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A research team from the Division of Gastroenterology and Hepatology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, the University of Hong Kong (HKUMed) initiated a hepatitis C virus (HCV) micro-elimination¹ pilot programme, in collaboration with the Correctional Services Department (CSD), which aims to work towards the goal set by the World Health Organization (WHO) of eliminating viral hepatitis by 2030. In October 2023, the three-year programme was implemented in Stanley Prison, where rapid screening for HCV was provided to eligible persons in custody (PICs) on a voluntary basis. HCV-infected PICs were subsequently offered timely treatment, with the treatment success rate expected to exceed 90%.

This pilot programme is another community service initiated by the same research team that conducted a similar HCV screening project among high-risk populations in non-profit halfway houses and drug-rehabilitation centres. The project results were presented in November 2023 in the Liver Meeting, organised by the American Association for the Study of Liver Diseases, in Boston, USA [link to publication].

Background
Hepatitis C is a chronic liver disease transmitted primarily through contact with blood or body fluid, sexual contact, or from mother to infant during pregnancy. If left untreated, HCV infection may cause chronic hepatitis, which can later develop into cirrhosis and even liver cancer. Since most people with hepatitis C exhibit no symptoms, and traditional medication was historically ineffective in curing hepatitis C, both diagnosis and treatment outcomes were far from satisfactory. Thanks to medical advances, the direct-acting antivirals (DAA)² therapy widely used in recent years is highly effective in curing over 90% of HCV infections. Since 2020, the Government of HKSAR has provided fully subsidised DAA therapy to all HCV-infected patients managed under public health care settings.

The medical community has advocated that high-risk groups should be prioritised for screening and receiving DAA therapy upon diagnosis. By setting the goal of eliminating viral hepatitis by 2030, the WHO hopes that all countries will significantly reduce the incidence and mortality caused by HCV.³ In response to this, the HKUMed research team adopted the ‘micro-elimination’ strategy to conduct screening and treatment for high-risk groups. With a Hong Kong hepatitis C virus infection rate of only 0.32% (approximately 22,000 patients), ^{4, 5} it is difficult to identify HCV cases through mass screening. The ‘micro elimination’ strategy allows the team to focus its resources on high-risk groups, thus achieving greater effectiveness in screening and treatment. The HKUMed team previously collaborated with non-governmental organisations to reach high-risk individuals in halfway houses or drug rehabilitation centres who have a history of syringe sharing, imprisonment or illicit drug use. As part of the programme, 396 participants underwent hepatitis C screening; 187 of the participants (47.2%) were found to be HCV carriers. These individuals were promptly offered DAA treatment, with a cure rate of over 97%. Tapping the success of the project, the team expanded the screening programme to other high-risk groups with the ‘micro-elimination’ strategy.

Research significance
According to overseas studies, the prevalence of HCV is as high as 20% among PICs. However, most people have limited knowledge or awareness of HCV. It is common for many HCV-infected individuals to remain undiagnosed, or if diagnosed, not to seek treatment in a timely manner, thereby missing the opportunity for early intervention. HKUMed formed a dedicated outreach team to conduct site visits at correctional facilities to increase awareness and improve understanding of HCV among PICs. Through simplification of the linkage-to-care pathway, eligible PICs who voluntarily agree to participate in the screening programme undergo rapid testing for HCV. DAA treatment is prescribed upon diagnosis of HCV to reduce the risk of adverse liver outcomes, such as cirrhosis and liver cancer.

The leader of the research project, Professor Richard Yuen Man-fung, Chair Professor and Chief of Division of Gastroenterology and Hepatology, Department of Medicine, School of Clinical Medicine, HKUMed, said, ‘The majority of HCV-infected individuals are asymptomatic. This programme aims to improve HCV awareness among individuals in correctional facilities and provide screening and treatment for eligible PICs. When HCV-infected persons are provided timely treatment, their willingness to receive and comply with the treatment is heightened. This approach not only helps prevent the disease from developing into serious liver damage, but also alleviates the burden on the local healthcare system and resources caused by delayed treatment.’ For many years, Professor Yuen has been devoted to promoting the elimination of HCV through various community services. He believes that prevention is better than cure, and that early detection through screening is an effective way to reduce the risk of HCV transmission, ultimately benefiting the community at large.

Dr Loey Mak Lung-yi, Clinical Assistant Professor, Division of Gastroenterology and Hepatology, Department of Medicine, School of Clinical Medicine, HKUMed, remarked, ‘The three-year HCV screening pilot programme is in line with the Hong Kong Viral Hepatitis Action Plan 2020 - 2024. The programme was successfully launched in Stanley Prison and the testing process went very smoothly. PICs diagnosed with HCV undergo a two- to three-month course of DAA therapy. Upon successful treatment, patients will experience a complete recovery, provided that they do not have cirrhosis of the liver. The “micro-elimination” approach allows for optimal allocation of resources to implement intervention measures in smaller, well-defined high-risk groups more efficiently and effectively. More HCV-infected PICs are expected to benefit from the programme.’

Wong Kai-tai, Senior Superintendent (Health Care), CSD, said, ‘There are on-premises hospitals or sick bays staffed by qualified personnel in all correctional institutions, where round-the-clock basic health care services are provided to PICs. Moreover, visiting medical specialists from the Hospital Authority or the Department of Health provide consultations and treatment to PICs on a regular basis. For HCV, overseas research data reveals that PICs are at high risk of contracting Hepatitis C, but there is no relevant research data in Hong Kong. The HKUMed team visited the Stanley Prison through the outreach service to launch the pilot programme, in collaboration with correctional officers with nursing qualifications, to provide PICs with health education and rapid HCV tests, along with treatment for HCV-infected PICs. The process is fast and straightforward, and there is no need to escort PICs to outside hospitals for tests and treatment. Eligible PICs have been enthusiastic about taking part in the programme.’

Research progress
The HCV screening pilot programme for PICs was launched in Stanley Prison, with the aim of enrolling about 500 eligible PICs. As at 4 December 2023, a total of 106 PICs had participated in the programme. All PICs confirmed to be HCV-infected were given the full course of DAA within one month of diagnosis; the treatment course takes two to three months.

The research team will perform data analysis upon completion of data collection by the end of 2026.

About the research team
The research project is led by Professor Richard Yuen Man-fung, Li Shu Fan Medical Foundation Professor in Medicine, Chair Professor and Chief of Division of Gastroenterology and Hepatology, Deputy Chairperson, Department of Medicine, School of Clinical Medicine, HKUMed; and Dr Loey Mak Lung-yi, Clinical Assistant Professor, Division of Gastroenterology and Hepatology, Department of Medicine, School of Clinical Medicine, HKUMed.

Acknowledgements
The study was supported by the Health and Medical Research Fund, Health Bureau, HKSAR Government (reference number: 20211881).

Media enquiries
Please contact LKS Faculty of Medicine of The University of Hong Kong by email (medmedia@hku.hk).

¹Micro-elimination: This strategy defines and segments population groups by demographics, such as age, subpopulations, environmental factors, geographical areas and premises, for which tailor-made measures are designed and implemented to gradually eliminate diseases. In the case of hepatitis C, the target groups are defined by the disease burden. Implementing intervention measures in smaller, well-defined high-risk groups will help achieve the goal of eliminating hepatitis C more efficiently and effectively.

²Direct-acting Antiviral, DAA: A highly effective first-line oral medicine of hepatitis C treatment that can cure over 90% of HCV infections. The treatment usually takes 8 to 12 weeks. Compared with traditional hepatitis C treatment using PEGylated interferon and ribavirin, DAA is not only better tolerated, but also more effective.

³World Health Organization Global Health Sector strategies 2022–2030.
https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies

⁴The Government of the Hong Kong Special Administrative Region. (2020, October). Hong Kong Viral Hepatitis Action Plan 2020–2024. Retrieved from https://www.hepatitis.gov.hk/doc/action_plan/Action%20Plan_Full%20Version_PDF_tc.pdf

⁵The Government of the Hong Kong Special Administrative Region. Thematic Report on Viral Hepatitis (Population Health Survey 2020-22). Retrieved from https://www.hepatitis.gov.hk/english/health_professionals/files/Results_at_a_glance_Thematic_report_PHS_2020-22.pdf