Research and analysis

Hepatitis C in England 2023

Updated 7 March 2024

This report summarises England’s progress towards the World Health Organization (WHO) elimination targets for hepatitis C virus (HCV) infection with data to end of 2022.

Foreword

The Hepatitis C in England report comes at the final push towards the elimination of HCV as a public health threat. The UK government has adopted the WHO’s updated Global Health Sector Strategies (GHSS) that support its ambition to eliminate viral hepatitis by 2030. As part of our strategic priority to reduce the impact of infectious diseases, UK Health Security Agency (UKHSA) has prioritised work to reduce the harmful impact to health of HCV, hepatitis B virus (HBV) and HIV. In this report we review the progress that has been made in England towards the WHO elimination targets for HCV with data to the end of 2022.

We continue to see progress towards achieving the WHO elimination goals with reduced chronic prevalence, implementation of comprehensive testing initiatives, and lowering of mortality associated with HCV infection. From 2015 to 2022, the number of people living with chronic HCV infection in England has fallen dramatically in the general adult population by 51.6% and is now estimated at 62,600. This is largely due to improved testing and access to treatment with substantial development being made to increase the numbers of individuals accessing direct-acting antivirals (DAAs). This access to testing and treatment has reduced HCV-related mortality to 0.44 per 100,000 population, the lowest mortality rate for the past 10 years.

People who inject drugs (PWID) are the main risk group for HCV infection and considerable progress has been made to reduce chronic prevalence within this group which is now at 11.8%. Since 2015, the proportion of people clearing a previous infection has almost doubled, delivered through intensive HCV testing and treatment within drug services.

As the epidemiology of HCV changes there will be new challenges to support people who continue to live with chronic HCV, focusing on ensuring equitable and easy access to testing and treatment. This will require not only novel but person-centred holistic approaches that address the complex needs of the individual.

Around 7 out of 10 PWID who are still living with HCV were unaware of their HCV infection or were awaiting a testing result and this is associated with evidence of potential plateauing in the decline in prevalence. Data from the Unlinked Anonymous Monitoring (UAM) survey suggests that new infections and reinfections continue to occur in PWID, indicating that more needs to be done to prevent infections. One area of concern is the provision of needles and syringes for people to use drugs safely, with around 1 in 3 of PWID reporting inadequate availability to meet their needs. Further work is required to quantify and describe the distribution of harm reduction activities in England.

As we move to the final stages of elimination of HCV, we will need to redouble our efforts to continue to make progress, further developing our surveillance and early warning capabilities to detect any future threats to elimination.

The achievements to date have been driven by a collective desire to eliminate hepatitis as a public health problem in England. UKHSA, as system leader, commits to work collaboratively with the NHS, local government, and the voluntary sector to continue the final push towards elimination ensuring that equity, community engagement, and human rights stay at the forefront of the response.

Professor Susan Hopkins
Chief Medical Advisor at UKHSA

Recommended actions

This report provides several recommended actions which could support the evidencing of progress towards eliminating HCV by strengthening the need to reduce incidence, increase testing and linkage into care, and reduce mortality. These should be considered within the context of the UKHSA’s ongoing programme of work to eliminate HCV as a health threat by 2030 in line with the WHO targets for HCV infection and includes collaboration with other stakeholders.

Monitoring incidence of HCV

Recommended action

Establish a multi-stakeholder working group to further develop new and existing data sources and methodologies to estimate incidence of HCV in the general population and PWID.

Rationale

Building on the Hepatitis C in England report 2022 recommendation to consider alternative approaches to monitor HCV incidence, UKHSA held a HCV deep dive round table in 2023 to review the metrics and evidence required to validate progress towards the WHO viral hepatitis elimination targets, and to identify gaps or additional data sources and analyses required to support this. This work identified that at present there is no established and agreed methodology for estimating the WHO elimination indicator for HCV incidence in the general population and among PWID in England.

UKHSA also presented on methods to estimate incidence at the 2023 European Association for the Study of the Liver (EASL) congress. Various approaches are currently being explored, including the use of laboratory testing data to estimate HCV seroconversion among risk groups, and the development of a new modelling study to estimate incidence using seroprevalence data. UKHSA data also feeds into models being developed by academic partners to estimate incidence.

Stakeholders

Multi-stakeholder group co-ordinated by UKHSA.

Preventing new infections

Recommended action

Pilot a monitoring system to quantify and identify gaps in the provision of sterile and safe needles and syringes for PWID in England.

Rationale

Harm reduction measures, such as providing sterile needles and syringes, are essential to prevent incident infections or reinfections. Despite this, there is limited data on needle and syringe provision (NSP) in England and no established methodology to estimate the WHO target of 300 sterile needles and syringes provided per PWID per year.

The Hepatitis C in England 2022 report set out a recommendation to scope how access to, and uptake of, NSP in all settings can be mapped and monitored to contribute to evidence of NSP impact. In 2023, UKHSA and The Hepatitis C Trust, in collaboration with other stakeholders, mapped out the distribution and types of services offering NSP. The analysis of this mapping work is ongoing and will be used to identify gaps in NSP service provision, and to inform the implementation of a new monitoring system for NSP provision. UKHSA has led on the design and development of the proposed monitoring system in collaboration with a multistakeholder group. The aim of the pilot is to assess the feasibility and acceptability of national monitoring for NSP to quantify provision, and to identify areas for improvement. The next steps will involve the selection of pilot sites and the collection of a standardised data set.

Stakeholders

Led by UKHSA in collaboration with a multi-stakeholder group.

Testing and diagnosis

Recommended action 1

Undertake data analysis and behavioural insights work to understand the characteristics of PWID who have not been tested for HCV and/or are unaware of their infection.

Rationale

Based on data from the UAM survey, the decline in chronic HCV prevalence among PWID has slowed between 2021 and 2022. Furthermore, the UAM survey found that around 7 out of 10 PWID who were living with chronic HCV (ribonucleic acid (RNA) positive) were unaware of their infection, and for the first time in 2022 the survey was able to refine the estimate to differentiate those who remained unaware of their infection or were awaiting a test result. After taking this into consideration, 31.3% of PWID remained potentially unaware of their chronic infection in 2022.

A preliminary analysis explored HCV testing history and injecting practices for these individuals, but further information is needed to triangulate with UAM survey data to better understand the characteristics of people who remain undiagnosed, whether their infection is newly acquired or not, and potential barriers to engaging in timely testing and treatment for HCV. A common barrier to engagement in testing and care is the stigma surrounding HCV. UKHSA held a workshop in 2023 to discuss options for monitoring and exploring stigma.

Stakeholders

UKHSA in collaboration with NHS England (NHSE) and The Hepatitis C Trust.

Recommended action 2

Develop a methodology to estimate the proportion of people living with HCV who have been diagnosed in England.

Rationale

The proportion of people diagnosed with chronic HCV assesses whether current testing coverage is sufficient to identify most people who are living with chronic HCV. The HCV deep dive round table identified that at present there is no established methodology for estimating the WHO elimination indicator for the proportion of people diagnosed with HCV in England.

Work is underway to triangulate surveillance data, including testing, diagnosis, and treatment data, with information obtained through a national treatment re-engagement exercise, to estimate the number of people with a laboratory confirmed diagnosis. This data will be linked to modelled prevalence estimates of the number of people living with HCV to estimate the proportion diagnosed.

Stakeholders

Multi-stakeholder group co-ordinated by UKHSA.

Recommended action 3

Undertake evaluation for case finding interventions such as the ongoing evaluation of the emergency department (ED) bloodborne virus (BBV) opt-out testing pilot and planning the evaluation of the national HCV web testing platform, to understand their effectiveness, optimise implementation, and assess health economics.

Rationale

Evaluation is important to understand whether interventions meet their aims and objectives, and that funding is spent in the most effective way to support the elimination of HCV in England. Building on the Hepatitis C in England report 2022 recommendation to evaluate new models of testing and service delivery, UKHSA and the University of Bristol have conducted the interim 12-month public health and implementation evaluation for the ED BBV opt-out testing pilot, and planning is now underway for subsequent evaluations. The ED testing programme is being expanded to new sites in England from April 2024. The national HCV web testing platform became fully operational in May 2023, and it will be important to understand who is engaging with testing, and the effectiveness of the platform in newly identifying people living with HCV.

Stakeholders

UKHSA in collaboration with NHSE, intervention and evaluation stakeholders.

Linkage to care

Recommended action 1

Identify and integrate new sources of data on HCV treatment into routine surveillance.

Rationale

The WHO elimination indicator for HCV treatment coverage is equal to, or greater than, 80% of people diagnosed with chronic HCV infection treated within a specified timescale. UKHSA is currently undertaking an evaluation of the hepatitis C national patient re-engagement exercise using qualitative methods. This work follows on from the recommendation in the Hepatitis C in England 2022 report to consider what lessons can be learnt from the re-engagement exercise to improve the use of surveillance data for case-finding and engagement in care.

Qualitative work is also underway to explore the barriers and facilitators to ongoing engagement in care and harm minimisation amongst people who have experienced HCV reinfection. HCV testing and treatment data can be used to illustrate engagement and retention in care, as well as potential gaps. However, current treatment registry data under reports the number of treatment initiations in England. This data needs to be triangulated with other sources of data, such as data from NHSE’s Blueteq system (which facilitates access to high-cost drugs for HCV treatment), to provide a more accurate estimate of the proportion of people diagnosed who are linked to care.

Stakeholders

UKHSA in collaboration with NHSE

Recommended action 2

Integrate prison healthcare data into routine HCV surveillance to support insights into testing, linkage to care, and the need for harm reduction in prisoners and persons who have been recently released from prison.

Rationale

HCV affects a larger proportion of people in prison and other secure and detained settings than in the wider population. Sustained virological response (SVR) following treatment in people diagnosed with HCV in prisons is lower than the general population. In addition, a recent UKHSA study (1) showed that a high rate of reinfection is seen in people who were tested for HCV in prison.

In 2023, UKHSA co-hosted the WHO Health in Prisons conference which highlighted the importance of strengthening prison data collection. Integration of prison healthcare data will provide greater insights into the number of people tested and diagnosed, and their characteristics, to inform the delivery of evidence-based interventions. Prison healthcare data would also include some data on point of care testing, which is not fully captured through current laboratory surveillance.

Stakeholders

UKHSA in collaboration with NHSE Health and Justice.

Reducing mortality

Recommended action

Define a national target to further reduce HCV-related End Stage Liver Disease (ESLD) and/or hepatocellular carcinoma (HCC) deaths.

Rationale

HCV-related mortality is a key measure of the progress towards elimination. England has already met the WHO impact target for HCV-related mortality. To further reduce mortality, a concerted effort is needed to improve early diagnosis and linkage to care and treatment for people who remain undiagnosed.

Stakeholders

UKHSA in collaboration with a multi-stakeholder group.

Introduction

HCV is a BBV that infects the liver. Persistent infection over time can cause serious liver damage leading to cirrhosis, liver failure and cancer. Globally, there are estimated to be 1.5 million individuals newly infected with HCV leading to around 290,000 HCV-related deaths each year. PWID are at greatest risk of HCV infection in the UK. Other people at risk are those who have:

• been in prison
• experienced homelessness
• are from a country with a higher prevalence of HCV
• received a blood transfusion before September 1991 or a blood product (such as clotting factor) before 1986 in the UK

Fortunately, since the availability of DAA drugs, which cure HCV with a short (8 to 12 weeks) course of oral treatment, many people have been successfully treated for HCV, both globally and in England.

In 2016, the UK signed up to the WHO Global Health Sector strategy (GHSS) to eliminate viral hepatitis as a public health threat by 2030. This strategy includes targets to increase the number of people tested, diagnosed, and treated for HCV with the aim to reduce new infections and deaths from HCV.

In 2023, WHO published the latest guidance on country validation of viral hepatitis elimination. This guidance featured absolute impact targets for annual incidence of less than or equal to 5 per 100,000 in all persons and less than or equal to 2 per 100 in PWID. Previous guidance featured a standalone mortality target for HCV of less than or equal to 2 per 100,000 persons, however the preferred approach now is to demonstrate a combined HCV and HBV mortality rate of less than or equal to 6 per 100,000 population. Programmatic targets remain the same with WHO requiring:

• at least 90% of people living with chronic HCV to be diagnosed
• at least 80% of people who are diagnosed with HCV to be treated
• 100% of medical injections to be administered using safety engineered devices
• 100% of blood donations screened
• 300 needles and syringes provided per PWID per year

In addition to these targets, the WHO established a set of milestones called the pathway to elimination (PTE). The PTE provides an alternative approach to full elimination and offers a stepwise approach to achieving elimination targets. PTE has 3 tiers: bronze, silver, and gold.

The UK is committed to eliminating HCV as a public health threat by 2030. UKHSA is taking forward a programme of work to support evidencing HCV elimination. This report summarises England’s progress towards the WHO elimination targets for HCV infection with data to end of 2022.

Reducing the incidence of HCV infection

The number of individuals newly infected with HCV (incidence) is a key measure of progress towards elimination. When the number of new cases is low it demonstrates that current prevention and control measures are effective at supressing the spread of the virus in England. To achieve validation of HCV elimination, annual incidence rates must be below the WHO absolute target of less than or equal to 5 per 100,000 in all persons, including less than or equal to 2 per 100 in PWID, given their elevated burden of disease, increased risk of transmission and smaller population size (Table 1a).

Previous WHO guidance recognised a reduction in chronic HCV prevalence as an alternative (proxy) measure of incidence (Table 1b, Table 1c). However, updated guidance requires incidence to be estimated directly or modelled. Modelled incidence estimates for HCV are being developed, and collection of other data, such as through seroprevalence studies among specific populations including the large-scale NHSE needs assessment study, are underway.

Prevalence, the total number of people estimated to be living with HCV at a single time point, remains a useful marker to measure progress towards elimination and when assessed in conjunction with incidence can describe the total disease burden and risk of transmission respectively. In the absence of robust incidence estimates, prevalence estimates are presented here to provide an indication of progress towards reducing the incidence of HCV in England.

Table 1a. WHO impact targets for reducing incidence of HCV infection

Impact target area	WHO GHSS 2025 target	WHO GHSS 2030 target
Annual incidence: number of new chronic HCV infected individuals.	13 per 100,000 persons. 3 per 100 persons for PWID.	Less than or equal to 5 per 100,000 persons. Less than or equal to 2 per 100 for PWID.

Table 1b. WHO proxy measures for reducing incidence of HCV infection in the general population and in PWID

Impact target area	WHO GHSS 2030 target
Alternative (proxy) measurement indicators.	Reduction in HCV viraemia prevalence by 80% from 2015 baseline (in general population and PWID).

Table 1c. Progress in England for reducing incidence of HCV infection in the general population and in PWID

Measure	Progress in England
Proxy measure: reduction in HCV viraemia prevalence from 2015 baseline in the general population.	51.6% in 2022 (45.8% to 2021) [note 1].
Proxy measure: reduction in HCV viraemia prevalence from 2015 baseline in PWID.	60.8% in 2022 (55.1% to 2021) [note 2].

[note 1] This measure is used currently but may be subject to change as other methods are developed.

[note 2] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be considered when interpreting data for these years.

Further information can be found in Technical notes.

Estimated HCV prevalence in England in the general adult population

In England, around 62,600 adults aged over 16 (95% credible interval (CrI) 48,900 to 77,800) were estimated to be living with chronic HCV infection in 2022 (modelled estimate, see Technical notes for further information), a 51.6% decrease from 129,400 (95% CrI 109,900 to 147,000) in 2015 (Figure 1). This is equivalent to a prevalence of 0.14% (95% CrI 0.11% to 0.17%) in England. Among adults who have ever been infected with HCV (antibody positive), the proportion estimated to be currently living with a chronic HCV infection (RNA positive) has declined to 32.5% in 2022 (95% CrI 28.3% to 36.9%) from 59.5% in 2015 (95% CrI 56.5% to 61.9%).

Of the 62,600 adults estimated to be living with chronic HCV infection, 20.1% of infections are estimated to be in current or recent PWID and 64.5% are in those with a past drug injecting history but who are no longer injecting. This implies that there are an estimated 9,600 people with chronic HCV infection who do not have a history of injecting drug use. If the reduction in chronic HCV infection continues at the same rate as in recent years, England is likely to achieve the previous WHO target of an 80% reduction in chronic prevalence by 2030.

Figure 1. Estimated prevalence of chronic HCV infection [note 3][note 4] in England, 2011 to 2022 general adult population [note 5]

Shaded line shows 95% CrI.

Data sources:

Modelled estimates of chronic HCV prevalence based on the following:

• HCV prevalence data from the UAM survey of PWID
• estimates of the number of PWID (2)
• Hospital Episode Statistics (HES), NHS England, produced by UKHSA (data on severe HCV-related liver disease)
• Trent cohort data (estimates of disease progression probabilities)
• data on HCV treatment (IMS sales data, the NHSE HCV Patient Registry and Treatment Outcome System)

[note 3] We calculate the proportion of people with chronic infection out of all those alive who have ever been infected (that is people who are HCV antibody positive) in England. This includes people who have ever been infected and are still alive with current or past infection. The latter may have cleared their infection through achieving an SVR post treatment, or through spontaneous clearance.

[note 4] The model assumes that the proportion who spontaneously clear the virus after infection is a fixed quantity with no uncertainty (24% of infections spontaneously clear). Therefore prior to DAA treatment, the credible intervals for the proportion of chronic infections are very narrow.

[note 5] The model estimates the percentage of the adult (aged 16 years or over) population with chronic infection in England. Virtually all infections are in those aged 16 or over, so a more accurate picture is given by excluding children from the denominator.

Further information can be found in Technical notes.

Estimated HCV prevalence amongst PWID

In England, the most important risk factor for HCV infection is injecting drug use (previous or current) (3). The prevalence of chronic HCV infection among PWID has declined substantially since 2017 (3). In 2022, just over half of PWID surveyed as part of the UAM survey (53.4%) had evidence of ever being infected with HCV. The proportion that had evidence of current (HCV RNA positive) infection decreased to 11.8% in 2022 compared to 12.9% in 2021 and 28.7% in 2015.

Since 2015, the proportion of people that had cleared a previous infection has almost doubled, from 23.0% in 2015 to 41.6% in 2022 (Figure 2). The decline in the prevalence of chronic HCV infection in PWID is likely due to improved treatment, as the proportion of PWID who have ever been infected has remained relatively stable over the past 10 years, but the proportion of PWID who have cleared their infection has increased. However, the decline in chronic prevalence has slowed between 2021 and 2022, suggesting that innovative approaches will be needed to support those individuals, who for a variety of reasons remain undiagnosed (including people who have refused testing, are unaware of their HCV infection risk, or have not engaged with services), to be tested and access treatment.

Figure 2. Trend in HCV prevalence among HIV negative people injecting psychoactive drugs, 2013 to 2022 in England [note 6][note 7][note 8][note 9]

Vertical lines show 95% confidence intervals (CIs).

Data source: UAM survey of PWID.

[note 6] Retrospective analysis of HCV RNA (2011 to 2016) was performed as part of the EPIToPE study, funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (Grant Reference Number RP-PG-0616-20008). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

[note 7] Estimates for chronic and cleared HCV infection have been adjusted to consider antibody-HCV positive samples with missing RNA status. The ratio of chronic to cleared infection was applied to the antibody-HCV positive samples with missing RNA status by year and region.

[note 8] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be considered when interpreting data for these years. Please see Technical notes for more details.

[note 9] People living with HIV can have sub-optimal HCV antibody responses as a result of their HIV infection. Therefore, people living with HIV or with unknown HIV status are excluded.

Estimated HCV incidence in PWID

Accurately measuring the incidence of HCV infection among PWID remains a significant challenge (4). The gold standard approach would be to monitor the actual or estimated number of new HCV infections that arise annually in PWID, as well as any that result from net migration and other sources. However, direct measurement is challenging because a significant proportion of acute infections are asymptomatic and remain undiagnosed leading to an underestimate of the incident population. Furthermore, the dynamic nature of the PWID population, characterised by high rates of entry and exit, creates uncertainty when estimating the total population in England (2, 5 to 7). Selecting and following up a representative sample of PWID in England is challenging for the reasons already outlined, and additionally recruitment and monitoring would require contact with services or healthcare, which would exclude an important part of the PWID population.

Further work is underway to use surveillance and study data sources to develop new models to estimate incidence among PWID in England. An example here includes the use of Sentinel Surveillance of Bloodborne Virus Testing (SSBBV) data to estimate HCV antibody seroconversion among people with more than one test result (8). Location of test, and other demographic data can be used to estimate HCV incidence among risk groups. A new modelling approach is also being explored to estimate HCV incidence among PWID using seroprevalence data from the UAM survey.

In the absence of these data, direct and indirect measures of HCV incidence in PWID from the UAM survey are a valuable source of data to monitor trends among PWID. However, as these measurements relate to a sampled population the findings should not be over generalised. The UAM survey can be used to look for evidence of a decline in incidence through direct measurement of persons who are RNA positive (HCV viraemia) and antibody negative (indicating recency of infection acquisition), and through indirect measurement of antibody prevalence among people who have recently initiated injecting drugs.

PWID who are RNA positive and antibody negative

Incidence of HCV infection can be estimated directly from the UAM survey by assessing the number of people who have evidence of HCV viraemia but are HCV antibody negative. These individuals have markers of current infection (RNA) but are yet to mount an antibody response, suggesting that they have likely acquired their infection recently. A limitation of this approach is that it does not consider people who have an incident HCV reinfection. In addition, incidence is estimated using a fixed window period of 51 days (length of time an individual is RNA positive and HCV antibody negative), and there is some uncertainly over this duration (9). Data from the UAM survey suggests that estimated incidence of infection has remained relatively stable in the past 5 years (Figure 3). Therefore, this data does not suggest any evidence for a decline in incidence in recent years. This data should be interpreted with caution due to the small sample size which has resulted in wide and overlapping 95% CIs.

Figure 3. Estimated incidence of HCV among HIV negative PWID who injected in the last year, 2013 to 2022 [note 10][note 11][note 12]

Vertical lines show 95% CIs.

Data source: UAM survey of PWID.

[note 10] To estimate incidence, a fixed window period of 51 days was used (time after exposure to HCV when RNA is detectable, but the individual has not yet formed antibodies) and there is some uncertainty regarding the use of this measure. Estimates for 2014 and 2015 are not available as RNA testing was not conducted on anti-HCV negative samples.

[note 11] Incidence is calculated among people who are anti-HCV negative. People living with HIV can have sub-optimal HCV antibody responses as a result of their HIV infection. Therefore, people living with HIV or with unknown HIV status are excluded.

[note 12] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be considered when interpreting data for these years. Please see Technical notes for more details.

Estimated HCV antibody prevalence among recent initiates to injecting

An indirect measurement of incidence among PWID examines HCV antibody prevalence among recent initiates to injecting. As most new HCV infections are acquired via injecting drug use, the detection of HCV antibodies (indicating someone has been exposed to the HCV virus) in a person who has recently initiated injecting drug use is indicative of an incident HCV infection associated with that behaviour. It should be noted that this value does not include incident reinfections. Data from the UAM survey suggest a year-on-year decrease over the last 3 survey years with 32.8% of recent initiates having antibodies to HCV in 2018 to 19.5% in 2022 (Figure 4). The downward trend in prevalence in recent initiates could suggest a decline in incidence of HCV in this sub-group of PWID. It should be noted that the small sample size has resulted in imprecise 95% CIs which overlap suggesting potentially no difference between the annual point estimates.

When assessed in combination with the direct measure of incidence presented in the previous section, we cannot confidently determine whether there has been a change in incidence in the PWID population. Triangulation with additional data, such as the NHSE needs assessment (HCV antibody and RNA testing of 10,000 people attending drug and alcohol services, NSP and community pharmacies across England, with follow-up testing 6 months to one year later), and new methods including incidence models, are required to better estimate incidence in the PWID population in England.

Figure 4. Estimated prevalence of antibodies to HCV among HIV negative recent initiates to injecting, 2013 to 2022 in England [note 13][note 14][note 15]

Vertical lines show 95% CIs.

Data source: UAM survey of PWID.

[note 13] Recent initiates are defined as PWID who commenced injecting drugs within the 3 years prior to their participation in the UAM survey.

[note 14] People living with HIV can have sub-optimal HCV antibody responses as a result of their HIV infection. Therefore, people living with HIV or with unknown HIV status are excluded.

[note 15] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be considered when interpreting data for these years. Due to small numbers, data for 2020 and 2021 are combined. Please see Technical notes for more details.

Reinfections

People who have been previously treated for HCV infection, but continue to engage in risk behaviours, such as injecting drugs without adequate access to and use of safe needles and syringes, are at risk of becoming reinfected with HCV.

Reinfection can be estimated using data on repeat HCV treatment from the NHSE Hepatitis C Patient Registry and Treatment Outcome System linked to serial HCV RNA testing data from SSBBV. In England, a person who is reinfected is identified as a person who is positive for HCV RNA and/or has a subsequent treatment following a reported SVR or negative RNA result in a person who had previously been treated for an HCV infection. A period of 196 days between first and second treatment initiation is used to define reinfection (1) as the majority of individuals receiving treatment will have achieved an SVR within 6 months (182 days), in addition, 2 weeks (14 days) is also added to account for delay in treatment initiations. A control group of persons who had a post-treatment RNA test at least 196 days after first treatment initiation is used to calculate the reinfection rate.

Among people who initiated treatment between 2015 and 2022 in England, the reinfection rate was 7.8 per 100 person years (95% CI: 7.5 to 8.0 per 100 person years). This means that for every 100 years of follow-up data post treatment initiation, there are estimated to be around 8 individuals who experience HCV reinfection. Analyses of those who initiated treatment between 2015 and 2019 found the highest rates of HCV reinfection among people who had more recently injected drugs (22.6 per 100 person years, 95% CIs (20.0 to 25.5)) and among people who initiated HCV treatment in prison (20.4 per 100 person years, 95% CIs (17.2 to 24.2)) (1) . The data is reliant upon persons initiating treatment being added to the NHSE Hepatitis C Patient Registry and Treatment Outcome System, sufficient identifiers being available to link between the treatment and SSBBV databases and on people being tested post treatment.

Reducing HCV-related mortality

HCV-related mortality is a key measure of the progress towards elimination, as it demonstrates that the current testing and treatment infrastructure is effective at identifying persons infected with HCV in a timely way. Prompt diagnosis and treatment will reduce mortality associated with HCV through early clearance of the virus before it can cause damage to the liver that could cause chronic liver disease.

To reflect the overarching goal to eliminate viral hepatitis the updated WHO guidance provides a new combined HCV and HBV target for mortality equal to or less than 6 per 100,000 population. Previous WHO elimination metrics were to achieve an HCV-related annual mortality rate of less than or equal to 3 per 100,000 persons by 2025 and 2 per 100,000 persons by 2030 (Table 2a). These targets have already been met, with the annual HCV-related ESLD and HCC mortality rate at 0.44 per 100,000 population in 2022 (Table 2b), a fall from 0.69 per 100,000 in the 2015 WHO baseline year (Figure 5).

In England, the number of death registrations from HCV-related ESLD and HCC peaked at 381 in 2014 and remained at a similar level in 2015 (380 death registrations). Between 2015 and 2022 these numbers fell by 34.0% (to 251 death registrations), which was primarily driven by the decrease in HCV-related ESLD, which fell by 45.4% during this period (Figure 6).

The decline in mortality is likely to be the result of increased access to DAA drugs that were introduced in 2015, particularly for individuals with more advanced disease (10). Treatment in persons with advanced disease extends life expectancy but does not reverse cirrhosis. Therefore, early treatment is vital as this prevents progression to cirrhosis and prevents HCV-related mortality. While England has met the 2030 WHO impact target of less than or equal to 2 per 100,000, the mortality rate in the 2015 baseline year was already below the 2030 target. Further declines in the mortality rate and the absolute number of death registrations will require a concerted effort to ensure early diagnosis and linkage to care and treatment for people who remain undiagnosed.

Table 2a. WHO impact targets for reducing HCV-related mortality

Impact target area	WHO GHSS 2025 target	WHO GHSS 2030 target
Mortality: viral HCV deaths (target).	3 per 100,000 persons.	Equal to or less than 2 per 100,000 persons.

Table 2b. Progress in England for reducing HCV-related ESLD and/or HCC deaths

Measure	Progress in England
Mortality: HCV-related ESLD and/or HCC deaths.	0.44 per 100,000 population (2022) [note 16][note 17][note 18].

[note 16] Based on Office for National Statistics (ONS) mid-year population estimates: Estimates of the population for the UK, England and Wales, Scotland and Northern Ireland (ONS)

[note 17] Even if reporting of HCV on death certification has not improved beyond levels historically reported (11 to 12) these preliminary figures show the 2030 WHO elimination metric has already been met.

[note 18] Excluding deaths registered in England when the deceased’s usual residence is outside England.

Further information can be found in Technical notes.

Figure 5. Death registrations [note 19] for HCV-related ESLD [note 20] and HCC in England: 2005 to 2022 [note 21]

Data source: ONS. Based on ONS mid-year population estimates: Estimates of the population for the UK, England, Wales, Scotland and Northern Ireland.

[note 19] Death registrations for England are those where HCV is mentioned on the death certificate.

[note 20] Defined by codes or text entries for ascites, bleeding oesophageal varices, hepato-renal syndrome, hepatic encephalopathy, or hepatic failure.

[note 21] Excluding deaths registered in England when the deceased’s usual residence is outside England.

Figure 6. Death registrations [note 22] for HCV-related ESLD [note 23] and HCC in England: 2005 to 2022

Data source: ONS.

[note 22] Death registrations for England are those where HCV is mentioned on the death certificate.

[note 23] Defined by codes or text entries for ascites, bleeding oesophageal varices, hepato-renal syndrome, hepatic encephalopathy, or hepatic failure.

Proportion of people with chronic HCV diagnosed and aware of their infection

The proportion of people diagnosed with chronic HCV assesses whether current testing coverage is sufficient to identify the majority of people who are living with HCV. The current WHO target is to diagnose greater than or equal to 90% of all people living with HCV (Table 3a). Currently there is no direct measurement available for this indicator and work is underway to use surveillance data to estimate progress towards this indicator (Table 3b).

The approach triangulates surveillance data, including testing, diagnosis and treatment data, alongside information collected through data linkage, and feedback obtained through a national treatment re-engagement exercise, to estimate the RNA status of people with a laboratory confirmed diagnosis. Those alive and currently RNA positive, contribute to the diagnosed numerator and the estimated number of individuals living with chronic HCV (modelled prevalence estimates) will be used as the denominator. Additional work is underway to continue to enhance information on individuals where the RNA status is still unknown.

Table 3a. WHO programme targets for HCV diagnosis and awareness of infection

Service coverage or programme target area	WHO GHSS 2025 target	WHO GHSS 2030
Proportion of people with chronic HCV diagnosed [note 24].	Greater than or equal to 60%.	Greater than or equal to 90%.

Table 3b. Progress in England

Measure	Progress in England
Greater than or equal to 90% of people with chronic HCV diagnosed [note 24].	No estimate currently available.

[note 24] The numerator for this indicator in terms of HCV diagnoses is the number of persons with chronic HCV infection who have been diagnosed, and the denominator is the estimated number of persons with chronic HCV infection.

Awareness of HCV infection in PWID

Awareness of HCV infection is an important indicator of unmet testing and treatment needs. As more persons are treated for their HCV infection, we would expect the proportion of persons who are aware of their infection to decrease as persons who know about their infection have been cured. Persons who remain un- or under-tested are less likely to be aware of their primary infection or reinfection and as a result have unmet testing and treatment needs. UAM survey data can be used to assess the proportion of PWID who are unaware of their HCV status. These data can be used to identify at need populations and can help target testing initiatives.

In 2022, 28.9% of PWID who reported injecting in the past year who were living with chronic hepatitis (antibody-HCV and HCV RNA positive) were aware of their infection at the time of completing the survey (Figure 7). This proportion is similar to what was observed in 2021 (23.7%) but is part of downward trend in awareness of infection over the past 6 years with 50.3% of PWID surveyed aware of their infection in 2017.

It is important to note that the proportion aware of their chronic infection at the time of UAM survey completion is likely an underestimate. Diagnostic HCV testing is frequently offered by participating drug and alcohol services alongside the UAM survey. Therefore, respondents are likely to receive their diagnostic test results shortly after survey completion.

In 2022, 55.9% of UAM survey participants who were unaware of their chronic HCV infection reported accessing diagnostic HCV or BBV testing at the time of completing the survey or that they were awaiting their test result. After accounting for this, the proportion of PWID who injected in the last year who were potentially aware of their chronic infection was 68.7% in 2022. However, missed opportunities for testing and prompt diagnosis also remain; 31.3% of PWID who injected in the last year remained potentially unaware of their chronic infection in 2022. Of these people, 57.7% reported they had never been tested or that their last HCV test was more than 2 years ago and 69.4% reported injecting in the past 4 weeks. The majority (94.2%) of people who remained potentially unaware of their chronic infection were recruited to the UAM survey outside of London.

The lower levels of awareness in recent years may be partly explained by an increase in UAM survey recruitment through outreach services, compared to traditional recruitment through services offered at the drug service building. Participants recruited through outreach may be less likely to engage with drug and alcohol services, and thus less likely to be aware of their current HCV infection.

UAM survey data supports the need to better understand the characteristics of people who are unaware of their chronic infection, and their needs, so that holistic testing interventions can be targeted in a timely manner. Early diagnosis of HCV infection is important for the most effective treatment and care and this data highlights the potential for late diagnosis of HCV in a sub-set of people who are not being regularly tested. Nearly half of people potentially unaware of their chronic infection reported a recent test (current or previous survey year), so these data also emphasise the importance of testing those with ongoing risk regularly to identify reinfection and reduce the risk of transmission.

Figure 7. Estimated proportion of HIV negative PWID testing positive for HCV who are aware of their infection, 2013 to 2022 in England [note 25][note 26][note 27][note 28][note 29]

Data source: UAM survey of PWID.

[note 25] Due to a change in the questionnaire for 2017, completion of the self-reported status question was lower, resulting in a higher proportion of missing data in 2017 and 2018.

[note 26] Data regarding awareness of HCV RNA result, and therefore chronic infection status, are available for 2017 onwards due to changes in the UAM survey questionnaire.

[note 27] People living with HIV can have sub-optimal HCV antibody responses as a result of their HIV infection. Therefore, people living with HIV or with unknown HIV status are excluded.

[note 28] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be considered when interpreting data for these years. Please see Technical notes for more details and for more information.

[note 29] These figures are for PWID who had injected drugs in the last year and differ from those in UAM data tables which refer to all PWID.

Monitoring access to HCV treatment

The WHO elimination target for treatment coverage is equal or greater than 80% (Table 4a). Treatment coverage is defined as the proportion of individuals diagnosed with chronic HCV infection (HCV, RNA or HCV core antigen positive) who were treated during a specified time frame (Table 4b).

Table 4a. WHO programme targets for monitoring access to HCV treatment

Service coverage or programme target area	WHO GHSS 2025 target	WHO GHSS 2030 target
Treatment coverage of people diagnosed with chronic HCV.	Equal to or greater than 50%.	Equal to or greater than 80%.

Table 4b. Progress in England for monitoring access to HCV treatment between 2015 and 2022

Measure	Progress update	Percentage of diagnosed individuals with chronic HCV initiated treatment
Between 2015 and 2022.	81.2% [note 30] of diagnosed individuals with chronic HCV were linked to specialist HCV treatment services. 79.7% [note 31] of diagnosed individuals with chronic HCV initiated treatment. 88.5% [note 32] of individuals who initiated treatment and had an outcome reported. 77.3% [note 33] of those who initiated treatment were reported to have achieved SVR either as a treatment outcome or a proxy SVR [note 34]. 87.3% of those who initiated treatment and had an outcome reported achieved SVR.	79.7% [note 31] (2015 to 2022).

[note 30] Numerator: number of individuals linked to specialist HCV treatment services via Operational Delivery Networks (ODNs) (identified through successful linkage to the NHSE Hepatitis C Patient Registry and Treatment Outcome System). Denominator: number of individuals who tested positive for HCV RNA with NHS number or name and date of birth reported through SSBBV. Data quality is assessed on an ongoing basis to verify the number of people who tested positive for HCV RNA.

[note 31] Numerator: number starting treatment; denominator: number of individuals who tested positive for HCV RNA with NHS number or name and date of birth.

[note 32] Numerator: number of individuals who had a treatment outcome reported. Denominator: number of individuals who started treatment.

[note 33] Numerator: number achieving an SVR (in the absence of a reported an SVR, a proxy SVR result has been used, where there is a reported RNA negative test recorded at 168 days or more after the treatment start date). Denominator: number starting treatment. The proportion reported as achieving an SVR is likely to be lower than the true proportion.

[note 34] In the absence of a reported an SVR, a proxy SVR result is used when an RNA negative test is recorded at 168 days or more after the treatment start date. Further information is available in Technical notes.

HCV treatment pathway

HCV testing and treatment data has been used to follow individuals through the care pathway. Between 2015 to 2022, 90,181 individuals tested positive for HCV RNA. Of these, 81.2% were linked to the NHSE Hepatitis C Patient Registry and Treatment Outcome System (Table 4b). Of those linked to the NHSE Hepatitis C Patient Registry and Treatment Outcome System, 98.1% started treatment, however, when all individuals who tested positive for HCV RNA (and have a recorded NHS number) are considered 79.7% were recorded as having initiated treatment.

The treatment outcome was reported for 88.5% of individuals who started treatment, and of these 87.3% achieved an SVR (Figure 8, Table 4b). When considering all individuals who initiated treatment, 77.3% achieved an SVR. A proxy SVR result has been used in the absence of a reported SVR, where there is a reported RNA negative test result recorded at 168 days or more after the treatment start date.

The HCV treatment pathway can be used as tool to illustrate engagement and retention in care, and clinical outcomes, and to identify gaps in care and/or monitoring. The treatment data presented are from ODNs reported through the NHSE Hepatitis C Patient Registry and Treatment Outcome System which is known to variably underreport treatment initiations in England. As a result, the proportion of persons initiating treatment is expected to be an underestimate.

Figure 8. Treatment pathway 2015 to 2022 [note 35]

Data sources:

• SSBBV
• NHS England data from the Hepatitis C Patient Registry and Treatment Outcome System as of October 2023

[note 35] HCV RNA and antigen tests were linked to the NHSE Hepatitis C Patient Registry and Treatment Outcome System using NHS Number, Name, DOB, hospital number and excludes children aged under one. Patient identifiable data submitted by SSBBV laboratories is variable, particularly from sexual health and drug and alcohol services, which limits the ability to link data sets or de-duplicate. Data is de-duplicated subject to availability of date of birth, Soundex, NHS number and first initial. All data is provisional.

[note 36] In individuals testing HCV RNA positive with no linkage to the Hepatitis C Patient Registry and Treatment Outcome System, there are no time restrictions on a subsequent RNA negative test after the initial RNA positive test. Therefore, these individuals may include those that have spontaneous clearance their infection or individuals who have cleared infection as a result of treatment but were not linked to the NHSE Hepatitis C Patient Registry and Treatment Outcome System.

[note 37] In the absence of a reported an SVR, a proxy SVR result is used when an RNA negative test is recorded at 168 days or more after the treatment start date.

[note 38] Numerator: number of individuals linked to the treatment database. Denominator: number of individuals who tested positive for HCV RNA with NHS number or name and date of birth.

[note 39] Numerator: number of individuals who started treatment (post PCR positive). Denominator: number of individuals linked to the treatment database.

[note 40] Numerator: number of individuals who had a treatment outcome reported. Denominator: number of individuals who started treatment (post PCR positive).

[note 41] Numerators: number of individuals who achieved an SVR. Denominator: number of individuals who had a treatment outcome reported.

Access to HCV treatment

From 2015, NHSE commissioning data shows significant increases in the number of people accessing HCV treatment, as access to new DAA drugs increased in England (13 to 19) (Figure 9). By tax year 2019 to 2020, the number of treatment initiations peaked at 12,229. This was a 140.0% increase on the mean level reported in earlier years (5,096, 2008 to 2014).

In tax year 2020 to 2021, the number of individuals accessing HCV treatment decreased by 35.9% to 7,835, likely due to COVID-19 pandemic restrictions on service provision and challenges in finding and engaging under-reached HCV positive individuals. Nevertheless, the lifting of pandemic restrictions, re-engagement with services, and a renewed focus on DAA roll-out is likely to be the reason for the 21.7% increase in treatment initiations between tax years 2020 to 2021 and 2021 to 2022.

Provisional data for tax year 2022 to 2023 shows a decrease of 0.6% in the number of treatment initiations compared to the previous tax year. Overall, between tax years 2015 to 2016 and 2022 to 2023, NHSE commissioning data shows that 77,862 treatment initiations took place.

Figure 9. Numbers initiating HCV treatment in England, calendar years 2007 to 2014 and from tax year 2015 to 2016 to tax year 2022 to 2023

Data sources:

• DAA drug commissioning data for tax years 2015 to 2016 and 2022 to 2023 (commissioning data is based on clinician intention to treat and invoicing and is subject to data quality issues and contract adjustments)
• SSBBV for scaled estimates for the period 2012 to 2014
• estimates from Roche sales, IMS supply chain manager, and Pharmex data for 2007 to 2011 (20)

HCV testing and diagnoses in key populations

Sexual health and HIV services

The risk of transmitting HCV through condomless sex is generally considered to be low. However concurrent sexually transmitted infections, having sex with multiple partners, and engaging in anal sex appear to increase a person’s risk for HCV. High testing coverage in sexual health services (SHSs) is essential for identifying and treating those at risk of HCV (gay, bisexual and other men who have sex with men (GBMSM) and persons living with HIV), thereby preventing further transmission, and reducing the risk of serious health complications.

Data on HCV testing at SHSs is available from SSBBV. These data show that HCV testing in SHSs increased by 8.8% between 2015 and 2019. However, testing decreased by 37.7% between 2019 and 2020 as a result of the reconfiguration of SHSs and the reduction in the number of face-to-face consultations during the national response to COVID-19. In 2022, SSBBV data show that testing for HCV in SHSs increased compared to 2021 but was still lower than pre-COVID-19 pandemic testing levels (17.0% fewer tests in 2022 compared to 2019). Of those tested in SHSs and reported to SSBBV, the number that had a positive HCV test in 2022 was 1.1%, which is similar to pre-COVID-19 pandemic test positivity levels (0.9% in 2019).

In 2018, the British HIV Association (BHIVA) set a target to achieve 100% micro-elimination of HCV for people living with diagnosed HIV by 2021. This was thought feasible due to the existing robust infrastructure around HIV care facilitating the delivery of DAAs. Data from the HIV and AIDS reporting system (HARS) shows that between 2015 and 2016 (the baseline), 4.6% (3,172 of 68,974) of people seen for HIV care had evidence of a current HCV infection. HCV positivity was highest among PWID (50.5%, 558 of 1,105), those exposed through blood or blood products (21.3%, 108 of 507), and GBMSM (6.0%, 1,649 of 27,397). By the end of 2022, excluding those who died or with no further attendances, 79% (2,397 of 3,035) were either explicitly recorded as having achieved an SVR, or had evidence of having done so (2 consecutive negative HCV test results recorded in HARS at least 28 weeks apart, and sustained to the end of 2022). A further 142 individuals had no evidence of infection at their last attendance, but no second negative test result to confirm clearance (21).

The GUMCAD STI Surveillance System is the mandatory surveillance system for STIs in England, and holds data on all STI and BBV tests, diagnoses and services from all commissioned SHSs in England. GUMCAD includes data from specialist services commonly accessed by key populations at an increased risk of HCV infection, including GBMSM and people who are living with HIV (22 to 23). GUMCAD data reported by specialist SHSs shows that HCV diagnosis rates, defined as anti-HCV positive or HCV RNA positive, have continued to fall among all attendees living with HIV (125.1 per 100,000 attendees in 2018 to 41.6 in 2022) and among GBMSM living with HIV (from 195.8 per 100,000 attendees in 2018 to 55.5 in 2022) (Figure 10). Although HCV diagnosis rates are lower among people who are HIV negative or of unknown status, a fall has also been observed over time (from 21.2 to 14.6 per 100,000 in all attendees; from 55.6 to 24.2 per 100,000 in GBMSM attendees). The reasons for the decline during this time are likely to be multifactorial, including changes in HCV testing guidelines for GBMSM and among HIV negative people taking HIV pre-exposure prophylaxis (PrEP). Work is underway to explore the data further to better understand HCV diagnosis trends among people accessing SHSs.

Figure 10. Rates of HCV diagnoses [note 42] by HIV status in SHSs per 100,000 attendees, [note 43] shown for all attendees [note 44] and GBMSM alone, England residents [note 45][note 46], 2018 to 2022 [note 47]

Data source: GUMCAD STI Surveillance System reported by specialist SHSs providing STI related care.

[note 42] Data is sourced from specialist SHSs only; data from non-specialist services is not included. Therefore, HCV data presented here will not match Table 4 of the STI annual data table publication.

[note 43] Data for all attendees includes everyone, regardless of gender or sexual orientation. Data for GBMSM attendees includes gay, bisexual and other men who have sex with men.

[note 44] Data for HCV diagnoses is based on the first reported diagnosis only, defined as anti-HCV positive or HCV RNA positive; diagnoses do not distinguish between current and past infections.

[note 45] Data for diagnosis rates are calculated using the number of SHS attendees as the denominator, and not the number of attendees tested for HCV; data on HCV testing is not currently available.

[note 46] Residence data includes people resident in England and people with an unknown residence.

[note 47] Data for 2020 and 2021 is impacted by the reconfiguration of SHSs during the national response to COVID-19; the number of HCV diagnoses reported for these years was lower than previous years.

Prisons

Prisons and other places of detention (PPDs) are an integral part of the HCV elimination agenda given the disproportionate burden of infection amongst residents of these settings, often associated with a history of injecting drug use. SSBBV data shows that HCV RNA positivity among people tested in prison has decreased from 5.2% (1,700 of 32,537) in 2018 to 2.7% (632 of 23,653) in 2022. It should be noted that SSBBV data does not cover all HCV testing being undertaken in prisons. The decrease in HCV RNA positivity is likely due to intensive testing and treatment initiatives in PPDs.

Since 2014, NHSE have commissioned a national programme of opt-out BBV screening for every new prison entrant for HCV, HBV and HIV. Uptake of a test on first and second reception testing in prisons has risen from 10.5% in tax year 2016 to 2017 to 72% in tax year 2022 to 2023. The increase in test uptake has not yet been sufficient in all prisons to achieve the 95-100% of reception testing that would be needed to achieve prison micro-elimination, though some prisons have reached 100% reception testing.

To supplement opt-out testing, NHSE commissions High Intensity Test and Treat (HITT) initiatives in selected prisons. This programme aims to test everyone in prisons for HCV and fast track them onto treatment within a 2-week timeframe. By the end of tax year 2022 to 2023, over 60% of prisons in England had facilitated at least one HITT, involving the testing of over 40,000 individuals. In tax year 2022 to 2023, there were 19 HITTs, testing 14,749 individuals (94% uptake), finding 1,140 persons who were antibody positive of which 152 were RNA positive for HCV (1% positivity overall). There are estimated to be 40 HITTs due to be completed in tax year 2023 to 2024, including repeat testing in prisons that have previously had HITTs or that have declared micro-elimination. As the prevalence of HCV in England continues to fall, testing strategies will need to evaluate what the most effective approaches are to finding cases of HCV in PPDs, and ensure healthcare teams remain motivated to deliver approaches in support of the elimination agenda.

Achieving continuity of care in PPDs can be challenging. Only 78.2% of people diagnosed with a positive HCV RNA test in prison had a reported SVR compared to 87.3% in the general England care cascade. However, it should be noted that evidence of follow up testing may be limited in persons tested in prisons, and an SVR may therefore be incompletely recorded. Furthermore, research data has shown a high rate of HCV reinfection amongst people in prison (20.4 per 100 person years, 95% CIs (17.2 to 24.2)), notably amongst women prisoners (32.1 per 100 person years, 95% CIs (21.7 to 47.5)) (1). This data suggests the need to feedback data on persons who test negative when moving between or leaving prison and improve continuity of care and ensure access to preventative and harm reduction measures on return to the community from prison.

Initiatives to raise awareness and increase numbers diagnosed

ED opt-out testing

NHSE funded a 3-year programme of opt-out testing for BBVs in EDs which began in April 2022. Over its first year, the programme was rolled out across 33 EDs in London, Manchester, Blackpool, and Brighton that were selected due to being in areas of very high diagnosed HIV prevalence. London adopted a city-wide implementation approach to ED testing, including all Type 1 EDs (major EDs that provide a consultant-led 24-hour service with full facilities for resuscitating patients). The programme aims to provide testing for HIV, HBV and HCV for anyone aged 16 years or over (18 years and over at some sites) and having a routine blood test during their ED attendance, unless they opt out. Universal opt-out testing aims to improve case finding and reduce stigma associated with HCV testing.

An interim 12-month public health and implementation evaluation undertaken by UKHSA and the University of Bristol shows that in the first year of the programme, according to programme reported data, 857,117 HIV tests, 473,723 HCV tests, and 366,722 HBV tests were done. Overall, with between-site variation, approximately half of eligible attendees were tested. The scale of the programme has significantly increased the number of BBV tests conducted in England annually.

Hundreds of people have been newly diagnosed through the programme. The highest number of new diagnoses was for HBV, reflecting the higher prevalence of people living with undiagnosed HBV compared to HIV and HCV. This is both a sign of success for HIV and HCV diagnosis and treatment programmes, and an indication of the disparity between BBVs with considerable unmet need and lack of investment for HBV. Among those diagnosed with current HCV infection (using surveillance data from 16 of the 33 sites), 6 of 339 were reinfections.

Linkage to care was sub-optimal for all BBVs and was lower for HBV and HCV than for HIV. This highlights the additional difficulties in linking to care from ED, which may include challenges in contacting individuals due to being homeless and incomplete or outdated contact information. Improvements to care pathways and support in engagement in care are needed to ensure that the people are started on treatment to prevent complications of infection and reduce onward spread.

Implementing standardised opt-out procedures in line with the good practice guidance provided to sites, including automated test requests and knowing when to use verbal prompts and signposting, is essential to achieve high testing rates. This will also ensure that between-site variations do not cause inequalities in offer and access to testing.

A new research project, to be commissioned through National Institute for Health and Care Research (NIHR), will evaluate an expansion of the ED opt-out testing programme in an additional 47 sites in areas of high diagnosed HIV prevalence starting from April 2024.

Antenatal opt-out testing

NHSE are working with UKHSA and other partners to support universal opt-out testing in antenatal settings in a time-limited pilot. Currently, the UK National Screening Committee (UKNSC) does not recommend a national opt-out screening programme for HCV in antenatal settings due to a lack of evidence. At present some HCV testing does take place in antenatal settings, however unlike HBV and HIV, HCV testing is often based on individual patient risk and is not opt-out. The NHSE HCV Elimination Programme is committed to funding a pilot opt-out programme to identify new and existing cases of HCV and obtain data to support the UKNSC’s next review on whether HCV should be included in antenatal screening alongside HBV, HIV and syphilis.

Web testing portal

NHSE commissioned Preventx Ltd to develop, implement and run a national HCV web testing portal in 2022. The portal went live on 4 May 2023, becoming fully operational from 13 May 2023. The portal is available to everyone in England aged 18 and over and is available in English and Urdu with future plans to include other languages.

The purpose of the portal is to ensure that everyone in England aged 18 years and over is able to access HCV testing (capillary blood sampling) in a free and confidential way and does not rely on other resource-stretched services providing this testing (primary care, drug and alcohol services, sexual health). As of October 2023, 11,500 individuals had ordered a test via the online service with a return rate of 58%. Testing by the service has identified 40 people who tested positive for HCV RNA and who were all subsequently engaged in treatment by their local ODN.

Future developments to the web testing portal include increased media coverage and marketing to raise awareness of HCV and how to access testing through the web portal. This includes targeted marketing to the most at-risk groups, including persons who are current or former injecting drug users, including those who use Image and Performance Enhancing Drugs (IPED), people from Eastern Europe and South Asia, and people who have had a blood transfusion before September 1991 or received an infected blood product before 1986.

Patient Search Identification (PSI) tool and primary care

It is expected that many persons who engaged in high-risk behaviours in the past are not aware of their HCV status and are not engaged in other healthcare settings, such as drug and alcohol services, where they would be offered testing. The NHSE HCV Elimination Programme is utilising the PSI tool, co-produced by MSD and NHSE as part of the HCV Elimination strategic procurement to identify persons at risk of HCV infection in primary care settings. The PSI tool searches patient health records to generate a list of patients who have a recorded HCV diagnosis, or evidence of HCV risk factors. The search tool contributes towards elimination by identifying patients with a recorded HCV diagnosis, ensuring that the diagnosis is correct and, if they have not cleared the virus already, arranging for treatment and appropriate follow up. Additionally, the tool identifies patients who may have a historical risk for HCV that they are not aware of so they can be offered testing.

The PSI tool is available to all GP practices in England. An example of the PSI tool being used is in North Yorkshire where 8 GP practices used the tool to search across approximately 35,000 patient records. The search identified 43 HCV positive patients, of whom 12 had not received treatment. An additional 2000 patients were identified as being at risk of HCV and will be offered testing via the web testing portal. To support the roll out of the PSI tool the HCV Elimination Programme has recruited GP Champions to support GPs and ODNs to manage the patient lists.

Treatment re-engagement exercises

In 2018, UKHSA (then Public Health England (PHE)) in partnership with NHSE launched a national patient re-engagement exercise. The exercise aimed to support the NHS in identifying people diagnosed with HCV in the period before DAAs were widely available. Individuals with a recorded HCV laboratory diagnosis between 1996 and 2017, who were alive, registered with a GP and had no evidence of treatment were shared with ODNs. For individuals for whom their last known RNA result was positive or unknown the ODNs were asked to engage with each individual’s GP and/or the individual directly to offer confirmatory testing and if positive DAAs.

Since the reengagement lists were shared with the ODNs, 13% of individuals have had a record of treatment entered onto the NHS treatment register. Half (n=11) of ODNs returned data for an evaluation, of which an estimated 39% of individuals did not respond or could not be contacted and were considered to be ‘not engaged’ with services.

Paediatric operational delivery network (pODN) re-engagement exercise

In 2019, UKHSA (then PHE) identified around 1,000 children who had previously tested either HCV antibody or RNA positive. Following further review, 481 children were referred to the pODN for follow up. GP registration data were available for 431 children who were under the age of 18 years, of whom 348 required no further follow up (including those who re-tested negative, had already been treated, or whose initial test was miscoded), 31 were awaiting retesting, 32 were awaiting a response or results from the GP, and 20 required further follow-up. Phase 2 follow up commenced in winter 2023 and aims to trace the remaining children who have a record of a positive test result but no indication of treatment or clearance.

Peer education and support

The Hepatitis C Trust has a range of services to support case finding in the general population as well as in important risk groups and in people experiencing health inequalities. This includes an extensive peer programme working across local communities, drug services and the English prison estate. The programme provides peer-to-peer education, peer services to support people through testing, treatment, and care, as well as partnership working to support pathway coordination.

The Trust continues to operate outreach services and testing vans to reach the most at-risk populations in areas where testing is less easily accessible. These services offer clear information and advice, point of care testing, as well as harm reduction advice and peer-led NSP to key risk groups such as people experiencing homelessness.

The Trust also provides a South Asian Outreach programme, which holds awareness and testing events within the South Asian community at Melas, Mosques and other community centres, in partnership with community leaders and local health authorities.

The Hepatitis C Trust peer programme supports patients diagnosed with HCV in ED settings to access treatment. Patients are typically referred for peer support if the clinical team have found difficulty in engaging them post diagnosis. 69% of patients referred to the peer programme who have been diagnosed in ED settings have successfully started treatment. The Hepatitis C Trust is working to expand the peer offer so that more patients may benefit from peer support.

In 2022, The Hepatitis C Trust had a team of 110 staff and 314 volunteers working across community and criminal justice programmes, dedicated to working with people affected by HCV. Through the community programmes, 5,691 outreach events were held in 2022, and a further 268 formal awareness training sessions were held for staff and members of the community. In the same period, 27,260 people were tested for HCV at outreach events and 2,150 were supported through treatment. A total of 1,077 outreach events were run through criminal justice programmes in 2022, and a further 376 formal awareness training events were held for staff and members of the community. 10,402 people were tested for HCV through HITT initiatives, and 355 people were supported through treatment.

Royal College of General Practitioners (RCGP) eLearning courses

Since 2023, UKHSA has supported open access to 2 eLearning courses produced by the RCGP which help raise awareness of viral hepatitis in primary care and among other professionals working with groups at elevated risk of viral hepatitis infection. To complete the course and gain a certificate, a user would have needed to complete all components of the course, including the modules and the pre-and post-course assessments. By August 2023, 2,179 users completed the HCV: Enhancing Prevention, Testing and Care course and were awarded a certificate since its launch in 2015. The Hepatitis B and C course was launched in November 2018. It was recently updated in August 2023. Since its launch in 2018, 525 users have completed the course and have been awarded a certificate. These figures are not comparable to previous reports as a different methodology has been used to calculate course completion.

Prevention of infection including adequate harm reduction in PWID

Measures to prevent transmission of HCV are a cornerstone of the public health response to eliminate HCV as a public health threat in England. Harm reduction measures such as providing sterile needles and syringes and adequate opioid agonist therapy (OAT) are essential to prevent incident infections or reinfections. WHO targets for prevention of HCV are to have 300 needles and syringes per PWID per year, and greater than or equal to 40% of PWID receiving OAT (Table 5a). Currently it is difficult to estimate the number of sterile needles and syringes provided per PWID per year using programmatic data, but survey data from the UAM indicates that around one third of PWID report inadequate NSP for their needs (Table 5b). In relation to OAT provision, 58% of opioid dependent PWID have received OAT between 2019 and 2020.

Preventing incident infections in people receiving medical care and blood products is another WHO programmatic target. These targets include 0% unsafe injections in healthcare facilities and 100% of donated blood to be screened for BBV infections (HBV, HCV, HIV and syphilis) (Table 5a). England currently meets the target for screening blood donations with 100% of all blood products tested for BBVs. Based on procurement data England is yet to meet the target for safe injections with 85% of all sharps purchased being safety engineered in 2022 (Table 5b).

Table 5a. WHO programme targets for prevention and harm reduction

Service coverage or programme target area	WHO GHSS 2025 target	WHO GHSS 2030 target
Prevention and harm reduction.	At least 200 sterile needles and syringes provided per person who injects drugs per year.	At least 300 sterile needles and syringes provided per person who injects drugs per year. Greater than or equal to 40% of people who inject. 100% of donated blood screened for HCV (24). 90% of health care injection devices procured are safety-engineered.

Table 5b. Progress in England

Prevention and harm reduction
Among people injecting psychoactive drugs participating in the UAM survey during 2022, 68.1% reported adequate NSP [note 48] for their needs (65.6% in 2021) [note 49]. 58.1% of opioid dependent PWID receive OAT (tax year 2019 to 2020). 100% of donated blood screened for HCV. In 2022, 85% of safety engineered sharps [note 50] had been purchased for use in healthcare settings.

[note 48] NSP is considered ‘adequate’ when the reported number of needles received met or exceeded the number of times the individual reported injecting in the past month. Further information can be found in the Technical notes.

[note 49] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be considered when interpreting data for these years.

[note 50] A ‘safety engineered sharp’ is defined as all products purchased that have a safety device which meets 2010/32/EU directive. Safety-engineered injection devices are those with a sharps injury protection feature (SIP) or the use of injection devices with a reuse prevention feature (RUP).

Prevention of infection by ensuring adequate harm reduction in PWID

Needle and syringe provision

Access to adequate harm reduction interventions such as sterile injecting equipment and OAT are important for PWID as they can prevent and reduce the risk of transmission of HCV as well as reduce the risk of reinfection after treatment (25 to 30). In addition, the use of low dead space injecting equipment instead of traditional needles has been shown to reduce HCV transmission (31). National Institute for Health and Care Excellence (NICE) recommends that services offer, and encourage the use of, low dead space equipment.

In 2022, 68.1% of PWID reported having adequate needle or syringe provision for their needs. This is similar to the 65.6% of people in 2021 (Figure 11). The observation that approximately 1 in 3 of persons do not report having sufficient needles and syringes for their need indicates that more needs to be done to support PWID to use drugs safely. UKHSA, with partners, are planning a pilot to explore the feasibility of a needle and syringe monitoring system to understand current provision and whether any gaps exist.

Figure 11. Estimated proportion of PWID reporting adequate NSP, 2013 to 2022 [note 51][note 52]

Data source: UAM survey of PWID.

[note 51] NSP is considered ‘adequate’ when the reported number of needles received met or exceeded the number of times the individual reported injecting in the past month.

[note 52] During 2020 and 2021, recruitment to the UAM survey was impacted by the COVID-19 pandemic. As a result, there were changes in the geographic and demographic profile of people taking part. This should be taken into account when interpreting data for these years.

Opioid agonist therapy (OAT)

OAT for PWID who are dependent on opiates is important as it reduces their risk of acquiring and transmitting HCV. Data shows that the WHO target for at least 40% of opioid dependent PWID to be receiving OAT by 2020 (6) has been met in England (58.1% in tax year 2019 to 2020); this figure was calculated by comparing the opiate use prevalence estimates from the Office for Health Improvement and Disparities (OHID) and UKHSA with prescribing data from OHID’s National Drug Treatment Monitoring System (NDTMS). When comparing 2019 to 2020 prevalence estimates (the latest available) with 2022 to 2023 prescribing data, 56.3% of opioid dependent PWID were receiving OAT. It should be noted that opiate use prevalence estimates may have changed since 2019 to 2020.

Prevention of infection by ensuring safe injections in health care and safe blood supplies

Safe injections: percentage of injections administered with safety engineered devices in and out of health facilities

The UK adheres to the EU Directive for the prevention of sharps injuries in the health care setting, by using safety engineered devices. The 2030 target requires 90% of healthcare injection devices procured to be safety-engineered. In 2022, 85% of all sharps purchased by NHS procurement had been safety engineered, this had increased from 58% in 2015 (Figure 12). Sharps have been defined as per the NHS Supply Chain framework for Syringes, Needles and Associated Products, Intravenous Cannulas and Associated products and Blood Collection Systems. Non-safety engineered sharps may be purchased for several reasons, including unavailability of safety engineered devices (for example, spinal, epidural, and biopsy sharps), supply chain disruptions (for example, COVID-19), lower cost, and clinical preference or need.

Figure 12. The number and proportion of safety engineered sharps [note 53] purchased by year

Data source: NHS Supply Chain [note 54].

[note 53] A ‘safety engineered sharp’ is defined as all products purchased that have a safety device which meets 2010/32/EU directive. Safety-engineered injection devices are those with a SIP or the use of injection devices with a RUP.

[note 54] Data from NHS Supply Chain which has over 90% market share of purchasing syringes, needles and associated products, intravenous cannulas and associated products and blood collection systems.

Blood safety: proportion of donations screened in a quality-assured manner

Blood donors are a group with a lower overall risk of BBVs than the general population as they undergo risk-based screening before they can donate. Monitoring infections in blood donors is important as it can identify unmet needs in the wider population. All donations are screened for HCV.

Overall, in England, rates of HCV positivity in new blood donors who have not been screened by NHS Blood and Transplant (NHSBT) before, remain low at around 23.6 per 100,000 donations in 2022, with 27 new donors confirmed to be antibody positive that year. There were no new confirmed positive cases in repeat donors who have had their donation screened before. All were identified by HCV antibody screening and just under half appeared to have cleared the virus with 4 reporting treatment while 51.8% (14 out of 27) were also positive for HCV RNA (annual range for period 1999 to 2022: 50.0% to 89.3%; average 73.8%). All donors who tested antibody positive, including those who had antibody positive RNA negative tests, were referred on for follow-up care.

In 2022 , 15 of the 27 donors who tested positive for HCV antibody in England were male, the median age was 47 years, range 20 to 63 years. Half (14 of 27) of donors who tested positive for HCV were born abroad, mainly in Europe or Asia. In contrast, 82% of new whole blood donors were of White British origin.

There was a lack of information around risk factors. Eleven did not have any risk factor identified and 7 did not have anything specific in their history except for being born in a part of the world where HCV is more common than the UK, mainly Asia or Eastern Europe. Two reported possible blood contact abroad through medical injections, surgery, tattoos, or dental work. Three HCV positive UK-born individuals reported a history of injecting drug use, which they had not disclosed at the donation session, 3 UK-born individuals may have been exposed to HCV via a household, occupational or sexual contact who used drugs, and one UK-born individual did not have a clear route of infection, reporting multiple potential low risk factors including sex between men and women, tattoos abroad and intranasal drug use.

Rates of confirmed anti-HCV positivity in donations from new donors have declined overall since 1991. Rates were at their lowest point of 12.4 per 100,000 donations in 2018, with a subsequent increase from 2019 up to 23.6 per 100,000 donations in 2022, similar to 2021 (Figure 13) (32 to 33).The overall fall in rates among new donors is likely to be the result of the declining number of older HCV positive donors of White-British ethnicity, often with a past history of injecting, thus leaving a higher proportion of HCV positive donors with possible blood contact and/or endemic country as the potential source of infection (33). The slightly increased rates from 2019 are due to an increase in the number of positive older White British donors from 5 in 2018 to 12 in 2022.

Further data on donors with HCV is also available from the NHSBT and UKHSA Epidemiology Unit Annual Review.

Figure 13. Rate of HCV among donations from new and repeat blood donors in England: September 1991 to 2022 [note 55]

Data source: NHSBT UKHSA Epidemiology Unit.

[note 55] 1991 to 1995 includes Wales,1996 to 2016 includes North Wales.

Technical notes 

These technical notes outline or describe the methodology used to produce the figures and tables used within this report.

Reducing the incidence of HCV infection

Due to challenges measuring incident infections directly, England uses the reduction in HCV viraemia prevalence as a proxy measure (supported by WHO guidance). A modelling approach is used to estimate prevalence, including both diagnosed and undiagnosed infections. Multiple sources of routine surveillance data is included to track progress over time, including seroprevalence data, HCV-related liver disease, and information on the number of PWID and other risk groups.

The HCV burden model used to estimate chronic prevalence is described online. The following data sources are used to inform the model:

• incidence of HCV infection in PWID over time, estimated via a force of infection model using 20 years of cross-sectional UAM survey data
• rates of disease progression from the Trent cohort (annual, age-specific probabilities of progression through mild, moderate, cirrhosis, HCV-related HCC and/or ESLD states)
• disease endpoint data (age-specific HCV-related ESLD and HCC from HES, 2011 onwards)
• rates of injecting cessation
• mortality (drug-related mortality for people currently injecting, plus background mortality)
• recent estimates of the size of the PWID population
• background rates of infection in never-injecting populations
• treatment data to model, and predict, the impact of treatment scale up and those clearing chronic infection through an SVR

The model reconstructs the epidemic of injecting drug use and associated HCV infections that would be consistent with several main sources of surveillance data: the UAM survey, estimated numbers of PWID and the numbers of people with HCV who progress to HCV-related HCC or HCV-related or ESLD over time.

The advantage of a combined approach is that surveillance data alone provides information only on infections in people who are currently injecting. Data on disease progression and endpoints (using ‘back-calculation’ methods) provides information on longer-term infections, but prevalence in people who have acquired HCV more recently (that is, currently injecting) is highly uncertain.

The disadvantage of the model is the reliance on knowledge of the disease progression process. Also, the model allows for the inflow of initiates to injecting drug use, but does not explicitly allow for migration in this group, which could have an effect if there is a sudden inflow to the population. Migration in non-injecting groups is also not accounted for. Future work will aim to address these limitations and explore the use of other sources of surveillance data in prevalence modelling.

Model outputs thus include the total number of chronic infections over time, and the current and future burden in terms of HCV-related cirrhosis, ESLD and HCC. The model also estimates underlying rates of incident chronic infection (new and reinfections). However, these estimates are not at a fine temporal granularity and ongoing work is being carried out to generate incidence estimates in PWID for monitoring purposes.

UAM survey methodology

The UAM Survey of PWID monitors BBVs, and associated risk and protective behaviours among PWID in England, Wales and Northern Ireland. The survey is voluntary and includes people who have ever injected psychoactive drugs, including people who currently inject drugs, or people who have done so previously. People are recruited to participate in the survey through specialist agencies. These agencies provide a range of services to PWID, from medical treatment to NSP and outreach work. People who agree to participate in the UAM survey provide a dried blood spot sample and self-complete a behavioural questionnaire.

It is important to note that the COVID-19 pandemic response had a negative impact on access to services for PWID, including BBV testing, treatment, and harm reduction. Innovative models of service delivery were rolled out during the pandemic to ensure continued access, such as the provision of injecting equipment and BBV testing kits by post or through peer distribution (34). There was also greater community engagement and the provision of outreach services, including services for people re-housed in hostels and hotels. When restrictions were lifted, services began to return to pre-pandemic practice, but found that the remote interventions were still helpful to some service users.

The COVID-19 pandemic, and subsequent changes in service delivery also had an impact on recruitment to the UAM survey in 2020 and 2021 as summarised below.

In 2020, fewer services took part and the geographical distribution of services that did take part was different to 2019.

Compared to those taking part in 2019, PWID recruited in 2020 were slightly older, had been injecting for longer and a higher proportion reported homelessness in the last year. The increase in the proportion reporting recent homelessness may be related to changes in recruitment, as in 2020, participation in the UAM survey was being offered alongside outreach services to people re-housed in hostels and hotels as part of the government’s COVID-19 ‘Everybody In’ policy.

People recruited in 2020 were also more likely to report sharing of needles, syringes and other equipment and more sexual partners compared to 2019. The increase in high-risk injecting practices may also be due to changes in recruitment, as in 2020, anecdotal evidence from drug and alcohol services suggests face-to-face appointments were being reserved for emergencies or for clients experiencing chaotic lifestyles.

In 2021, the number of services taking part and the number of participants was higher than in 2020, but still below pre-pandemic levels, and there remained significant differences in the geographical distribution of services taking part. The risk profile of participants in 2021 was similar to pre-pandemic levels.

In 2022, the number of services taking part in the survey, and the number of participants was comparable to pre-pandemic levels. However, there were significant differences in the geographical distribution of participants in 2022 compared to 2019. The risk profile of participants was broadly similar to 2019, including the proportion reporting homelessness in the last year. Compared to 2019, the proportion of participants of younger age was smaller, as was the proportion of people who reported that they initiated injecting drug use within the 3 years prior to survey participation.

The proportion of PWID with adequate NSP for their needs is calculated using data from the UAM survey. NSP is considered ‘adequate’ when the reported number of needles received met or exceeded the number of times the individual reported injecting in the past month. This calculation uses 4 questions asked in the UAM survey:

• ‘How many times do you visit a needle exchange in a typical month?’
• ‘How many needles do you typically collect during each visit?’
• ‘In the last month, on how many days have you injected drugs?’
• ‘On the last full day that you injected, how many times did you inject drugs?’

Coverage is calculated as the proportion of ‘needles collected’ (needles collected per visit multiplied by visits per month) divided by ‘needles required’ (injections per day multiplied by days injected per month). People who collected 100% or more of the needles required were categorised as having ‘adequate’ coverage, whereas those collecting less than 100% of their required needles were categorised as having ‘inadequate’ coverage. The calculation does not account for the fact that an individual may take multiple attempts to insert a needle before successfully accessing a vein, also known as achieving a ‘hit’.

Reducing HCV-related mortality

The number of HCV-related deaths are used to measure mortality. Deaths are based on the year they were registered and where HCV is mentioned on the death certificate along with codes for ESLD and/or HCC.

These deaths were estimated using slightly different ICD-10 codes from those used by WHO. A comparison of the codes used can be found in previous HCV reports.

Monitoring access to HCV treatment

HCV treatment initiation data is used to monitor access to HCV treatment; records from individuals with a diagnosis of HCV are linked to individuals in the NHSE Hepatitis C Patient Registry and Treatment Outcome System database. Treatment coverage is defined as the proportion of individuals diagnosed with chronic HCV infection (HCV RNA or HCV core antigen positive) and who initiated treatment during a specified time frame over the number of individuals diagnosed with chronic HCV infection for the specified time period.

The NHSE Hepatitis C Patient Registry and Treatment Outcome System was commissioned by NHSE in 2017 from the Arden and Greater East Midlands Commissioning Support Unit to capture more detailed information for patients. The HCV treatment monitoring in England report summarises the data held within the registry and Treatment Outcome System up to the end of April 2018.

Blood safety: proportion of donations screened in a quality-assured manner

NHSBT currently collects blood donations from donors in England. All donations are screened for anti-HCV and RNA using nucleic acid testing (NAT) in pools of 24 while repeat reactive donations undergo confirmatory testing (Figure 13) (35). The UK residual risk for 2020 to 2022 of screening tests failing to detect an infectious HCV donation are estimated at less than 1 in 64 million, which would mean that it could be up to 34 years before an HCV infectious donation goes undetected. Data on HCV testing in the blood donor population is available from the NHSBT UKHSA Epidemiology Unit.

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Acknowledgments

Monica Desai (editor), Annastella Costella, Ross Harris, Sema Mandal, Holly Mitchell, Simon Packer, Rachel Roche, and Ruth Simmons.

Our thanks also go to Chelsea Allen, Ashley Brown, India Clancy, Eleanor Clarke, Jamie Crummy, Peter Dearman, Stephen Duffell, Chantal Edge, Beatrice Emmanouil, Mark Gillyon-Powell, Lucy Foster, Katherine Fuller, Rachel Halford, Ana Harb, Matthew Hibbert, Stefan Jahr, Zoe James, James Lester, Carla Lloyd, Stephanie Migchelsen, Hamish Mohammed, Amber Newbigging Lister, Aneesha Noonan, Annabel Powell, Siri Ranlund, Leila Reid, Claire Reynolds, Stuart Smith, Hana Soini, Georgia Threadgold.

We would like to thank the clinicians, microbiologists, public health practitioners and other colleagues who have contributed to the surveillance systems used in this report. In particular:

• the drug service staff and The Hepatitis C Trust peer workers who support, and participants in, the Unlinked Anonymous Monitoring (UAM) survey of people who inject drugs
• Hospital Episode Statistics (HES), NHS England, produced by UK Health Security Agency (copyright © 2024, re-used with the permission of the NHS England, all rights reserved)
• NHS England and Arden and Greater East Midlands Commissioning Support Unit
• Office for National Statistics (ONS carried out the original collection and collation of the data but bears no responsibility for their future analysis or interpretation)
• North of England Commissioning Support (NECS) team
• Practice Plus Group (PPG) who contributed prison data
• NHS England for supplying treatment monitoring data for tax year 2015 to 2016 up to tax year 2022 to 2023 in England

In addition, we would like to acknowledge and thank the staff who work in the laboratories who contribute to the laboratory surveillance of HCV and SSBBV.

Suggested citation

UKHSA. Hepatitis C in England 2023: working to eliminate hepatitis C as a public health problem. Data to end of 2022. London, UKHSA, January 2024

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