Prise en charge des personnes infectées par les virus de l’hépatite B ou de l’hépatite C

Objectives

The report sets out a national framework for improving prevention, screening, diagnosis, treatment and long-term support for people living with hepatitis B or C in France. Its central priorities are to renew prevention, particularly hepatitis B vaccination; organise disease-specific, coordinated care pathways; and reduce social, geographical and regional inequalities in access to screening, vaccination and care.[1][2]Hepatitis C elimination is presented as a realistic objective through identifying and treating affected people with highly effective therapies, alongside action on medicine affordability.[3]

• Strengthen primary prevention through universal and targeted hepatitis B vaccination, risk-reduction measures for people who use drugs, safer healthcare and blood-transfusion practices, and prevention of sexual and mother-to-child transmission.[4][5][6]
• Expand combined hepatitis B, hepatitis C and HIV screening, including risk-based testing, outreach and rapid diagnostic testing for people with limited access to conventional care, pregnant women and other priority populations.[7][8][9]
• Improve early detection of fibrosis, cirrhosis and hepatocellular carcinoma, and maintain surveillance for complications after viral control or cure where residual risk remains.[10][11][12]
• Provide effective antiviral treatment according to disease severity, clinical circumstances and patient preference, while supporting hepatitis B viral suppression and hepatitis C cure.[13][14][15]
• Address comorbidities, including alcohol use, metabolic syndrome, psychiatric conditions, addictions, renal disease, HIV co-infection and social vulnerability, as integral elements of hepatitis care.[16][17][18]
• Improve knowledge, reduce stigma and support quality of life through therapeutic patient education, patient-association involvement, family support and research on patients’ experiences.[19][20][21]
• Reduce inequities affecting migrants, people who use drugs, people in detention, people experiencing poverty or precariousness, overseas populations and other underserved groups.[22][23][24]

Implementation

Implementation is conceived as a collective, multidisciplinary national effort involving public authorities, health professionals, researchers, patients, patient associations, industry and the media. The recommendations were developed by around 200 clinicians, researchers, patients and association representatives through 22 thematic expert groups, with validation and synthesis by an independent committee under the National Agency for Research on AIDS and Viral Hepatitis and the French Association for the Study of the Liver.[3][25][26]Delivery relies on integrated pathways linking primary care, hospital expert services, specialist care, laboratories, addiction and harm-reduction services, medico-social support and community organisations.[27][28][29]

• Use general practitioners and first-contact services to provide prevention advice, vaccination, screening, early assessment, referral, follow-up and therapeutic education, supported where appropriate by remuneration linked to public-health objectives.[4][30][31]
• Coordinate hospital-based expert hepatitis services with community specialists, local care networks, social workers, addiction specialists, mental-health professionals and patient associations, especially for complex cases and vulnerable populations.[28][32][22]
• Develop multidisciplinary case-review meetings in every region for complex patients, producing written care proposals that address antiviral treatment, fibrosis, comorbidities, addiction, psychological health and social needs.[22][33][34]
• Deliver low-threshold community and outreach services through addiction-care and harm-reduction centres, anonymous and free screening services, medical microstructures, peer-led initiatives and mobile provision of rapid tests, vaccination and fibrosis assessment.[35][36][37]
• Provide therapeutic patient education across diagnosis, treatment and post-treatment follow-up, using multidisciplinary teams and patient experts to strengthen autonomy, adherence, quality of life and sustained engagement in care.[38][39][40]
• Adapt action to regional and overseas-territory epidemiology, workforce capacity and access barriers, with particular concern for territories with limited specialist availability and under-resourced patient associations.[41][42][43]
• Support research through the ANRS, clinical reference centres, cohorts such as Hépather, clinical trials, social-science research and collaborations between public research bodies, hospitals, universities and industry partners.[44][45][46]

The proposed accountability approach is stronger for selected operational areas than for the overall strategy. Regional Health Agencies are expected to coordinate regional delivery, authorise therapeutic education programmes and support funding traceability, while the French Institute for Public Health Surveillance is envisaged as a contributor to regional monitoring systems and dashboards.[47][29][48]The report proposes annual regional dashboards combining vaccination, screening, treatment, healthcare, medico-social and long-term-condition data, plus annual follow-up of disadvantaged regions and medico-economic evaluation of bundled care-pathway financing experiments.[48][49]It also calls for regularly updated epidemiological scorecards covering the proportions screened, assessed, treated, cured or controlled.[50]However, it does not specify a comprehensive national indicator set, reporting timetable, named accountable body or dedicated budget for the full recommendations.[2][51]

Monitoring & Evaluation

The report combines epidemiological surveillance, clinical monitoring, programme evaluation and research evidence, but does not establish one consolidated national indicator framework, reporting timetable or accountability system for all recommendations.[3]It nevertheless identifies priorities for tracking prevention, diagnosis, care access, treatment outcomes, inequalities and the burden of liver disease.[2][51]

• Monitor hepatitis B and C prevalence, incidence, mortality, diagnosis, screening and treatment across the general population, higher-risk groups, regions and overseas territories.[52][53][51]
• Develop annual regional dashboards combining vaccination, screening, healthcare, medico-social management, long-term-condition data, health-insurance claims and hospital information, including reporting for overseas territories.[48][49]
• Address evidence gaps, including incomplete regional epidemiological data, insufficient information on marginalised populations, lack of national chronic hepatitis notification, and limited surveillance in overseas territories.[25][54][55]
• Track hepatitis B vaccination coverage, regional disparities, screening in pregnancy, neonatal serovaccination and post-vaccination serology.[56][57][58]
• Assess screening delivery through laboratory activity, community testing, traceability of tests undertaken outside laboratories, and reporting completeness, particularly for hepatitis C.[54][59][60]
• Monitor clinical outcomes through viral load, treatment response, fibrosis stage, cirrhosis complications, hepatocellular carcinoma surveillance and mortality.[61][62][63]
• Use cohorts, including Hépather, and research networks to generate longitudinal evidence on treatment effectiveness, safety, resistance, comorbidities, quality of life and health-economic outcomes.[52][46][64]
• Evaluate therapeutic patient education through annual self-evaluation, four-yearly Regional Health Agency assessment, activity and participation measures, patient and professional satisfaction, autonomy, adherence and quality of life.[65][66][67]
• Strengthen accountability in selected services through Regional Health Agency approval and oversight of community screening, traceability of expert-service funding, annual evaluation of care structures, and proposed physician-level public-health objectives.[35][68][30][57]

Costing & Financing

Costing is largely undeveloped: the recommendations recognise that access to new hepatitis C treatments, diagnostic tools, vaccination, harm reduction, specialised services and social support requires resources, but do not provide a consolidated national budget, funding gap or financing plan.[3][51]Economic considerations focus on treatment affordability, reimbursement, cost-effectiveness research and targeted financing mechanisms.[14][69]

• Reduce hepatitis C medicine prices to support treatment expansion and the stated objective of eradication, including through collaboration with pharmaceutical companies, generic competition and intellectual-property flexibilities.[70][14][71]
• Use Health Insurance and State financing for specified screening services: Anonymous and Free Screening Consultations are financed by Health Insurance, while Centres for Information, Screening and Diagnosis of Sexually Transmitted Infections are financed by the State.[60]
• Recognise explicit test-cost references, including an approximate screening-test unit cost of 15 euros and an approximate rapid diagnostic-test unit cost of 10 euros.[59][72]
• Support hepatitis B vaccination through Health Insurance reimbursement in screening and diagnostic centres, free provision in selected screening settings, employer-funded occupational vaccination where justified, and reimbursement of the expanded three-marker hepatitis B test package.[73][74][75][76]
• Address reimbursement gaps for non-invasive fibrosis tests, which were reimbursed for selected untreated hepatitis C patients from 2012 but not for hepatitis B at the time described.[77][78][79]
• Experiment with flat-rate financing for hepatitis B and C care pathways and assess it against existing arrangements through medico-economic evaluation.[22][80][7]
• Provide traceable public-interest, teaching, research, reference and innovation allocations to expert viral-hepatitis services, while recognising difficulties in ensuring funds reach intended services.[68]
• Resource therapeutic patient education, multidisciplinary coordination, outreach, patient associations, accommodation and interpreting, all of which are identified as necessary but insufficiently funded or not costed.[81][82][43]
• Increase public investment in independent viral-hepatitis research over the following five years, coordinated principally through the National Agency for Research on AIDS and Viral Hepatitis.[83][84]