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Page 8 of 18 Franco et al. Hepatoma Res 2018;4:74 I http://dx.doi.org/10.20517/2394-5079.2018.94

tries on track to achieve HCV elimination targets. However, this is estimated to require a 3 to 5-fold increase
in diagnosis and/or treatment rates from baseline; and robust, highly inclusive public health programs, fo-
cused on hard-to-reach populations and PWIDs [167,83] . Much progress is needed to make HCV elimination
an explicit and adequately resourced public health priority, using appropriate means at all levels through
collaborations between individual citizens, civil society organizations, researchers, healthcare professionals,
the private sector, local and national governmental bodies [170] . Countries have been challenged to dissemi-
nate models of enhanced screening and DAA delivery in and outside tertiary care settings, such as com-
munity primary care [171] , nurse-led models of care [172] and prisons [173] . Studies have demonstrated the utility
of nurse-physician partnerships and training programs to improve engagement in HCV care, translated
into high proportions of patients receiving counselling, education, and successful treatment with cure rates
comparable to contemporary clinical trials, during the interferon and early DAA eras [171,174-176] . The results of
the ASCEND trial suggested that DAAs can be independently administered by primary care physicians and
nurse practitioners to challenging sub-populations, setting the foundation to HCV micro-elimination inter-
ventions such as the one carried out within the Cherokee Nation Health Services system [177,178] . HCV elimi-
nation should not be an impossible task if taken as a “think global, act local” approach, in which clinics are
structured to support vulnerable populations, also in connection with harm reduction venues in the form
of needle and syringe services programs (NSP) and co-location of treatment to OST clinics [179] . For example,
Iceland’s geographical isolation and relatively small population- comparable in size to many cities glob-
ally - makes it an important case study. In general, Iceland provide favorable conditions for geographically-
targeted policies to reduce transmission among PWID (setting up testing and treatment programs, NSPs and
OST in consultation with local healthcare and community service providers) without the unpredictable bias
of population mobility to and from areas with varying program coverages or HCV epidemiology within the
same country [180] . It is estimated that DAA scale-up to levels already being experienced, coupled with rea-
sonable efforts to diagnose and treat PWIDs, could turn Iceland one the first countries to eliminate HCV as
early as 2020 [181] .

The European Union (EU) rely on advanced health-care infrastructure, and is uniquely poised to eliminate
[182]
HCV . Estimates indicate that over one million people had been identified with positive viremic status by
2015 (36% of total viremic pool) and 133,000 were cured in 2015 alone (4% of the total infected population or
9% of the diagnosed population). The number of cures in that year was higher than the estimated number of
new infections (~58,000) added to the number of HCV-infected immigrants (~30,000) believed to have en-
tered the EU. Austria, France, Germany, Netherlands and Spain have led the way with at least 8% of infected
individuals cured in 2015. But many other countries (Bulgaria, Croatia, Czech Republic, Finland, Hungary,
Latvia, Lithuania, Poland, Romania, Slovakia) have seen greater estimated numbers of new infections than
the number of people cured. In order for the EU to be on track with WHO targets by 2025, unrestricted
treatment still needs to increase by 25% until then, and annual new diagnosis rates by 2-fold compared to
2015 baseline [182] .

In Australia, an active HCV screening program has led to 82% of HCV-infected population being diagnosed,
placing the country on-track to achieve WHO elimination targets. The Australian unrestricted DAA pro-
gram, launched in March 2016, adopts a fixed priced approach where the country pays a single fee for ad lib
access to as much DAA therapy as it can use over a fixed period of time. This approach eliminates the “fee
for service” model and instead uses a public health model that incentivizes patients and providers to employ
universal screening and treat all who test positive. This has resulted in an estimated 58,500 individuals (26%
of total HCV-infected population) initiating treatment through 2017. Treatment uptake has been high among
sub-populations at greater HCV transmission risk (22% of PWIDs and > 60% of those with HIV/HCV coin-
fection initiated DAA treatment in 2016) and the country has enhanced surveillance efforts to track the pro-
gram’s future results. It is estimated that Australia could eliminate HCV from the continent by 2020 [183] .