Research and analysis

Hepatitis C in England 2024

Updated 12 March 2025

This report summarises England’s progress towards the World Health Organization (WHO) elimination targets for hepatitis C virus infection with data to end of 2023.

Foreword

The UK government is committed to eliminating viral hepatitis as a public health threat by 2030, and the UK Health Security Agency (UKHSA) continues to prioritise work that evidences progress towards achieving this goal. The Hepatitis C in England 2024 report provides an assessment of our progress towards achieving and demonstrating the WHO targets for elimination.

There are successes to be celebrated, including substantial declines in chronic hepatitis C prevalence, largely achieved through high levels of testing and curative treatment. Between 2015 and 2023, the number of people living with chronic hepatitis C in England has fallen dramatically in the general population by 56.7% and is now estimated at 55,900. Increased access to treatment has also led to a low hepatitis C virus-related mortality rate of 0.41 per 100,000 population.

Substantial declines in chronic hepatitis C prevalence have also been observed among people who inject drugs, the main group at risk of acquiring hepatitis C. The prevalence of chronic hepatitis C among people who inject drugs is now at 7.2%. Since 2015, the proportion of people who inject drugs clearing a previous infection has almost doubled, primarily delivered through intensive testing and treatment within community drug services.

However, there remain challenges to achieving and maintaining elimination. Over one third of people who inject drugs who were living with chronic hepatitis C were potentially unaware of their status. A focus on equitable and easy access to testing and treatment, with person-centred holistic approaches that involve peer support, will be important to address more complex needs. Stigma can be a barrier to accessing services, and work is underway to better understand how stigma affects people living with hepatitis C and how this can be addressed. UKHSA is also working with partners to evaluate different testing initiatives, such as the emergency department (ED) opt-out testing programme, which aim to increase the number of people living with chronic hepatitis C who are diagnosed and linked to care.

An additional area of concern is the provision of needles and syringes for people to use drugs safely, with around 1 in 3 people who inject drugs reporting inadequate availability to meet their needs. It is vital that adequate harm reduction programmes are provided to prevent new and reinfections.

The achievements to date have been driven by a collective desire to eliminate hepatitis C as a public health problem in England. UKHSA, as system leader, is committed to working collaboratively with partners to continue the final push towards elimination ensuring that equity, community engagement, and human rights stay at the forefront of the response. Ongoing engagement with stakeholders is vital to strengthen our data systems and reporting mechanisms to ensure we can detect any threats to elimination and future maintenance.

Professor Susan Hopkins

Chief Medical Advisor at the UKHSA

Main messages

The main findings are below.

In England, around 55,900 adults aged 16 years and over (95% credible interval (CrI) 44,200 to 69,900) were estimated to be living with chronic hepatitis C (hepatitis C virus antibody positive and hepatitis C virus ribonucleic acid (RNA) positive) in 2023, a decrease of 56.7% since 2015.

The prevalence of chronic hepatitis C in people who inject drugs has continued to decrease since 2017 and was 7.2% in 2023. The proportion of people who inject drugs who have cleared hepatitis C virus continues to increase with 45.4% in 2023, which is almost double compared to 2015 at 23.0%. This decline is strongly associated with the scale-up of direct-acting antiviral (DAA) treatment.

Work is underway to estimate progress towards the WHO absolute target for incidence among people who inject drugs.

Between 2015 and 2023, the rate of reinfection with hepatitis C was 6.4 per 100 person-years.

The annual hepatitis C virus-related End-Stage Liver Disease (ESLD) and/or hepatocellular carcinoma (HCC) mortality rate was 0.41 per 100,000 population in 2023, indicating that the WHO target to reduce mortality to less than or equal to 2 per 100,000 has been surpassed in England.

Currently, there is no direct measurement available to monitor progress towards the WHO target of greater than or equal to 90% of people living with chronic hepatitis C being diagnosed. Work is underway to use surveillance data to estimate progress towards this indicator, however, ascertaining the RNA status of each individual is dependent on the quality and completeness of data. Additional work is needed, in collaboration with stakeholders, to enhance existing surveillance data where RNA status is unknown and to improve the coverage of laboratory surveillance data, including negative test results.

Based on data from the Unlinked Anonymous Monitoring (UAM) Survey, 27.8% of people who inject drugs who were living with chronic hepatitis C were aware of their status. After accounting for participants who reported having a diagnostic test or were awaiting their test result, 61.7% were potentially aware. This highlights that opportunities for testing and prompt diagnosis remain.

78.3% of individuals diagnosed with chronic hepatitis C between 2015 and 2023 were recorded as having initiated treatment in surveillance data. This proportion indicates that England has nearly achieved the WHO target for treatment coverage of greater than or equal to 80%. Where individuals who were diagnosed with chronic hepatitis C between 2015 and 2023 were linked to specialist treatment services, 96.1% had initiated treatment.

1 in 3 people who reported injecting drugs in the past month reported having inadequate needle and syringe provision (NSP) for their needs. This highlights potential gaps to prevent new and reinfections through adequate provision of harm reduction. Further work is underway to monitor the provision of NSP and to estimate progress towards the WHO target of providing at least 300 needles and syringes per person who injects drugs per year.

The WHO target for at least 40% of people who inject drugs who are dependent on opioids to be receiving opioid agonist therapy (OAT) has been met in England (58.1% in tax year 2019 to 2020).

Procurement data shows that the proportion of sharps purchased by NHS Supply Chain that were safety-engineered has increased over time from 58% in 2015 to 83% in 2023; this proportion is currently below the WHO target of 90% of healthcare injection devices procured being safety-engineered.

100% of donated blood was screened for hepatitis C virus infection, indicating that England has met the WHO target for blood safety.

A summary of the WHO targets for viral hepatitis C elimination and England’s progress towards meeting them can be found below.

Table 1. Summary of WHO Impact and programmatic targets and progress in England in 2023

Target type	Target	WHO GHSS 2030 target	Progress in England
Impact	Annual hepatitis C virus incidence rate	Less than or equal to 5 per 100,000 persons Less than or equal to 2 per 100 people who inject drugs	No estimate available
Impact	Annual mortality rate of hepatitis C virus-related deaths	Equal to or less than 2 per 100,000 persons	0.41 per 100,000 population in 2023
Programme	Proportion of people with chronic hepatitis C diagnosed	Greater than or equal to 90%	No estimate available
Programme	Proportion of people diagnosed with hepatitis C initiating treatment	Equal to or greater than 80%	78.3% of people diagnosed between 2015 and 2023 initiated treatment
Programme	Harm reduction	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 drugs who are dependent on opioids receiving OAT	No estimate available 58.1% for tax year 2019 to 2020 (latest available)
Programme	Blood safety	100% of donated blood screened for hepatitis C virus	100%
Programme	Safe injections	100% of healthcare facilities with safe injections 90% of healthcare injection devices procured are safety-engineered	No estimate available 83% in 2023

Introduction

Hepatitis C virus is a bloodborne virus (BBV) that infects the liver and over time can cause severe liver damage leading to cirrhosis, liver failure and cancer. Globally an estimated 50 million people are living with chronic hepatitis C and there are around 1 million new infections per year. The WHO estimated that approximately 242,000 people died from hepatitis C in 2022, mostly from cirrhosis and HCC.

In the UK, the most important risk factor for acquiring hepatitis C virus infection is injecting drug use (past or current) through sharing of injecting equipment. Other people who may have been exposed to hepatitis C include people who are from a country with a higher prevalence of hepatitis C, and those who received a blood transfusion or a blood product before widespread screening was introduced in the UK (see Technical notes) for further information). The wide availability of DAAs, which have a short, well-tolerated treatment course (8 to 12 weeks), has resulted in many people being successfully treated for hepatitis C.

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. To validate elimination of viral hepatitis, it is necessary to demonstrate the achievement of the WHO impact and programmatic targets. The impact targets include absolute thresholds for incidence and mortality, and programmatic targets focus on diagnosis, treatment and prevention.

The impact targets for annual incidence are less than or equal to 5 per 100,000 in all persons and less than or equal to 2 per 100 in people who inject drugs. The mortality rate target is now combined for both hepatitis C and hepatitis B to reflect the overarching goal to eliminate viral hepatitis and is less than or equal to 6 per 100,000 population. Previously, the standalone mortality target for hepatitis C was 2 per 100,000 persons.

The programmatic targets are:

• at least 90% of people living with chronic hepatitis C to be diagnosed
• at least 80% of people who are diagnosed with hepatitis C to be treated
• at least 300 needles and syringes provided per person who injects drugs per year or at least 40% of people who inject drugs who are dependent on opioids to be receiving OAT
• 100% of healthcare facilities with safe injections or 90% of healthcare injection devices procured to be safety-engineered
• 100% of blood donations to be screened

This report summarises England’s progress towards the WHO elimination targets for hepatitis C virus infection with data to the end of 2023.

Reducing prevalence and incidence of hepatitis C virus infection

Estimated prevalence in the general adult population

Prevalence, the total number of people estimated to be living with hepatitis C at a single time point, describes the total disease burden and monitoring trends in its decline is an important indicator to monitor progress towards elimination. Prevalence estimates also feed into other WHO targets across the care cascade.

In England, around 55,900 adults aged 16 years and over (95% CrI, 44,200 to 69,900) were estimated to be living with chronic hepatitis C in 2023 (hepatitis C antibody and RNA positive, modelled estimate, see Technical notes for further information) (Figure 1). This is equivalent to a prevalence estimate of 0.12% (95% CrI, 0.10% to 0.15%) in England. When compared to 2015 (the baseline year in the 2016 WHO GHSS), the number of people living with chronic hepatitis C has declined by 56.7% (from 129,000 (95% CrI, 109,900 to 147,000)).

In 2023, there were estimated to be 188,700 (95% CrI, 170,100 to 204,700) adults who had ever had hepatitis C (hepatitis C virus antibody positive). The proportion estimated to be currently living with chronic hepatitis C was 29.7% (95% CrI, 26.0% to 33.8%) (see Technical notes for further information). This estimate has declined from 59.5% in 2015 (95% CrI, 56.5% to 61.9%). The reduction in prevalence over time is largely due to the introduction of DAAs in 2015 and improved access to treatment achieved in part through a comprehensive and far reaching ‘Elimination Initiative’ programme led by NHS England (NHSE) in partnership with NHS Trusts, the pharmaceutical industry and lived-experience partners.

Of the 55,900 adults estimated to be living with chronic hepatitis C in 2023, modelling has also estimated that 18.4% of these were adults who were currently or recently injecting drugs. This estimate includes people who were, and were not, accessing specialist drug and alcohol services, and any individual who had not permanently ceased injecting.

Those with a past drug injecting history but who were no longer injecting were the largest group, which was estimated to be 66.2% (95% CrI, 44.8% to 79.4%) of those living with chronic hepatitis C. This implies that there were an estimated 8,600 people with chronic hepatitis C who did not have a history of injecting drug use, although data on this group is limited and further work is required to understand the impact of other factors, such as migration.

Figure 1. Estimated prevalence of chronic hepatitis C [note 1][note 2] in the general adult population [note 3] in England, 2012 to 2023

Shaded line shows 95% CrI.

Source: Modelled estimates of chronic hepatitis C prevalence based on multiple sources of information. Further information can be found in Technical notes.

Note 1: The model calculates the proportion of people living with chronic hepatitis C out of all those alive who have ever had hepatitis C (that is people who are hepatitis C virus antibody positive). The latter may have cleared their infection through achieving a sustained virological response (SVR) post treatment, or through spontaneous clearance.

Note 2: The model assumes that the proportion of people who spontaneously cleared hepatitis C without treatment is a fixed quantity with no uncertainty (24% of infections spontaneously clear without treatment). Therefore prior to DAA treatment, the CrI for the proportion of chronic infections is very narrow.

Note 3: The model estimates the percentage of the adult (aged 16 years and over) population with chronic hepatitis C infection. Virtually all infections are in those aged 16 years and over, so a more accurate picture is given by excluding children from the denominator.

Estimated prevalence among people who inject drugs

Among people who inject drugs who took part in the UAM Survey (see Technical notes for further information), the prevalence of chronic hepatitis C has continued to decrease since 2017, with 7.2% (95% confidence interval (CI) 6.4% to 8.2%) estimated to be living with chronic hepatitis C in 2023 (Figure 2).

Correspondingly, the proportion of individuals who have cleared hepatitis C virus continues to increase. In 2023, 45.4% (95% CI, 43.6% to 47.1%) of people who inject drugs had cleared hepatitis C virus, which is almost double compared to 2015 at 23.0% (Figure 2).

The proportion of individuals who have ever had hepatitis C, which includes those who have cleared the virus, has remained relatively stable at 52.6% in 2023, which is likely reflective of ongoing new infections associated with long-term injecting use, as well as an ageing population of people who have hepatitis C virus antibodies who are living longer after being treated for chronic hepatitis C. Among individuals who have ever had hepatitis C, the proportion with chronic hepatitis C has declined to 13.8% in 2023 compared to 55.4% in 2015.

Statistical modelling using UAM Survey data has also provided strong evidence for an association between community scale-up of treatment and reductions in chronic hepatitis C prevalence, which supports the effectiveness of treatment as prevention in people who inject drugs.

Figure 2. Trend in hepatitis C prevalence among people injecting psychoactive drugs in England, 2014 to 2023 [note 4][note 5][note 6]

Vertical lines show 95% CIs.

Source: UAM Survey of people who inject drugs.

Note 4: Retrospective analysis of hepatitis C virus RNA (2014 to 2016) was performed as part of the EPIToPE study, funded by the National Institute for Health and Care 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 (DHSC).

Note 5: Estimates for chronic and cleared hepatitis C virus infection have been adjusted to consider hepatitis C virus antibody positive samples with missing RNA status. The ratio of chronic to cleared infection was applied to the hepatitis C virus antibody positive samples with missing RNA status by year and region.

Note 6: 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.

Monitoring WHO targets for hepatitis C incidence

A key indicator to monitor progress towards eliminating hepatitis C as a public health threat is the number of people newly acquiring hepatitis C (incidence). This indicator describes the risk of transmission and measures progress towards reducing new infections, including primary infections and reinfections.

In order to achieve validation of hepatitis C elimination, the annual incidence rates must be below the WHO absolute target of less than or equal to 5 per 100,000 in the general adult population, and less than or equal to 2 per 100 in people who inject drugs (Table 2).

Table 2. WHO impact targets for reducing the incidence of hepatitis C

Impact target area	WHO GHSS 2030 target	Progress in England
Annual hepatitis C virus incidence rate	Less than or equal to 5 per 100,000 persons Less than or equal to 2 per 100 people who inject drugs	No estimate available

WHO guidance requires incidence to be estimated directly or modelled. The gold-standard method for measuring hepatitis C incidence is a prospective study that involves retesting people at risk of infection. However, this approach is resource-intensive and challenging to implement and repeat over time, particularly in low-incidence settings. Robust mathematical modelling can be used as an alternative approach whereby routine surveillance data is used to inform the model input parameters. Various approaches to estimating incidence are being explored through a multi-stakeholder working group (see Recommended actions for further information). When considered together, these approaches will be used to provide evidence of progress towards achieving the WHO incidence target.

One of the approaches being explored is the use of mathematical deterministic modelling to estimate incidence. This approach has been carried out to assess the impact and cost-effectiveness of scaling up hepatitis C testing and treatment among people who inject drugs in 4 out of 23 regional Operational Delivery Networks (ODNs) of England. Multiple sources of routine surveillance data were used to parameterise and calibrate the model including the UAM Survey, Sentinel Surveillance of Blood Borne Virus (SSBBV) testing, and NHSE Hepatitis C Patient Registry and Treatment Outcome System (see Technical notes for further information).

The model estimated hepatitis C incidence at the end of 2023 and projected whether the WHO incidence target would be reached by 2030 if existing testing and treatment initiatives were continued or whether further interventions were required from 2024. By the end of 2023, hepatitis C incidence was estimated to range from 1.9 to 4.9 per 100 person-years with one of the 4 ODNs modelled achieving the hepatitis C elimination target (incidence less than 2 per 100 person-years). 3 out of 4 ODNs had a lower CI value below the WHO elimination target. By 2030, hepatitis C incidence projections ranged from 0.2 to 2.2 per 100 person-years across the 4 regions when existing initiatives were continued, with 3 regions projected to meet the incidence target of less than or equal to 2 per 100 person-years.

Scaling up of testing in drug services to 80% of attendees each year (from 27%) or ensuring that 75% of people were tested whilst in prison (from 55%) from 2024 was projected to result in the 4th region also achieving the WHO target by 2030. Existing testing and treatment strategies as well as these improvements in testing were found to be highly cost-effective. The model is being further developed to provide incidence estimates for England and these are expected to be available for the Hepatits C in England 2025 report.

A second approach being explored is the use of force of infection models to estimate trends in the rate of first hepatitis C virus infection among people who inject drugs utilising data from the UAM Survey (reinfections are not currently considered). The incidence rate increased in those injecting for 1 year or less from 17 per 100 person-years (95% CI, 16 to 19) in 2011 to 26 per 100 person-years (95% CI, 23 to 30) in 2020. In those injecting for longer durations, incidence rates were stable over time at around 5 per 100 person-years. While these results do not show evidence for a decline in incidence between 2016 to 2020, the estimated trend was uncertain and the expected impact in the initial stages of community scale-up of DAAs among people who inject drugs (from 2017) is likely to be modest. The models are currently being updated to incorporate more recent data and to explore treatment and reinfection.

Direct and indirect measures of hepatitis C incidence in people who inject drugs from the UAM Survey also provide a valuable source of data to monitor trends over time among people who inject drugs. It is important to note that these estimates are based on a sample of the population. As a result, the methods of data collection should be carefully considered when interpreting the findings.

People who inject drugs testing hepatitis C virus RNA positive and antibody negative

Data from the UAM Survey can be used to demonstrate whether there is evidence of a decline in the incidence of hepatitis C. This can be done by directly measuring the number of people who have evidence of hepatitis C virus viraemia and who are also hepatitis C virus antibody negative and whether this changes over time. These individuals are likely to have acquired hepatitis C virus infection recently and are yet to mount an antibody response.

Data from the UAM Survey suggests that the estimated incidence of hepatitis C has remained relatively stable in recent years (Figure 3). While the annual point estimate was lower in 2023 compared to previous years, the small sample size has resulted in wide CIs. Therefore, the data provides little or no evidence of a decline in incidence in recent years.

A further limitation of this approach is that it does not consider people who have an incident hepatitis C virus reinfection. In addition, there is some uncertainty over the 51 day window period used to estimate incidence (that is the time after exposure to hepatitis C virus when RNA is detectable, but the individual has not yet formed antibodies).

Figure 3. Estimated incidence of hepatitis C among people who injected drugs in the last year in England, 2016 to 2023 [note 7][note 8]

Vertical lines show 95% CIs.

Source: UAM Survey of people who inject drugs.

Note 7: For the incidence calculations, a fixed window period of 51 days was used and there is some uncertainty regarding the use of this measure.

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.

Estimated hepatitis C virus antibody prevalence among people who recently started injecting drugs

An indirect measurement of incidence among people who inject drugs examines hepatitis C virus antibody prevalence among recent initiates to injecting. As most new hepatitis C virus infections are acquired via injecting drug use, the detection of hepatitis C virus antibodies in a person who has recently started injecting drugs is likely reflective of a recent infection associated with that behaviour. It should be noted that this value does not include incident reinfections.

Data from the UAM Survey suggests that in people who recently started injecting drugs (within the past 3 years) there has been a year-on-year decrease between 2018 and 2022 in the proportion with antibodies to hepatitis C virus (32.6% in 2018 to 19.3% in 2022) (Figure 4). The proportion in 2023 was similar to 2022 at 19.1%. The downward trend in prevalence in people who recently started injecting drugs between 2018 and 2022 could suggest a decline in incidence of hepatitis C in this sub-group of people who inject drugs. However, it should be noted that the number of people in the UAM Survey with a short duration of injecting is small, and declining, so this approach has limited power to detect a change in incidence.

Data on incidence is limited, and we cannot confidently determine whether there has been a change in incidence in people who inject drugs based on this information alone. Triangulation with additional data, such as the NHSE Needs Assessment Project (hepatitis C virus antibody and RNA testing of 11,024 people attending drug and alcohol services and in some areas, community settings with follow-up testing 6 months to 1 year later) and the further development of modelled incidence estimates for England, are required to better estimate incidence in the population of people who inject drugs (see Recommended actions for further information).

Figure 4. Estimated prevalence of antibodies to hepatitis C virus among people who started injecting drugs within the last 3 years in England, 2014 to 2023 [note 9]

Vertical lines show 95% CIs.

Source: UAM Survey of people who inject drugs.

Note 9: 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 is combined. Please see Technical notes for more details.

Reinfections

People who have been previously treated for hepatitis C, 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 experiencing hepatitis C virus reinfection (people who have lived with hepatitis C more than once).

Reinfection can be estimated using data on treatment from the NHSE Hepatitis C Patient Registry and Treatment Outcome System linked to serial hepatitis C virus RNA or core antigen testing data from SSBBV.

In England, reinfection is defined in an individual who is positive for hepatitis C virus RNA or core antigen and/or has a subsequent treatment episode following a reported SVR or negative RNA or core antigen result after they had previously been treated for hepatitis C (see Technical notes for further information). A period of 196 days between first treatment and reinfection diagnosis is used to define reinfection as the majority of individuals receiving treatment will have cleared hepatitis C virus within 6 months (182 days). A further 2 weeks (14 days) is added to account for any delays in treatment initiations. Reinfection after spontanteous clearance is not included.

A control group of persons who had a post-treatment RNA or core antigen test at least 196 days after first treatment initiation is used to calculate the reinfection rate. 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.

Among people who initiated treatment between 2015 and 2023 in England, the reinfection rate was 6.4 per 100 person-years (95% CI: 6.3 to 6.6 per 100 person-years). This means that if 100 people treated for hepatitis C were followed up for one year, an estimated 6 individuals among them are likely to experience hepatitis C virus reinfection in that year. Further analyses are planned to monitor how the reinfection rate is changing over time and to provide updated estimates of reinfection among different population groups.

Reducing hepatitis C virus-related mortality

Hepatitis C virus-related mortality is an important measure of progress towards hepatitis C elimination as it monitors whether services are promptly diagnosing and treating people living with hepatitis C. Prompt diagnosis and treatment reduces the number of deaths related to hepatitis C virus by ensuring early clearance of the virus before it can cause damage to the liver.

The combined hepatitis C and hepatitis B absolute target for mortality is equal to or less than 6 per 100,000 population. Previously, the mortality targets separated hepatitis B and hepatitis C at 4 per 100,000 and 2 per 100,000 persons respectively. The hepatitis C target has already been met, with the annual hepatitis C virus-related ESLD and/or HCC mortality rate at 0.41 per 100,000 population in 2023 (Table 3, Figure 5).

Table 3. WHO impact target for reducing hepatitis C virus-related mortality

Impact target area	WHO GHSS 2030 target	Progress in England
Annual mortality rate of hepatitis C virus-related deaths	Equal to or less than 2 per 100,000 persons	0.41 per 100,000 population (2023) [note 10][note 11]

Note 10: Based on Office for National Statistics (ONS) mid-year population estimates for the UK, England, Wales, Scotland, and Northern Ireland.

Note 11: Death registrations for England are those where hepatitis C virus is mentioned on the death certificate and excludes deaths registered in England when the deceased’s usual residence is outside England.

Further information can be found in Technical notes.

Figure 5. Mortality rate [note 13] for hepatitis C virus-related ESLD [note 13] and/or HCC in England, 2005 to 2023

Source: Based on Office for National Statistics (ONS) mid-year population estimates for the UK, England, Wales, Scotland, and Northern Ireland.

Note 12: Death registrations for England are those where hepatitis C is mentioned on the death certificate and excludes deaths registered in England where the deceased’s usual residence is outside of England.

Note 13: Defined by codes or text entries for ascites, bleeding oesophageal varices, hepato-renal syndrome, hepatic encephalopathy, or hepatic failure (see Technical notes for further information).

In England, the number of death registrations from hepatitis C virus-related ESLD and/or HCC peaked at 381 in 2014 and remained at a similar level in 2015 (380 death registrations). Between 2015 and 2023 these numbers fell by 37.4% (to 238 death registrations). This was primarily driven by the decrease in hepatitis C virus-related ESLD, which fell by 52.5% during this period (Figure 6). Whilst the total number of hepatitis C virus-related ESLD and/or HCC deaths has continued to fall, a small increase of 7.8% in deaths from hepatitis C virus-related HCC was seen between 2022 and 2023 (141 and 152 deaths, respectively) and 2023. Nevertheless, this increase is still below levels seen in previous years.

Figure 6. Number of death registrations [note 14] for hepatitis C virus-related ESLD [note 15] and HCC in England, 2005 to 2023

Source: ONS

Note 14: Death registrations for England are those where hepatitis C is mentioned on the death certificate and excludes deaths registered in England where the deceased’s usual residence is outside of England.

Note 15: Defined by codes or text entries for ascites, bleeding oesophageal varices, hepato-renal syndrome, hepatic encephalopathy, or hepatic failure (see Technical notes for further information).

Proportion of people with chronic hepatitis C diagnosed and aware of their infection

The proportion of people diagnosed with chronic hepatitis C assesses whether current testing coverage is sufficient to identify the majority of people who are living with hepatitis C. The current WHO target is to diagnose greater than or equal to 90% of all people living with hepatitis C (Table 4). 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 4. WHO programmatic target for hepatitis C diagnosis and awareness of infection

Service coverage or programme target area	WHO GHSS 2030 target	Progress in England
Proportion of people with chronic hepatitis C virus diagnosed [note 16]	Greater than or equal to 90%	No estimate currently available

Note 16: The numerator for this indicator is the number of persons with chronic hepatitis C who have been diagnosed, and the denominator is the estimated number of persons living with chronic hepatitis C.

Laboratory reports of testing and diagnoses for hepatitis coupled with evidence of treatment underpin surveillance activities used to monitor efforts to diagnose and treat people living with chronic hepatitis C.

To estimate the number of people diagnosed, laboratory-confirmed reports of all hepatitis C diagnoses reported to UKHSA via NHS or private laboratories, or through point of care testing, are used to create a cohort of individuals who have been diagnosed with hepatitis C.

The RNA status of an individual within the cohort from a chosen baseline year is estimated using the last known RNA or core antigen test reported to UKHSA or through data linkage to established healthcare data sets (including NHSE’s Hepatitis C Patient Registry and Treatment Outcome System and NHSE’s Blueteq system), and information received directly from ODNs. Individuals are excluded if they died prior to the baseline year through linking to ONS death registrations.

The RNA status of an individual within the cohort is estimated with varying levels of confidence based on the data available. Further work is needed in collaboration with stakeholders to enhance information on individuals within the cohort where RNA status is still unknown (see Recommended actions for further information on the proposed methodology). Provisional estimates are expected to be available for the Hepatitis C in England 2025 report.

Awareness of hepatitis C virus infection in people who inject drugs

As more people are treated for their hepatitis C, the proportion of people who are aware of their infection should decrease as people who know about their infection are successfully treated. However, those who have not been tested or remain under-tested are less likely to be aware of their hepatitis C virus infection or reinfection, which reflects unmet testing and treatment needs.

UAM Survey data can be used to assess the proportion of people who inject drugs who are aware that they are living with hepatitis C by comparing information obtained from dried-blood spot testing with self-reported questionnaire data on hepatitis C virus infection status (see Technical notes for further information). This data can be used to help deliver initiatives which are focused on meeting the needs of the population.

In 2023, 27.8% of people who reported injecting in the past year and who were living with chronic hepatitis C (hepatitis C virus antibody and hepatitis C virus RNA positive) were aware of their infection at the time of completing the UAM Survey (Figure 7). This proportion is similar to what was observed in 2022 (28.7%) but is part of a downward trend in awareness of infection over the past 6 years with 50.8% of people who inject drugs aware of their infection in 2017. It is important to note that the proportion aware is likely an underestimate as diagnostic hepatitis C virus 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 2023, 46.9% of UAM Survey participants who were unaware they were living with chronic hepatitis reported accessing diagnostic hepatitis C virus or BBV testing at the time of completing the UAM Survey or that they were awaiting their test result. After accounting for this, the proportion of people who injected drugs in the last year who were potentially aware they were living with chronic hepatitis C was 61.7% in 2023. Therefore, 38.3% of people who inject drugs who injected in the last year remained potentially unaware of their status, suggesting that opportunities for testing and prompt diagnosis in this population could remain.

Among people who remained potentially unaware, 80.4% reported injecting in the past 4 weeks, of whom 48.8% reported that they had never been tested or that their last hepatitis C virus test was more than 2 years ago. Most people who remained potentially unaware of their chronic infection reported that they had experienced homelessness (54.0%) or being in prison (18.8%) in the current or previous year, and all reported that they had accessed a health service within the past year.

Figure 7. Estimated proportion of people who inject drugs who test positive for hepatitis C virus who are aware of their infection in England, 2014 to 2023 [note 17][note 18][note 19][note 20]

Source: UAM Survey of people who inject drugs

Note 17: 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 18: Data regarding awareness of hepatitis C virus RNA result, and therefore chronic infection status, is available for 2017 onwards due to changes in the UAM Survey questionnaire.

Note 19: 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 20: These figures are for people who had injected drugs in the last year and differ from those in the UAM data tables which refer to all people who inject drugs.

Monitoring access to hepatitis C treatment

The WHO elimination target for treatment coverage is equal to or greater than 80% (Table 5). Treatment coverage is defined as the proportion of individuals diagnosed with chronic hepatitis C who initiated treatment during a specified time frame (Table 5).

Table 5. WHO programmatic target and progress for monitoring access to hepatitis C treatment in England, 2015 and 2023

Target area	WHO GHSS 2030 target	Progress in England [note 21]
Proportion of people diagnosed with hepatitis C initiating treatment	Equal to or greater than 80%	81.4% of individuals diagnosed with chronic hepatitis C were linked to specialist treatment services [note 22] 96.1% of individuals linked to specialist treatment services initiated treatment [note 23] 78.3% of individuals diagnosed with chronic hepatitis C initiated treatment (WHO target) [note 24] 90.9% of individuals who initiated treatment had an outcome reported or had an RNA or core antigen test reported through SSBBV [note 25] 83.1% of individuals who initiated treatment were reported to have achieved SVR either as a treatment outcome or had an RNA or core antigen negative result reported through SSBBV [note 26] 91.5% of individuals who initiated treatment and had an outcome reported or an RNA or core antigen test reported through SSBBV were reported to have achieved SVR or had an RNA or core antigen negative test result [note 27]

Note 21: The total number of individuals diagnosed with chronic hepatitis C is based on the first hepatitis C virus RNA or core antigen positive test reported through SSBBV during the period 2015 to 2023.

Note 22: Numerator: number of individuals linked to specialist hepatitis C treatment services via ODNs (identified through successful linkage to the NHSE Hepatitis C Patient Registry and Treatment Outcome System and/or NHSE’s Blueteq system). Denominator: number of individuals who tested positive for hepatitis C virus RNA or core antigen with NHS number or name and date of birth reported through SSBBV who had not died before linkage to treatment and where there was no evidence of possible spontaneous clearance.

Note 23: Numerator: number starting treatment. Denominator: number of individuals linked to specialist hepatitis C treatment services via ODNs.

Note 24: Numerator: number starting treatment. Denominator: number of individuals who tested positive for hepatitis C virus RNA or core antigen with NHS number or name and date of birth reported through SSBBV who had not died before linkage to treatment and where there was no evidence of possible spontaneous clearance.

Note 25: Numerator: number of individuals who had a treatment outcome reported via the NHSE Hepatitis C Patient Registry and Treatment Outcome System, or in the absence of a recorded outcome, an RNA or core antigen test (positive or negative) recorded at 96 days or more after the treatment start date in SSBBV. Denominator: number of individuals who started treatment.

Note 26: Numerator: number clearing hepatitis C virus infection as a treatment outcome, or in the absence of a reported SVR, a RNA or core antigen negative test recorded at 96 days or more after the treatment start date in SSBBV. The proportion reported as clearing hepatitis C virus infection is likely to be lower than the true proportion. Denominator: number starting treatment.

Note 27: Numerator: number clearing hepatitis C virus infection as a treatment outcome, or in the absence of a reported SVR, an RNA or core antigen negative test recorded at 96 days or more after the treatment start date in SSBBV. Denominator: number of individuals with a treatment outcome recorded or with an RNA or core antigen test (positive or negative) recorded at 96 days or more after the treatment start date in SSBBV.

Further information is available in Technical notes.

Hepatitis C treatment pathway

Hepatitis C testing and treatment data has been used to follow individuals through the care pathway and identify gaps in care and/or monitoring. The number of individuals testing positive for hepatitis C virus RNA or core antigen was based on the first hepatitis C virus RNA or core antigen positive test reported through SSBBV during the period 2015 to 2023. Linked treatment data was then used to follow individuals through the care pathway including data from ODNs reported through the NHSE Hepatitis C Patient Registry and Treatment Outcome System and NHSE’s Blueteq System (which facilitates access to high-cost drugs for hepatitis C treatment). The estimates are reliant on sufficient identifiers being available to link between the treatment and SSBBV databases and on the completion of data reported; data quality is assessed on an ongoing basis. Further details are available in the Technical notes.

Between 2015 and 2023, 111,579 individuals had a hepatitis C virus RNA or core antigen positive test result reported in SSBBV. Among these individuals who had a recorded NHS number or name and date of birth available for linkage (73,424), 81.4% were linked to the NHSE Hepatitis C Patient Registry and Treatment Outcome System and/or NHSE’s Blueteq system (Table 4). Of those who were linked, 96.1% started treatment, however, when all individuals who tested positive for hepatitis C virus RNA or core antigen (and had a recorded NHS number or name and date of birth, who had not died and with no evidence of spontaneous clearance) were considered, 78.3% were recorded as having initiated treatment.

A recorded treatment outcome and/or a hepatitis C virus RNA or core antigen test 96 days or more after the treatment start date was available for 90.9% of individuals who started treatment, and of these 91.5% cleared hepatitis C virus infection and/or had a negative hepatitis C virus RNA or core antigen in the absence of a reported SVR (Figure 8 and Table 4). When considering all individuals who initiated treatment, 83.1% had cleared hepatitis C virus infection and/or had a negative hepatitis C virus RNA or core antigen test 96 days or more after the treatment start date).

There were 2,399 individuals included within the care pathway who had a subsequent positive test for hepatitis C virus RNA or core antigen following successful treatment (that is a hepatitis C virus reinfection; data not included in Figure 8 or Table 4), of which 47.7% started treatment. Among these individuals who initiated treatment, 72.5% cleared hepatitis C virus infection and/or had a negative hepatitis C virus RNA or core antigen test 96 days or more after the treatment start date.

Resistance to DAAs does emerge, with data showing that in 2023, 5% of subtype 1a samples from individuals who had not received treatment before were resistant to the NS5a inhibitors class of antiviral drugs. In addition, some endemic hepatitis C virus subtypes that are prevalent in Asia and sub-Saharan Africa show inherent resistance to some DAAs. UKHSA is expanding genomic surveillance for hepatitis C virus aiming to monitor drug resistance and progress towards elimination.

Figure 8. Treatment pathway in England, 2015 to 2023

Sources:

SSBBV

NHSE Hepatitis C Patient Registry and Treatment Outcome System as of October 2024

NHSE’s Blueteq system as of October 2024

Note 28: In individuals testing hepatitis C virus RNA or core antigen positive with no linkage to the Hepatitis C Patient Registry and Treatment Outcome System or NHSE’s Blueteq System, there are no time restrictions on a subsequent RNA or core antigen negative test after the initial RNA or core antigen positive test. Therefore, these individuals may include those that have spontaneous clearance of 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 or NHSE’s Blueteq System.

Note 29: In the absence of a reported SVR as a treatment outcome in the NHSE Hepatitis C Patient Registry and Treatment Outcome System, an RNA or core antigen negative test recorded at 96 days or more after the treatment start date in SSBBV was used.

Note 30: Numerator: number starting treatment. Denominator: number of individuals who tested positive for hepatitis C virus RNA or core antigen with NHS number or name and date of birth reported through SSBBV who had not died before linkage to treatment and where there was no evidence of possible spontaneous clearance.

Note 31: Numerator: number of individuals linked to specialist hepatitis C treatment services via ODNs (identified through successful linkage to the NHSE Hepatitis C Patient Registry and Treatment Outcome System and/or NHSE’s Blueteq system). Denominator: number of individuals who tested positive for hepatitis C virus RNA or core antigen with NHS number or name and date of birth reported through SSBBV who had not died before linkage to treatment and where there was no evidence of possible spontaneous clearance.

Note 32: Numerator: number starting treatment. Denominator: number of individuals linked to specialist hepatitis C treatment services via ODNs.

Note 33: Numerator: number clearing hepatitis C virus as a treatment outcome, or in the absence of a reported SVR, an RNA or core antigen negative test recorded at 96 days or more after the treatment start date in SSBBV. The proportion reported as clearing hepatitis C virus is likely to be lower than the true proportion. Denominator: number starting treatment.

Note 34: Numerator: number of individuals who had a treatment outcome reported via the NHSE Hepatitis C Patient Registry and Treatment Outcome System, or in the absence of a recorded outcome, an RNA or core antigen test (positive or negative) recorded at 96 days or more after the treatment start date in SSBBV. Denominator: number of individuals who started treatment.

Note 35: Numerator: number clearing hepatitis C virus as a treatment outcome, or in the absence of a reported SVR, an RNA or core antigen negative test recorded at 96 days or more after the treatment start date in SSBBV. Denominator: number of individuals with a treatment outcome recorded or with an RNA or core antigen test (positive or negative) recorded at 96 days or more after the treatment start date in SSBBV.

Access to hepatitis C treatment

NHSE commissioning data shows an increase in the number of people accessing hepatitis C treatment from 2015 onwards reflecting the increase in access to new DAA drugs in England (Figure 9). In 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).

The number of treatment initiations from tax year 2015 to 2016 onwards from NHSE’s Blueteq system is based on invoicing and is subject to data quality issues and contract adjustments. The data include treatment for every new case of hepatitis C and some people may have been previously treated and subsequently experienced re-infection. Treatment initiations for people who have initially failed a first course of treatment are excluded. Treatments that did not actually start are also excluded subject to data quality and reporting.

In tax year 2020 to 2021, the number of treatment initiations for hepatitis C fell to 7,835, a fall of 35.9% from the previous year. This was likely due to the COVID-19 pandemic restrictions on service provision. 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.

Between tax years 2022 to 2023 and tax years 2023 to 2024 the number of treatment initiations remained stable. Overall, the cumulative number of treatment initiations since tax year 2015 to 2016 was 87,346.

Figure 9. Number of treatment initiations for hepatitis C in England, calendar years 2007 to 2014 and from tax year 2015 to 2016 to tax year 2023 to 2024

Sources:

-DAA drug commissioning data (NHSE’s Blueteq System) for tax years 2015 to 2016 and 2023 to 2024 . The data is based on 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

Prevention of infection including adequate harm reduction in people who inject drugs

Measures to prevent transmission of hepatitis C virus are a cornerstone of the public health response to eliminate hepatitis C as a public health threat in England.

Harm reduction interventions such as sterile injecting equipment and OAT are important for people who inject drugs in order to prevent and reduce the risk of transmission of hepatitis C virus as well as reduce the risk of reinfection following treatment. Despite this, the 2021 independent review of drugs reported that harm reduction services, including specialist NSP services, had been cut back in many local areas.

The WHO target for harm reduction is at least 300 needles and syringes per person who injects drugs per year. Where this target cannot be demonstrated or fully documented, an alternative is greater than or equal to 40% of people who inject drugs who are dependent on opioids to be receiving OAT (Table 5). However, monitoring both targets is important as evidence suggests that NSP and OAT combined is more effective at reducing the risk of acquiring hepatitis C virus infection.

There is limited programmatic data on NSP in England to estimate the WHO target of 300 sterile needles and syringes provided per person who injects drugs per year. In addition, this data is essential to quantify NSP provision, to monitor any gaps and to identify areas for improvement. UKHSA has led on the design and development of a proposed NSP 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. Data collection at pilot sites is now underway with the results expected later in the year. In relation to OAT provision, 58.1% of people who inject drugs who are dependent on opioids received OAT between 2019 and 2020 (see section on Opioid agonist therapy (OAT)).

Other WHO programmatic targets focus on preventing incident infections in healthcare settings and among people receiving blood products (Table 6). These targets include 100% safe injections in healthcare facilities and 100% of donated blood to be screened for BBV infections (hepatitis B virus, hepatitis C virus, HIV and syphilis). An alternative target for safe injections is for 90% of healthcare injection devices procured to be safety engineered. England currently meets the target for screening blood donations with 100% of all blood products tested for BBVs. Based on procurement data, England has not met the target for safe injections with 83% of all sharps purchased being safety engineered in 2023 (see section on Safety-engineered healthcare injection devices).

Table 6. WHO programmatic targets for prevention and harm reduction

Service coverage or programme target area	WHO GHSS 2030 target	Progress in England
Harm reduction	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 drugs who are dependent on opioids receiving OAT	No estimate currently available 58.1% of people who inject drugs who are dependent on opioids received OAT (tax year 2019 to 2020)
Blood safety	100% of donated blood screened for hepatitis C virus	100% of donated blood screened for hepatitis C virus
Safe injections	100% of healthcare facilities with safe injections 90% of healthcare injection devices procured are safety-engineered	No estimate available In 2023, 83% of sharps purchased for use in healthcare settings were safety engineered [note 36]

Note 36: 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 (SIP) feature or the use of injection devices with a reuse prevention feature (RUP).

Harm reduction in people who inject drugs

Needle and syringe provision (NSP)

In addition to the programmatic data on NSP to monitor progress towards the WHO target, data from the UAM Survey can be used to provide an indication of the adequacy of NSP in relation to injecting needs. NSP is considered ‘adequate’ when the reported number of needles and syringes received met or exceeded the number of times the individual injected. The calculation also takes secondary distribution into account, that is, the number of needles and syringes collected for someone else is not included.

In 2023, 66.1% of people who injected drugs in the past year reported having adequate NSP for their needs (Figure 10). This figure is similar to previous years and highlights that 1 in 3 people continue to report inadequate NSP for their needs.

Work is also underway to assess whether UAM Survey data could be used to provide an estimate of progress towards the WHO target. The approach involves triangulation of survey data on NSP use in the last year, visits to a needle exchange per month, number of needles collected per visit and the collection of needles for others. The data will then be extrapolated to the number of needles collected per year. The denominator will be all people who reported injecting in the last year who answered the relevant questions used for the numerator.

Figure 10. Estimated proportion of people who inject drugs reporting adequate NSP in England, 2014 to 2023 [note 37][note 38][note 39]

Source: UAM Survey of people who inject drugs.

Note 37: A new UAM indicator was introduced in 2017 meaning that data from 2017 onwards cannot be directly compared with that from earlier years

Note 38: 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 39: 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)

Data shows that the WHO target for at least 40% of people who inject drugs who are dependent on opioids to be receiving OAT by 2030 is still being met in England (58.1% in tax year 2019 to 2020). This figure was calculated by comparing the most recent opiate use prevalence estimates from the DHSC and the UKHSA with prescribing data from DHSC’s National Drug Treatment Monitoring System.

When comparing 2019 to 2020 prevalence estimates (the latest available) with 2023 to 2024 prescribing data, 52.6% of people who inject drugs who are dependent on opioids were receiving OAT. It should be noted that opiate use prevalence may have changed since 2019 to 2020.

Safe injections in healthcare and safe blood supplies

Safety-engineered healthcare injection devices

The 2030 alternative WHO target requires 90% of healthcare injection devices procured to be safety-engineered. Safety-engineered injection devices are those with a SIP or RUP feature.

The UK adheres to the 2010/32/EU Directive for the prevention of sharps injuries in the hospital and healthcare setting, by using safety engineered devices. The Directive means that healthcare organisations must use safety engineered devices where it is reasonably practicable to do so.

Procurement data from NHS Supply Chain can be used to provide an estimate of the proportion of healthcare injection devices purchased that are safety-engineered. To calculate this estimate, 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. Safety engineered sharps have been defined as all products purchased that have a safety device which meets the 2010/32/EU Directive (that is those SIP or RUP features).

In England, the proportion of sharps purchased by NHS Supply Chain that are safety-engineered has increased over time from 58% in 2015 to 83% in 2023, although there has been a small fall in the proportion compared to 2022 (85%) (Figure 11a). The number of sharps purchased by NHS Supply Chain that were safety engineered increased by 64.8% between 2015 and 2023 (Figure 11b).

The purchase of non-safety engineered sharps may be necessary if suitable safety devices are not available, such as spinal and epidural needles, biopsy needles and intraosseous access needles. In some cases, non-safety devices may also be purchased if there is a clear clinical reason why a safety engineered device cannot be used, for instance, the device may compromise patient care. Supply chain disruptions (for example, during the COVID-19 pandemic) may also impact on number and proportion of safety engineered devices purchased.

Figure 11a. The proportion of safety engineered sharps [note 40] purchased by year in England, 2015 to 2023

Figure 11b. The number of safety engineered sharps [note 40] purchased by year in England, 2015 to 2023

Source: NHS Supply Chain [note 41]

Note 40: A ‘safety engineered sharp’ is defined as all products purchased that have a safety device which meets the 2010/32/EU Directive. Safety-engineered injection devices are those with a SIP or the use of injection devices with a RUP.

Note 41: 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 for secondary care settings. The market share in primary care settings and in private healthcare is not known.

Screening of blood donations

Blood donors are volunteers, aged 17 years and over, and a group at lower risk of BBV infections compared to the general population because some people with a history of associated risk factors are asked not to give blood

All donations are screened individually for hepatitis C virus antibody, and nucleic acid testing (NAT) for hepatitis C virus RNA is performed on pools of 24 donations. All screen reactive donations (hepatitis C virus antibody and/or RNA) are discarded, and the sample sent for confirmatory testing. Donors who have any combination of a confirmed positive test result are referred for follow-up care.

Overall, in England, the rate of hepatitis C virus infection in donations from first-time blood donors who have not been screened by NHS Blood and Transplant (NHSBT) before, has declined over time (Figure 12). In 2023, 23 out of 121,730 donations from first-time donors (18.9 per 100,000) were confirmed to be hepatitis C virus antibody positive. Of the 23 confirmed hepatitis C virus antibody positive donations from first-time donors, 61% (n=14) were also hepatitis C virus RNA positive and 39% (n=9) were hepatitis C virus antibody positive RNA negative reflective of spontaneous clearance or undeclared treatment. The proportion of donations that were hepatitis C virus antibody positive and RNA positive has been consistently below 70% since 2020 (average for 1999 to 2019 was 76%). It is rare to detect donations which are hepatitis C virus antibody negative and RNA positive, with zero in 2023.

Hepatitis C virus infection in repeat donors declined sharply after introduction of the antibody test from 1991 and is now low or zero with 1 out of 1,380,704 donations from repeat donors (0.07 per 100,000) confirmed to be antibody and RNA positive in 2023.

In 2023, 13 of the 24 donors who tested positive for hepatitis C virus antibody in England were male, the median age was 41 years, range 18 to 64 years.

In contrast with first-time whole blood donors where 72% were of White British (English, Welsh, Scottish, Northern Irish or British) ethnicity, only 2 of 23 (9%) first-time donors who tested positive for hepatitis C virus antibody were White British and where known, the majority (18 out of 20) were born outside of the UK in Europe (n=12), Asia (n=5) or elsewhere (n=1). Of the 14 first-time donors who were hepatitis C virus RNA positive, 9 were female and 12 were born outside of the UK.

In the 23 first-time donors who tested positive for hepatitis C virus antibody, 8 did not engage in a discussion with the blood services about their results and 2 of these donors were hepatitis C virus RNA positive. Among the other 15 first-time donors who did engage in a discussion about their results, most had no obvious route of exposure and 12 were hepatitis C virus RNA positive. Among the 12 donors who were hepatitis C virus RNA positive, 10 were born in an area where hepatitis C virus infection is more common than the UK, with 4 of these donors reporting more specific possible exposures such as tattooing abroad, intranasal drug use or having a close contact who had hepatitis, while the remaining 2 donors reported a history of injecting.

The repeat donor who tested positive for hepatitis C virus antibody and hepatitis C virus RNA was UK born with a negative donation approximately 30 months prior but no obvious route of exposure was reported since then.

Figure 12. Rate of hepatitis C virus infection among donations from first-time and repeat blood donors in England, September 1991 to 2023 [note 42]

Source: NHSBT UKHSA Epidemiology Unit

Note 42: 1991 to 1995 includes Wales,1996 to 2016 includes North Wales.

Recommended actions

The Hepatitis C in England 2023 report set out several recommended actions which could support the evidencing of progress towards eliminating hepatitis C as a public health threat by strengthening the need to reduce incidence, increase testing and linkage into care, and reduce mortality.

Progress made towards these recommended actions is summarised below, together with further activity that will continue or build upon work undertaken so far. Activity for these recommended actions should be considered within the wider context of UKHSA’s ongoing programme of work to co-ordinate the evidence and process for validating elimination of hepatitis C as a public health threat by 2030 in line with the WHO targets and includes collaboration with other stakeholders.

Monitoring incidence of hepatitis C virus

Recommended action from 2023

Establish a multi-stakeholder working group to further develop new and existing data sources and methodologies to estimate incidence of hepatitis C in the general population and people who inject drugs.

Progress update

Incidence is a key indicator to monitor progress towards elimination. A multi-stakeholder working group was established in early 2024 and is co-ordinated by UKHSA. Various modelling approaches to estimating incidence are currently being explored by academic partners, through the NIHR Health Protection Research Unit in Behavioural Science and Evaluation. UKHSA surveillance data is used to inform the model input parameters. Examples include mathematical deterministic modelling to estimate incidence and statistical modelling to evaluate the impact of treatment on trends in chronic hepatitis C prevalence. Results to date are presented in this report, including incidence estimates among people who inject drugs for 4 ODNs in England.

Between September 2022 and September 2024, NHSE conducted the Needs Assessment Project using prospective retesting of people at risk of acquiring hepatitis C. The project tested 11,024 people initially (hepatitis C virus antibody and RNA testing) and followed up the same people 6 months to 1 year later. Testing was carried out in drug and alcohol services, and in some areas, community settings were also included (for example, community pharmacies offering NSP or outreach testing in homeless shelters and soup kitchens). The data is currently being analysed and will be explored through the working group.

Further activity

Further development work is planned to provide modelled incidence estimates for people who inject drugs at a national level. This work will be led by the multi-stakeholder working group co-ordinated by UKHSA. Results from the NHSE Needs Assessment Project are expected to be available later in 2025 and will also be explored through the working group.

Preventing new infections

Recommended action from 2023

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

Progress update

The collection of programmatic data on NSP is required to estimate the WHO target of 300 sterile needles and syringes provided per person who injects drugs per year. In addition, this data is essential to monitor any gaps in provision, to identify areas for improvement and to contribute to the evidence of NSP impact on reducing hepatitis C transmission.

UKHSA has led on the design and development of a monitoring system for NSP in collaboration with a multi-stakeholder 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. Over the past year, UKHSA has worked with potential pilot sites and software providers to discuss arrangements for data collection, sharing and reporting of data, and to develop the technical specification. Data collection at pilot sites is now underway.

Further activity

Once data collection at pilot sites is complete, the next steps will involve the analysis of the data with preliminary results expected later in 2025. UKHSA will continue to lead this work in collaboration with the multi-stakeholder working group.

Testing and diagnosis

Recommended actions from 2023

Action 1: Develop a methodology to estimate the proportion of people living with hepatitis C who have been diagnosed in England.

Action 2: Undertake data analysis and behavioural insights work to understand the characteristics of people who inject drugs who have not been tested for hepatitis C and/or unaware of their infection.

Action 3: Undertake evaluation for case finding interventions such as the ongoing evaluation of the ED BBV opt-out testing pilot and planning the evaluation of the national hepatitis C web testing platform, to understand their effectiveness, optimise implementation, and assess health economics.

Progress update

UKHSA is leading a programme of work in collaboration with stakeholders to develop a methodology for estimating the proportion of people diagnosed. The approach involves triangulation of surveillance data, including testing, diagnosis and treatment data, with information obtained through data linkage and through engagement with ODNs. The data will be used to estimate the RNA status of all people who have had a diagnosis of hepatitis C since a chosen baseline year. Modelled prevalence estimates on the number of people who have ever had hepatitis C (hepatitis C virus antibody positive) or the number of people living with chronic hepatitis C will be used as the denominator.

Various approaches are currently being explored to estimate the proportion of people living with chronic hepatitis C who have been diagnosed which together could be used to estimate progress towards this indicator. One of these approaches aims to generate a cumulative estimate of the number of people diagnosed with chronic hepatitis C since the chosen baseline year to assess the impact of historical testing initiatives and coverage. This number includes those who have subsequently cleared infection (cured through treatment or spontaneously cleared hepatitis C virus without treatment) and those who have died since the baseline year. The denominator for this approach is the number of individuals who have had chronic hepatitis C since the chosen baseline year based on modelled prevalence estimates.

Another approach currently being explored aims to estimate the number of people diagnosed by the end of each year among all those alive and estimated to be living with chronic hepatitis C in that year. This estimate can be used to assess who remains undiagnosed to inform service planning and delivery. Triangulation with additional sources of data can then be used 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 hepatitis C. Additional sources of data include UAM Survey data on awareness of hepatitis C virus infection status, as well as data on the characteristics of people newly diagnosed through opt-out testing for BBVs in EDs. Furthermore, behavioural insights work would help to provide deeper insights into the characteristics of people who have not been tested for hepatitis C and/or remain undiagnosed, as well as barriers to engagement in testing and treatment, including the impact of stigma.

The RNA status of people within the cohort is estimated with varying levels of confidence based on the data available. UKHSA continues to work with stakeholders to increase the coverage of laboratory surveillance, including negative test results, but there remain ongoing challenges with data quality and local information governance procedures. Additional work is needed, in collaboration with stakeholders, to enhance information on individuals within the cohort where RNA status is still unknown. Ascertaining who is still living with hepatitis C is important for estimating the proportion of people diagnosed, and for planning how best to support these individuals to re-engage in care. The addition of data on point of care testing, which is not fully captured through current laboratory surveillance, will also help to improve estimates on RNA status.

A common barrier to accessing testing and treatment is the stigma surrounding hepatitis C. UKHSA is currently analysing the findings from the World Hepatitis Alliance Stigma Survey which can be used to assess and address stigma associated with hepatitis C. UKHSA also co-produced a stigma workshop with community partners that brought together people with lived experience, healthcare providers and academics to understand the experiences of people living with viral hepatitis and how we can strengthen collaboration to address stigma. To validate elimination of hepatitis C, it is necessary to demonstrate that services and interventions have been implemented in a manner that respects and protects human rights and promotes equity and community engagement. UKHSA are currently working with stakeholders to collate evidence for each of these considerations, and to identify gaps and areas for improvement.

UKHSA has conducted an analysis exploring the characteristics of people who inject drugs in the UAM Survey who were potentially unaware that they were living with chronic hepatitis C. Key findings have been included in this report and in the UAM Survey 2024 report.

Qualitative work is also underway to explore the barriers and facilitators to ongoing engagement in care and harm minimisation amongst people who have experienced hepatitis C more than once. The findings are expected to be available later in 2025.

UKHSA have supported NHSE with the roll-out of the Patient Search Identification tool in primary care. The tool searches patient health records to generate a list of patients who have a recorded hepatitis C diagnosis, or evidence of risk factors so that they can be offered testing and treatment.

UKHSA and the University of Bristol have conducted the 24-month public health and implementation evaluation for the ED BBV opt-out testing pilot, and planning is now underway for the final evaluation of the pilot. As part of the evaluation, an analysis was undertaken to better understand the characteristics of people newly diagnosed through the programme and how that compares to individuals diagnosed in other settings. The proportion of people diagnosed and linked to care through the ED BBV opt-out testing pilot was lower than the proportion linked to care overall in England, which could be reflective of complex needs and indicate the requirement for additional support to engage with care. UKHSA and the Hepatitis C Trust have conducted an analysis highlighting the impact of peer support for improving linkage to care and treatment. Linked surveillance data does not capture activity to support all steps in the engagement to care process. Therefore, triangulation of surveillance data wih clinical data can help to better understand linkage to care and treatment outcomes. UKHSA has also started preparations for the NIHR funded public health evaluation of the expansion of the ED opt-out testing programme to additional sites in areas of high diagnosed HIV prevalence.

UKHSA has recently undertaken a mixed-methods evaluation of the hepatitis C national patient re-engagement exercise which aimed to support the NHS in finding people diagnosed with hepatitis C to access treatment, many of whom were diagnosed in the period before DAAs were widely available. Overall, of those eligible for treatment, 18% were re-engaged in care. The exercise was unable to directly re-engage nearly 60% of individuals shared with ODNs who were thought to be alive, who may potentially still need treatment or may be hepatitis C virus RNA negative. Ascertaining which of these individuals are still living with hepatitis C is important for estimating the proportion of people diagnosed in England, and for planning how services can re-engage them into care. UKHSA has also conducted interviews with GPs to understand the barriers and facilitators to re-engagement in primary care and the findings will be available later in 2025.

UKHSA are working with NHSE to facilitate access to data from the national hepatitis C web testing platform. If available, the data would feed into routine surveillance and enable a public health evaluation of the web testing platform to be conducted.

Further activity

Following on from the national patient re-engagement exercise, UKHSA and NHSE will be conducting interviews with people who have lived experience of hepatitis C who have been contacted by ODNs about engaging or re-engaging in treatment and care. The project will aim to interview both individuals who have successfully been engaged in care as well as people who are not yet engaged.

NHSE has invited antenatal services to implement a pilot of opt-out hepatitis C testing. UKHSA is planning to evaluate the impact and effectiveness of the pilot (excluding health economics) which could inform decisions on implementing the pilot more widely.

UKHSA and the University of Bristol will continue to work on the final evaluation of the ED BBV opt-out testing pilot in very high HIV prevalence areas, which will include public health, implementation and cost-effectiveness evaluation. The findings are expected to be available later in 2025.

Following on from the stigma workshop, actionable next steps will be reviewed and agreed. The findings will also feed into the evidence review for human rights, equity and community engagement.

Linkage to care

Recommended actions from 2023

Action 1: Identify and integrate new sources of data on hepatitis C treatment into routine surveillance.

Action 2: Integrate prison healthcare data into routine hepatitis C 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.

Progress update

UKHSA now has access to data from NHSE’s Blueteq system (which facilitates access to high-cost drugs for hepatitis C treatment) and this data has been used in the report to provide a more accurate estimate of linkage to care and treatment outcomes. Additional work is underway to compare data from NHSE’s Blueteq system to information within the current treatment registry and to explore how the data can be incorporated into other analyses, such as estimating re-infection rates. UKHSA continues to share data with ODNs to support case finding, re-engagement into care, and to facilitate complete data recording on the treatment registry.

UKHSA continue to work with NHSE on integrating prison healthcare data into routine surveillance. 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.

The forthcoming 2025 Chief Medical Officer report is focusing on ‘Health in English prisons and probation’ and UKHSA have led the writing of the chapter on health protection. The report will present information about the health of the prison population, including hepatitis C, and will present recommendations for action.

Further activity

UKHSA will continue to work with stakeholders to optimise the use of surveillance data to better monitor hepatitis C testing, access to care and treatment outcomes. This work is being led by UKHSA in collaboration with NHSE.

Reducing mortality

Recommended action from 2023

Define a national target to further reduce hepatitis C virus-related ESLD and/or HCC deaths.

Progress update

England has already met the WHO impact target for hepatitis C virus-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.

UKHSA has undertaken a sensitivity analysis to evaluate the accuracy of estimated mortality rates by evaluating the impact of underreporting of hepatitis C as a cause of death on death certificates. The analysis found that the higher mortality rate estimates still fall below the WHO threshold. Results will be published later in 2025.

Further activity

UKHSA will analyse viral hepatitis related deaths to understand if other contributory factors, such as alcohol, were listed as a cause of death on death certificates. In addition, sensitivity analyses will also be conducted to assess whether someone was still living with chronic infection at the time of their death. These analyses will help to inform the development of a national target. This work is being led by UKHSA in collaboration with a multi-stakeholder working group.

UKHSA, in collaboration with clinical partners, is preparing to undertake a case note review to improve the estimate of the proportion of people with liver disease (ESLD and/or HCC) that is attributable to hepatitis C or to other risk factors. This proportion will then be applied to all deaths with an underlying cause of death attributable to ESLD and HCC.

Technical notes

These technical notes provide further detail on information contained within the report, and outline or describe the methodology used to produce the figures and tables.

Government Response to the Infected Blood Inquiry

Evidence shows the likelihood of acquiring hepatitis C virus infection via a blood transfusion after 1992 is extremely low following the introduction of universal blood screening to detect hepatitis C virus in September 1991. However, to address the Infected Blood Inquiry’s conclusion that it is ‘reasonably possible’ that some infections may have occurred from blood transfusions after universal screening was introduced, the UK Government has accepted the recommendation to offer a blood test for hepatitis C to individuals who are identified as having had a blood transfusion prior to 1996. For blood products (such as clotting factor) screening was introduced in 1986.

Estimating hepatitis C virus prevalence

A modelling approach is used to estimate the prevalence of hepatitis C virus, including both diagnosed and undiagnosed infections. Multiple sources of routine surveillance data are included to track progress over time, including seroprevalence data, hepatitis C virus-related liver disease, and information on the number of people who inject drugs and other risk groups.

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

• prevalence of hepatitis C in people who inject drugs over time, which informs incidence 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, hepatitis C virus-related HCC and/or ESLD states)
• disease endpoint data (age-specific hepatitis C virus-related ESLD and HCC from Hospital Episode Statistics (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 people who inject drugs 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 SVR (IMS sales data, the NHSE hepatitis C virus Patient Registry and Treatment Outcome System)

The model reconstructs the epidemic of injecting drug use and associated hepatitis C virus infections that would be consistent with several main sources of surveillance data: the UAM Survey, estimated numbers of people who inject drugs and the number of people with hepatitis C who progress to hepatitis C virus-related HCC or hepatitis C virus-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 hepatitis C virus infection 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 people who recently started injecting drugs, 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 hepatitis C virus-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; other work has been carried out to generate incidence estimates in people who inject drugs for monitoring purposes.

The model calculates the proportion of people living with chronic hepatitis C for each year out of all those who have ever had hepatitis C (that is people who are hepatitis C virus antibody positive who may have a current or past infection) and who are still alive in that year. Individuals with past infection may have cleared their infection through achieving a SVR post treatment, or through spontaneous clearance. The estimated number of people with chronic hepatitis C and the number of people who ever had hepatitis C who were still alive for 2015 and 2023 is shown in Table 7.

Table 7. Proportion of people living with chronic hepatitis C among those who have ever had hepatitis C in England with 95% Crls, 2015 and 202

Year	Proportion of individuals with chronic hepatitis C among all those who have ever had hepatitis C virus	Number of individuals with chronic hepatitis C	Number of individuals who have ever had hepatitis C
2015	59.5% (56.5% to 61.9%)	129,000 (109,900 to 147,000)	216,700 (194,500 to 238,700)
2023	29.7% (26.0% to 33.8%)	55,900 (44,200 to 69,900)	188,700 (170,100 to 204,700)

Estimating hepatitis C incidence

Mathematical modelling has been carried out to assess the impact and cost-effectiveness of scaling up hepatitis C virus testing and treatment among people who inject drugs in 4 regional ODNs of England. Data sources include the UAM Survey, NHSE Hepatitis C Patient Registry and Treatment Outcome System, NHSE Blueteq System, SSBBV, as well as baseline data from the NHSE Needs Assessment Project. The modelled population was stratified by incarceration status, OAT and NSP uptake, homelessness status, infection and disease progression, and the testing and treatment pathway.

UAM Survey methodology

The UAM Survey of people who inject drugs monitors BBVs, and associated risk and protective behaviours among people who inject drugs 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 people who inject drugs, 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. There are likely to be differences in the characteristics of survey participants compared to the overall population of people who inject drugs as most recruitment takes place in specialist drug and alcohol services. Around three quarters of UAM Survey participants in England report that they are receiving treatment for drug use.

It is important to note that the COVID-19 pandemic response had a negative impact on access to services for people who inject drugs, 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. 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, people who inject drugs 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 ‘Everyone 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 started injecting within the 3 years prior to survey participation. In 2023, the number of services and participants remained similar to 2019 and 2022. In addition, the risk profile of participants was consistent with 2022.

To estimate the proportion of people who inject drugs who are aware they are living with chronic hepatitis C, test results obtained from the dried blood spot are used to identify those living with chronic hepatitis C at the time of survey completion. The results are then triangulated with information on self-reported hepatitis C diagnostic testing and self-reported hepatitis C status to estimate the proportion of people who are aware of their chronic hepatitis C infection.

The proportion of people who inject drugs 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’.

Reinfection

In England, 3 criteria have been used to identify hepatitis C virus reinfection, any one of which would establish a person as experiencing reinfection. Firstly, individuals with a positive hepatitis C virus RNA test at least 196 days (28 weeks) after treatment start date among those with a SVR during their first treatment period. Secondly, a positive hepatitis C virus RNA test at least 196 days (28 weeks) after treatment start date where an individual has had a negative hepatitis C virus RNA test after being treated (used as a proxy for SVR where this has not been reported). Thirdly, a subsequent period of treatment after an initial SVR, and where this subsequent treatment period was at least 196 days after first treatment start date. Further work will aim to integrate data from NHSE’s Blueteq system into the methodology, and to explore reinfection among people who spontaneously cleared their primary infection without treatment.

It should be noted that there is no internationally agreed definition for defining hepatitis C reinfection and a different window period may be used to confirm SVR post treatment. For example, Scotland uses a negative test between 10 weeks and 12 months post treatment to confirm SVR. As we progress towards elimination of hepatitis C virus as a public health threat, ongoing work across the UK will aim to harmonise definitions of reinfection where possible and utilise multiple methods, including the use of whole genome sequencing, to better understand reinfection.

Reducing hepatitis C virus-related mortality

The number of hepatitis C virus-related deaths are used to measure mortality. Deaths are based on the year they were registered and where hepatitis C is mentioned on the death certificate along with international classification of diseases (ICD) tenth revision (ICD-10) codes for ESLD and HCC. The number of deaths was estimated using slightly different ICD-10 codes from those used by WHO. A comparison of the codes used can be found in the Hepatitis C in England 2022 report.

Monitoring access to hepatitis C treatment

Hepatitis C treatment initiation data is used to monitor access to hepatitis C treatment. Treatment coverage is defined as the proportion of individuals diagnosed with chronic hepatitis C (hepatitis C virus RNA or hepatitis C core antigen test positive) and who initiated treatment during a specified time frame over the number of individuals diagnosed with chronic hepatitis C for the specified time period.

Records from individuals with a diagnosis of chronic hepatitis C reported through SSBBV (positive hepatitis C virus RNA or antigen tests) are linked to the NHSE Hepatitis C Patient Registry and Treatment Outcome System using NHS Number, Name, date of birth (DOB), hospital number and NHSE’s Blueteq System using NHS Number, DOB, Blueteq number and excludes children aged under one year.

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. Data quality is assessed on an ongoing basis to verify the number of people who tested positive for hepatitis C virus RNA or core antigen. As individuals are followed through the care pathway, the denominator is updated to exclude people who have died or who have evidence of spontaneous clearance.

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

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 hepatitis C virus treatment monitoring in England report summarises the data held within the registry and Treatment Outcome System up to the end of April 2018.

Screening of blood donations

NHSBT currently collects blood donations from donors in England. All donations are screened for hepatitis C virus antibody and RNA using NAT in pools of 24 while repeat reactive donations are removed from the supply and undergo confirmatory testing. The UK estimated residual risk for 2021 to 2023 of screening tests failing to detect an infectious hepatitis C virus donation are estimated at less than 1 in 100 million, which would mean that it could be over 50 years before an infectious donation goes undetected. Note that the incidence of hepatitis C for the residual risk of non-detection is based on repeat donors seroconverting within 12 months. Data on hepatitis C virus antibody and RNA testing in the blood donor population is available from the NHSBT UKHSA Epidemiology Unit.

Acknowledgments

Authors: Holly Mitchell, Annastella Costella, India Clancy, Ross Harris, Matthew Hibbert, Annabel Powell, Rachel Roche, Sema Mandal, Ruth Simmons, Monica Desai

Contributors (in alphabetical author): Chelsea Allen, Ashley Brown, Eleanor Clarke, Jamie Crummy, Peter Dearman, Bennet Dugbazah, Beatrice Emmanouil, Katherine Fuller, Mark Gillyon-Powell, Rachel Halford, Matthew Hickman, Samreen Ijaz, Stefan Jahr, Arham Khawar, Ryan Matthews, Simon Packer, John Poh, Siri Ranlund, Leila Reid, Claire Reynolds, Justin Shute, Panida Silalang, Stuart Smith, Peter Vickerman

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:

• drug and alcohol service staff and The Hepatitis C Trust peer workers who support, and participants in, the UAM Survey of people who inject drugs
• HES, NHSE, produced by UKHSA (copyright © 2024, re-used with the permission of NHSE, all rights reserved)
• NHSE and Arden and Greater East Midlands Commissioning Support Unit
• ONS carried out the original collection and collation of the data but bears no responsibility for their future analysis or interpretation
• NHSE for supplying treatment monitoring data for tax year 2015 to 2016 up to tax year 2023 to 2024 in England
• NHSBT colleagues who support the NHSBT and UKHSA Epidemiology Unit Blood Donation Surveillance Scheme

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

Suggested citation

Holly Mitchell, Annastella Costella, India Clancy, Ross Harris, Matthew Hibbert, Annabel Powell, Rachel Roche, Sema Mandal, Ruth Simmons, Monica Desai and contributors. Hepatitis C in England 2024: working to eliminate hepatitis C as a public health problem. Data to end of 2023. London: UKHSA, January 2025.