl): S778 - S779. OtherPresentation by Secretary of State Prof. Fernando Araújo on Portugal’s national strategy and action plan at meeting on HCV elimination in Portugal held at the European Parliament, October 2017. |
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Romania |
There is currently no official national strategy or action plan addressing hepatitis available and no specific document addressing HCV treatment for PWID was identified. A draft national strategy on hepatitis B and C is being drafted (October 2017). Only patients with health insurance can receive HCV treatment and access to DAAs is limited (until 2015 only interferon-based regimens were reimbursed). In 2015-2016, about 5000 compensated (Fibrosis stage F4) patients were treated with DAAs, while non-cirrhotic (F1-F3) patients were only reimbursed when undergoing interferon-based therapies. In March 2017 a contract was signed with a pharmaceutical company to purchase DAA treatment for 2000 decompensated cirrhotic patients and a further contract is under preparation to expand DAA access to 10.000 patients with lower fibrosis stages and those at risk of transmitting HCV. The review of DAA restrictions criteria in Europe performed on behalf of the International Network on Hepatitis in Substance Users (INHSU) Network reported that a negative drug test is required before starting DAA treatment for patients co-infected with HIV/HCV (Marshall et al 2018). |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesNational Insurance (Nov 2015): PRECIZĂRI PRIVIND ACCESUL LA TERAPIA INTERFERON FREE [Requirements for access to interferon free therapy] Research and practiceProf. Adrian Streinu-Cercel: HCV Romanian framework – presentation held at the EU Parliament for the MEP Friends of the Liver meeting focusing on: The Challenge of Hepatitis C in Central and South Eastern Europe (22 March 2017) OtherMinisterul Sanatatii: Strategia Nationala de Sanatate 2014-2020 [The National Health Strategy 2014-2020. Document does not specifically mention PWID access to HCV treatment and care Kautz A, Enescu C., Chavdarova, L. (2013): The Romanian Hepatitis Action Paper: „The White Paper of Hepatitis C in Romania – Issues, challenges and solutions 2013-2018,Romanian Liver Patients Association (APAH-RO) & European Liver Patients Association (ELPA). Document does not specifically mention PWID access to HCV treatment and care |
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Slovenia |
A first national strategy for the management of HCV infection was established in 1999 and already included PWID. Since 2006, regular national conferences to discuss HCV management of HCV among PWID were held and in 2009, a specific national guideline for the clinical management of HCV was published. A National viral hepatitis expert board reviews and updates this guideline on a regular basis. An integrated national network approach to treatment of HCV among PWID is implemented with strong coordination between the five clinical centers for viral hepatitis treatment and the 18 drug treatment centers in the country. These centers also provide prevention activities such as: regularly voluntary testing on HCV, promotion of testing, counselling on HCV and HIV, promotion of treatment of HCV and they cooperate with several low threshold agencies including those providing syringes and other clean drug use equipment. Since 2016, transient elastography is available in the network of drug treatment centers and is performed in all HCV-infected PWID, followed by enhanced linkage-to care at one of the five regional viral hepatitis treatment centers. In 2015, DAAs were introduced for HCV treatment in Slovenia. While clinical guidelines initially included restrictions of DAA treatment access, depending on the clinical status (only for patients with advanced liver disease, HCC and HIV co-infection) but did not include any restrictions regarding drug use, all restrictions for the use of DAAs have been removed since December 2017, and they became the standard of care for all HCV-infected persons including PWID. Since 2011, intensive work has been going on to support the implementation of the HCV treatment guidelines for PWID, by presenting and discussing them at various national conferences with multi-stakeholder audiences, including addictions specialists, medical doctors, patient representatives, national health insurance authorities and medical policy makers. With the introduction of mobile units in 2018, testing for HCV, HBV and HIV as well as transient elastography will be offered in outreach settings, in order to reach PWID not in contact with treatment centers. National guidelines for such diagnosis and linkage-to-care are under preparation will be prepared by the National viral hepatitis expert board. |
Maticic M, Brinovec V, Lesnicar G, Vidmar L, Meglic-Volkar J: Hepatitis C v Sloveniji. ISIS 1999, 8:49-51. |
GuidelinesMaticic M, Kastelic A: National guidelines for the management of hepatitis C virus infection in drug users in Slovenia. ZdravVestn 2009, 78:529-539. Regular updates since then. Research and practiceMaticic 2014: A national multidisciplinary healthcare network for treatment of hepatitis C in people who inject drugs in Slovenia BMC Infectious Diseases 2014 14(Suppl 6):S6 |
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Slovakia |
No official national hepatitis policy document (strategy or action plan) currently exists. The current (2013) clinical treatment guidelines state that people who use drugs are required to be abstinent for a minimum of six months before starting HCV treatment. This limitation also applies also to people in opioid substitution treatment. However, hepatologists are in practice following the 2016 EASL recommendations regarding HCV treatment and that work is on-going to translate these into Slovak language and adopt them as official treatment guidelines. |
No specific document addressing national policy of HCV treatment and care for PWID identified. |
GuidelinesNational guideline for Hepatitis C diagnostic and treatment (September 2013) |
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Spain |
The Ministry of Health published the first national plan for responding to hepatitis C in the health system in 2015. PWID are mentioned as a key priority group. The current national HCV treatment guidelines also date from 2015. |
Ministry of Health (May 2015): PLAN ESTRATÉGICO PARA EL ABORDAJE DE LA HEPATITIS C EN EL SISTEMA NACIONAL DE SALUD [Strategic plan for tackling Hepatitis C in the Spanish Health System] (and update November 2016, ppt) |
GuidelinesAEEH (2015): Documento del II Consenso español sobre tratamiento de la hepatitis C [Guidelines on HCV treatment] Research and practiceRoncero et al (2017): Chronic hepatitis C and individuals with a history of injecting drugs in Spain: population assessment, challenges for successful treatment. European Journal of Gastroenterology & Hepatology OtherSeveral Spanish regions (e.g. Canarias (2014), Catalonia (2003), Madrid (2007)) have published regional policy documents (guidelines, action plans etc.) – these are referenced in the national strategy. |
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Sweden |
No overall strategy or action plan for viral hepatitis exists. However, the national board of health published comprehensive guidelines for the prevention of HIV and viral hepatitis among people who inject drugs in 2015. Also, the updated HCV treatment guidelines from 2016, includes an expanded section on PWID, mentioning specifically the need for and challenges with treating active PWID for HCV. In April 2017, a consensus document on how to improve HCV treatment among PWID was published by a multi-disciplinary group of Swedish experts. And in October 2017, the needle-exchange programme in Stockholm started offering HCV treatment to its clients. |
GuidelinesSee also national HCV key-document National HCV treatment guidelines (2016) Läkemedelsbehandling av hepatit C-virusinfektion hos vuxna och barn 2016 – Behandlingsrekommendation Research and practiceAlanko Blome, M et al (April 2017) Konsensusdokument om förbättringar i behandlingen av hepatit C för personer som injicerar droger [Consensus document on improvements in treatment of hepatitis C for people who inject drugs] |
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United Kingdom |
HCV policies in the UK date back to 2002, when England published a first hepatitis strategy, followed by a Hepatitis C Action Plan in 2004. The Scottish government launched the first phase of its Hepatitis C Action Plan in 2006. This plan has since evolved into a comprehensive Sexual Health and Blood Borne Virus Framework 2015-2020. Scotland is one of the few countries that has a governance body in place to monitor implementation of the response to viral hepatitis. Northern Ireland launched its Action Plan for the Prevention, Management and Control of Hepatitis C in 2007. The Welsh Assembly Government brought out a Blood Borne Viral Hepatitis Action Plan for Wales in 2010. All national plans address PWID. At national level, a multi-agency National Strategic Group on Viral Hepatitis (NSGVH) produces a national report ‘Hepatitis in the UK’ which addresses service coverage and impact of measures applied. National guidelines on HBV and HCV testing for people at risk of infection are published by the National Institute for Health and Care Excellence (NICE) and specifically address PWID. There is no restriction regarding access to HCV treatment for PWID in the UK. |
GuidelinesThe National Institute for Health and Care Excellence (NICE) Guidance on hepatitis. Guideline on Hepatitis B and C testing: people at risk of infection (PH43), Dec 2012 (New NICE guideline under development). Research and practiceWelsh Government (May 2015), Together for Health: Liver Disease Delivery Plan OtherDepartment of Health (2002): Hepatitis strategy for England. The Department of Health (2004): Hepatitis C Action Plan for England. Department of Health, Social Services and Public Safety Action Plan for the Prevention, Management and Control of Hepatitis C in Northern Ireland in 2007. Welsh Government Blood Borne Viral Hepatitis Action Plan for Wales 2010- 2015. The Scottish Government: Sexual Health and Blood Borne Virus Framework 2015-2020 Update. The Scottish Government: Sexual Health and Blood Borne Virus Framework 2011-2015. Hepatitis C Action Plan for Scotland, Phase II May 2008-March 2011 |
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