WHO Guidelines on hepatitis B and C testing. Dr. Philippa Easterbrook (Presented by Margaret Hellard)

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1 WHO Guidelines on hepatitis B and C testing Dr. Philippa Easterbrook (Presented by Margaret Hellard)

Outline of presentation Where are we now?

of HIV testing experience Diagnostic innovation Key

HCV? Testing Approaches and Service Delivery models How to

lab-based EIAs and one or two assays Detection of viraemic HCV

2 Outline of presentation Where are we now? Current status and challenges in scale-up of hepatitis testing Why are WHO testing guidelines needed? WHO guidelines methodology Limited evidence base, but 20 years of HIV testing experience Diagnostic innovation Key recommendations and rationale Who to test for chronic HBV and HCV? Testing Approaches and Service Delivery models How to test serologically for chronic HBV and HCV? RDTs vs. lab-based EIAs and one or two assays Detection of viraemic HCV infection and test of cure Use of Dried Blood Spots specimens Interventions to promote uptake of testing and linkage to care 2

3 WHO Global Health Sector Strategy on Hepatitis Vision : A world where viral hepatitis transmission is stopped and everyone has access to safe, affordable and effective prevention, treatment and care Goal: Eliminate viral hepatitis as a major public health threat by Framework: Universal health coverage and continuity of services 3

Hepatitis Prevention Linked / Retained in Care and Treatment % in care % in prevention

4 % in Prevention or Care Hepatitis testing is is at at Core core of care, Care, Treatment treatment and Prevention prevention cascade Cascade 100% Linked / Retained in Hepatitis Prevention Linked / Retained in Care and Treatment % in care % in prevention 80% 60% 40% 20% 0% Prevention Treatment 4 Source: Modified from Frits van Griensven, 2014 Thailand

treatment 7% 11% received treatment <3% diagnosed <1.

5 Large burden of undiagnosed and untreated hepatitis B and C HCV HBV <15% aware 180 million with chronic HCV <25% aware 250 million with chronic HBV USA USA EU <50% diagnosed Up to 90% undiagnosed 32% 38% referred to care <16% received treatment 7% 11% received treatment <3% diagnosed <1.5% on treatment Less than one quarter of persons with HBV aware of diagnosis Lai et al, 5Gastroenterol 2014;146: McMahon, Report of Institute of Medicine, Am J Medicine 2012; 125,

6 Barriers to testing and linkage to care Screening Diagnosis Case selection Treatment Monitoring Assess SVR Lack of awareness Patient Healthworker Lack of information and understanding Cultural beliefs (Stigmatisation) Lack of infrastructure Rapid diagnostic tests (varying quality, lack of quality approved choice) Nucleic acid tests (Expensive, complex, limited availability) Logistical problems (distance/time) 6 Financial (Expensive

7 7 Distinctive Features of WHO Guidelines

8 WHO Guidelines Development process Grading of Recommendation Assessment, Development and Evaluation Quality of Evidence Strength of Recommendation By outcome: High quality Moderate Low Very low Strong or Conditional depends on: Quality of evidence Balance of benefits and harms Values and preferences Resource use Feasibility

WHO Guidelines Development process Strong versus conditional recommendations Grading of Recommendation Assessment, Development and Evaluation Strong recommendation the

Recommendation High quality Moderate Low Very low Conditional recommendation the panel concludes that the desirable Strong or Conditional effects of adherence to a

9 WHO Guidelines Development process Strong versus conditional recommendations Grading of Recommendation Assessment, Development and Evaluation Strong recommendation the panel is confident that the desirable By outcome: effects of adherence to a recommendation outweigh the undesirable effects; Quality of Evidence Strength of Recommendation High quality Moderate Low Very low Conditional recommendation the panel concludes that the desirable Strong or Conditional effects of adherence to a recommendation probably outweigh the depends on: undesirable effects but is not confident Quality of evidence Balance of benefits and harms Values and preferences Resource use Feasibility

10 Key domains to consider in formulating recommendations 12 Systematic reviews HOW TO TEST? (DIAGNOSTIC PERFORMANCE) RDTs vs. EIAs 1 vs 2 assays NAT (quant/qual) HCVcAg Dried Blood Spots HOW TO OPTIMISE UPTAKE OF TESTING AND LINKAGE TO CARE? Target Product Profiles for diagnostics Evidence (GRADE) Values and Preferences Community and Health worker Values and Preferences Cost- Effectiveness Feasibility WHO TO SCREEN? CE studies and Modelling Diagnostic costs Surveys of country and implementing partners experience #HepTestContest Innovation Contest 64 contributions from 27 countries

11 Structure of the Guideline

12 12 WHO TO TEST? (Testing Approaches And Service Delivery)

13 Recommendations Who to test for HBV and HCV? Testing Approaches FOCUSED TESTING FOR THOSE AT HIGH RISK Recommendations In all epidemic settings, offer HBsAg or HCV Ab testing to adults and adolescents: - From populations most affected by HBV or HCV infection * (ie. populations with high seroprevalence or history of risk exposure and/or behaviour); - With a clinical suspicion of chronic viral hepatitis (ie. symptoms, signs, laboratory markers) - HBV: Sexual partners, children and other family members, and close household contacts of those with HBV infection; - Health-care workers: in all settings, and offer HBV vaccination not vaccinated previously. PWID, people in prisons and other closed settings, MSM and sex workers, HIV-infected, some mobile/migrant populations from high/intermediate endemic countries, some indigenous populations, and children of mothers with

14 Recommendations Who to test for HBV and HCV? Testing Approaches GENERAL POPULATION TESTING Recommendations In settings with intermediate (>2%)/high (>5%) prevalence, offer all adults routine access to testing, with linkage to care and prevention services. BIRTH COHORT TESTING (HCV) Consider where specific identified birth cohorts of older persons at higher risk of HCV infection ROUTINE ANTENATAL CLINIC TESTING (HBV) In settings with intermediate (>2%)/high (>5%) HBsAg prevalence, offer routine HBsAg testing to all pregnant women in antenatal clinic, with linkage to care and prevention services.

15 Recommendations - Service Delivery Use health facility or community- based testing services and opportunities Strategic use of focussed testing in health facilities/outreach High acceptance (HIV, antenatal & TB) But still many missed opportunities for testing Moving Testing Out of Health Center into community Outreach (mobile), campaigns and camps, home-based (house to house)

opportunities for testing Recommendation: Combination of strong Moving Testing Out of Health Center into community and

16 Recommendations - Service Delivery Use health facility or community- based testing services and opportunities Strategic use of focussed testing in health facilities/outreach High acceptance (HIV, antenatal & TB) But still many missed opportunities for testing Recommendation: Combination of strong Moving Testing Out of Health Center into community and conditional but all Outreach (mobile), campaigns and camps, home-based (house to house) with low or low/moderate quality evidence

17 17 HOW TO TEST? RDTs vs. Lab-based assays AND One or two assays

18 Recommendations What assays to use: RDTs vs. EIAs? HBV: For diagnosis of hepatitis B infection in adults and children (>12 months of age), a single serological assay (EIA or RDT) that meets minimum performance standards* is recommended. - EIAs are recommended as the preferred assay in settings where existing laboratory testing is available. - RDTs are recommended in settings where there is limited access to laboratory testing and/or in populations where access to rapid testing would facilitate linkage to care and treatment. HCV: To test for exposure to hepatitis C infection in adults and children (>18 months of age), a single serological assay (antibody or antibody/antigen combination) (either RDTs or EIAs) that meets minimum performance standards* is recommended. - RDTs are recommended in settings where there is limited access to laboratory testing and/or in populations where access to rapid testing would facilitate linkage to care and treatment. *Either WHO prequalification of IVDs or a stringent regulatory review for IVDs with regard to both analytical and clinical

EVIDENCE Performance of RDTs vs EIA HBsAg Systematic review 21 studies evaluated 25 brands of

specificity more consistent across studies. Pooled sensitivity: 72.3% in HIV +ve (5 studies).

assays Pooled sensitivity and specificity: 99% (95% CI: 98 100) and 100% (95% CI: 100 100) in

19 EVIDENCE Performance of RDTs vs EIA HBsAg Systematic review 21 studies evaluated 25 brands of RDTs using 15 EIAs as reference assays Pooled sensitivity and specificity: 90.0% (95% CI: ) and 99.5% (95% CI ). Significant variation in sensitivity between RDT brands and across studies for same brands; specificity more consistent across studies. Pooled sensitivity: 72.3% in HIV +ve (5 studies). HCV Ab Systematic review 32 studies evaluated 25 brands of RDTs using 15 EIAs as reference assays Pooled sensitivity and specificity: 99% (95% CI: ) and 100% (95% CI: ) in serum samples; 94% and 100% in oral samples. High sensitivity (>95%) and specificity (>99%) across populations. Insufficient studies in HIV +ve, but sensitivity likely to be lower.

20 RATIONALE Choice of RDT vs lab-based assay: Depends on diagnostic performance, ease of use, cost, test site facilities. RDTs: For settings with limited access to laboratory services, and for hard-to-reach and rural populations Benefits expand access and linkage: - Simplicity and less invasive sampling - Relatively low cost - Rapid turnaround time - Use in outreach programmes (eg prisons) - Well trained lay workers can perform Diagnostic accuracy: - HCV Ab RDTs have acceptable sensitivity and specificity across wide range of settings and populations. - HBsAg RDTs significant heterogeneity and sub-optimal clinical and analytic sensitivity Lab-based EIAs: More appropriate and cost-effective in settings with suitable existing laboratory infrastructure, and where highvolume throughput is likely. Testing can be automated HBsAg RDTs have reduced analytical sensitivity and limit of detection ( fold difference) compared to EIAs; minimal difference for HCV Ab. Sensitivity of RDTs poor (72%) in HIV +ve; appears better for EIAs. Limited availability of HBsAg quality-assured RDTs HBsAg Confirmatory test using neutralization step can be incorporated into EIAs.

cost - Rapid turnaround time - Use in outreach programmes (eg prisons) - Well trained lay workers can perform Diagnostic accuracy: - HCV Ab RDTs have acceptable sensitivity and specificity across

21 RATIONALE Choice of RDT vs lab-based assay: Depends on diagnostic performance, ease of use, cost, test site facilities. RDTs: For settings with limited access to laboratory services, and for hard-to-reach and rural populations Benefits expand access and linkage: - Simplicity and less invasive sampling - Relatively low cost - Rapid turnaround time - Use in outreach programmes (eg prisons) - Well trained lay workers can perform Diagnostic accuracy: - HCV Ab RDTs have acceptable sensitivity and specificity across wide range of settings and populations. - HBsAg RDTs significant heterogeneity and sub-optimal clinical and analytic sensitivity Lab-based EIAs: More appropriate and cost-effective in settings with suitable existing laboratory infrastructure, and where highvolume throughput is likely. Testing can be automated HBsAg RDTs have reduced analytical sensitivity and limit of detection ( fold difference) compared to EIAs; minimal difference for HCV Ab. Sensitivity of RDTs poor (72%) in HIV +ve; appears better for EIAs. Recommendation: Strong recommendation, low moderate quality evidence Limited availability of HBsAg quality-assured RDTs HBsAg Confirmatory test using neutralization step can be incorporated into EIAs.

22 Recommendations One or two assay testing strategy? For HBV and HCV - A single initial rapid diagnostic test or EIA in healthfacility or community-based testing, prior to supplementary NAT testing for evidence of current viraemic infection Prioritize NAT testing and linkage following testing HBV In low prevalence settings ( 0.4%), confirmation of HBsAg with a neutralisation step or a second different RDT assay for detection of HBsAg may be considered

23 EVIDENCE Predictive modelling Effect of Prevalence and Test Accuracy on Test Outcomes for 1 or 2 serological assays RATIONALE Use of single assay: Identifies most individuals likely to be infected and in need of further evaluation, and rules out those uninfected. Simplifies process of testing and reduces cost More rapid reporting of results will help improve linkage to care Minimal consequence of FP as all +ve require NAT confirmation prior to treatment Use of second assay: Two assays vastly improved PPV to > 97%, and ratio of TP:FPs from 0.2 to 40. Potential cost savings by reducing number requiring NAT testing But different RDT assays may fundamentally be the same, and prone to same false +ve

likely to be infected and in need of further evaluation, and rules out those uninfected.

improve linkage to care Minimal consequence of FP as all +ve require NAT confirmation prior to

vastly improved PPV to > 97%, and ratio of TP:FPs from 0.2 to 40.

24 EVIDENCE Predictive modelling Effect of Prevalence and Test Accuracy on Test Outcomes for 1 or 2 serological assays Recommendation: RATIONALE Use of single assay: Identifies most individuals likely to be infected and in need of further evaluation, and rules out those uninfected. Simplifies process of testing and reduces cost More rapid reporting of results will help improve linkage to care Minimal consequence of FP as all +ve require NAT confirmation prior to treatment Conditional recommendation, low quality evidence Use of second assay: Two assays vastly improved PPV to > 97%, and ratio of TP:FPs from 0.2 to 40. Potential cost savings by reducing number requiring NAT testing But different RDT assays may fundamentally be the same, and prone to same false +ve

25 25 DETECTION OF HCV VIRAEMIA (QUANT VS. QUAL NAT VS. CORE ANTIGEN?

26 Recommendations Confirmation of active viraemic HCV infection Directly following a positive HCV antibody serological test, the use of a nucleic acid testing (NAT) (either quantitative or qualitative RNA) is recommended as the preferred strategy to diagnose viraemic HCV infection. A core HCV antigen assay, that has comparable clinical sensitivity *, is an alternative to NAT to diagnose viraemic infection Conditional recommendation, moderate quality of evidence * A test with a limit of detection of 3000 IU/mL or lower would be acceptable and correspond to at least 95% clinical sensitivity from the data available..

27 Recommendations Confirmation of active viraemic HCV infection Directly following a positive HCV antibody serological test, the use of a nucleic acid testing (NAT) (either quantitative or qualitative RNA) is recommended as the preferred strategy to diagnose viraemic HCV infection. A core HCV antigen assay, that has comparable clinical Recommendation: sensitivity * Strong, is an alternative to NAT to diagnose viraemic infection recommendation, Conditional recommendation, moderate quality of evidence moderate/low quality evidence * A test with a limit of detection of 3000 IU/mL or lower would be acceptable and correspond to at least 95% clinical sensitivity from the data available..

28 Recommendations Confirmation of active viraemic HCV infection A core HCV antigen assay, that has comparable clinical sensitivity *, is an alternative to NAT to diagnose viraemic infection Recommendation: Conditonal recommendation, moderate evidence * A test with a limit of detection of 3000 IU/mL or lower would be acceptable and correspond to at least 95% clinical sensitivity from the data available..

EVIDENCE NAT qual vs. quant RATIONALE Sensitivity - What is good enough?

Systematic review 4 studies compared 3 Quant HCV NAT vs. reference Qual NAT.

depend on existing infrastructure and lab platforms if available.

29 EVIDENCE NAT qual vs. quant RATIONALE Sensitivity - What is good enough? Distribution of viraemia in chronic infection: 95% individuals have HCV RNA >10,000 IU/mL in chronic infection. Therefore clinically relevant sensitivity can be >1000 IU/mL Diagnostic accuracy + LoQ of NAT Systematic review 4 studies compared 3 Quant HCV NAT vs. reference Qual NAT. Lower limit of quantification (LoQ) of most commercial Qual assays is IU/mL and 600 Choice will depend on existing infrastructure and lab platforms if available. In DAA era less need for quantification just detection of RNA and test of cure. LoQ higher with quant than qual NAT, but newer assays have similar LoQ. Qual assays have potential to be cheaper and more accessible Hajarizadeh PLOS one 2015; Hajarizadeh J Med Virol 2014; Glynn Transfusion 2005

EVIDENCE HCV core antigen (HCVcAg) RATIONALE Systematic review Diagnostic accuracy of HCVcAg

Conditional recommendation - cag use HCVcAg assays can perform with high sensitivity (>90%)

Quantitative data - close correlation of cag and NAT >3000 IU/mL High cost of NAT assays and

Well-performing core Ag tests could serve as a replacement for NAT for HCV detection

30 EVIDENCE HCV core antigen (HCVcAg) RATIONALE Systematic review Diagnostic accuracy of HCVcAg vs. NAT 50 studies evaluated 7 commercial HCVcAg assays. Conditional recommendation - cag use HCVcAg assays can perform with high sensitivity (>90%) and specificity (>98%) compared with NAT. Quantitative data - close correlation of cag and NAT >3000 IU/mL High cost of NAT assays and lab requirements less available in LICs. Well-performing core Ag tests could serve as a replacement for NAT for HCV detection Potential to be more affordable than NAT <10USD (based on cost of goods analysis Accessibility POC suitability versus centralized testing possibly equal for both RNA/core Ag tests DBS for core Ag limited data - - Freiman et al, Ann Intern Med 2016

31 USE OF DRIED BLOOD SPOTS - HBsAg and HCV Ab serology - HBV DNA and HCV RNA virology 31

32 Recommendations Dried Blood Spots for HBV/HCV serology + virology The use of DBS specimens for HBsAg and anti-hcv antibody serology testing * and HBV and HCV NAT may be considered in settings where: there are no facilities or expertise to take venous whole blood specimens; or there are persons with poor venous access (e.g. PWID in drug treatment programmes, prisons) ; or RDTs are not available or their use is not feasible (serology). * There are currently no manufacturers protocols for use of DBS with their assays, or regulatory approval for use of DBS samples. Therefore, use of DBS specimens would be considered off-label.

33 Recommendations Dried Blood Spots for HBV/HCV serology + virology The use of DBS specimens for HBsAg and anti-hcv antibody serology testing Recommendation: * and HBV and HCV NAT may be considered in settings where: Conditional there are no facilities or expertise to take venous whole blood specimens; recommendation, or there are persons with poor venous access (e.g. PWID in combination of drug treatment programmes, prisons) ; or RDTs are moderate not available or their and use is low not feasible (serology). quality evidence * There are currently no manufacturers protocols for use of DBS with their assays, or regulatory approval for use of DBS samples. Therefore, use of DBS specimens would be considered off-label.

EVIDENCE RATIONALE Systematic reviews: accuracy of DBS compared to venous blood HCV Ab: (14 studies) Sensitivity 98% (95%CI 94-99) Specificity 99% (95%CI 97-100 HBV HBsAg: (9 studies) Sensitivity 96.

34 EVIDENCE RATIONALE Systematic reviews: accuracy of DBS compared to venous blood HCV Ab: (14 studies) Sensitivity 98% (95%CI 94-99) Specificity 99% (95%CI HBV HBsAg: (9 studies) Sensitivity 96.6% (95%CI ) Specificity 99.9% (95%CI ) HCV RNA: (9 studies) Sensitivity 96% (95%CI ) Specificity 97.7% (95%CI ) HBV DNA: (9 studies) Sensitivity 96% (95%CI 90-98) Specificity 99% (95%CI ) Source: Lange et al, unpublished Conditional recommendation Generally high diagnostic accuracy of DBS for both serology and NAT (more limited evidence), and good precision Benefits: Ease of specimen collection Ease of sample processing Ease of sample transport Minimal training required Facility to allow multiplex testing Limited programmatic experience in France, Scotland, UK Challenges and concerns: Storage conditions Manufacturers validation Lack of assays with regulatory approval Assay cut-offs Laboratory capacity

35 Evidence is limited, but promising Trained Peer and lay health worker in community settings Recommendations Linkage to care is key Strategies to consider for increasing uptake and improving linkage Clinician reminders to prompt provider initiated, facility-based testing Testing as part of Integration of services at a single facility, especially within mental health/drug treatment services On-site or immediate RDT testing with same day results

prompt provider initiated, facility-based testing moderate and low to very Testing as part of Integration of services at a single

36 Evidence is limited, but promising Recommendations Linkage to care is key Strategies to consider for increasing uptake and improving linkage Recommendation: Conditional Trained Peer and lay health worker in community settings recommendation, Clinician reminders to prompt provider initiated, facility-based testing moderate and low to very Testing as part of Integration of services at a single facility, especially within mental health/drug treatment services low quality evidence On-site or immediate RDT testing with same day results

The Road Ahead - Implementation HOW TO ORGANISE LABORATORY TESTING SERVICES 1.

Financing for testing services 3. Building capacity for testing services 4.

characteristics for assays 5. Assuring quality of testing services 6.

affected - undiagnosed burden 2. Set testing coverage targets. 3.

37 The Road Ahead - Implementation HOW TO ORGANISE LABORATORY TESTING SERVICES 1. National framework for viral hepatitis testing 2. Financing for testing services 3. Building capacity for testing services 4. Setting national standards for testing, including performance and operational characteristics for assays 5. Assuring quality of testing services 6. Assuring safety of testing services STRATEGIC SELECTION OF TESTING APPROACHES AND SERVICES 1. Review national and subnational epidemiology - prevalence - populations most affected - undiagnosed burden 2. Set testing coverage targets. 3. Review effectiveness of existing testing services, and identify gaps 4. Assess costs and cost effectiveness of different testing approaches. 5. Monitor, evaluate and adjust testing programme activities.

Conclusions Large burden of undiagnosed HBV and HCV infection, but very limited hepatitis testing services. Public health response lags behind public need and demand we need to catch up.

38 Conclusions Large burden of undiagnosed HBV and HCV infection, but very limited hepatitis testing services. Public health response lags behind public need and demand we need to catch up. New WHO recommendations on: - Testing strategies - Testing approaches for different priority populations in different settings - Effective ways to increase linkage to services Need for operational/implementation research agenda for different testing approaches - Innovative approaches community, self-testing, new technologies - Multi country experience of scale up of testing

39 Acknowledgments Chairs: Margaret Hellard (Burnet Institute, Melbourne Australia). Methodologist: Roger Chou (Oregon Health and Science University, Portland, USA Guidelines Development Group: Jacinto Amandua (Ministry of Health, Uganda); Isabelle Andrieux- Meyer (Médecins Sans Frontières, Geneva, Switzerland); Manal Hamdy El-Sayed (Egypt National Hepatitis Committee); Charles Gore (World Hepatitis Alliance, London, UK); Niklas Luhmann (Médicins du Monde, Paris, France); Michael Ninburg (Hepatitis Education Project, Seattle, USA); Richard Njouom (Centre Pasteur of Cameroon); John Parry (Public Health England, London, UK); Trevor Peter (Clinton Health Access Initiative, New York, USA); Teri Roberts (Foundation for Innovative New Diagnostics, Geneva, Switzerland); Giten Khwairakpram Singh (TREAT Asia/amFAR); Lara Tavoschi (European Center for Disease Prevention and Control, Stockholm, Sweden); Roger Chou (Oregon Health & Science University, Portland, USA)(Methodologist); External peer review group Jilian Sacks (Clinton Health Access Initiative, USA); Tanya Applegate (Kirby Institute, Australia); Cami Graham (Beth Israel Deaconess Medical Center, USA); Gilles Wandeler (University of Bern, Swizerland); Mark Sonderup (University of Cape Town, South Africa); Ponsiano Ocama (Makerere University, Uganda); Alaa Gad Hashish (Al Shams University, Egypt); Jean-Bosco Ndinokubwayo (WHO Regional Office for Africa); Yap Boum (Epicentre, Medecins sans Frontière, France); Joumana Hermez (WHO, Egypt); Jules Mugabo Semahore (WHO, Rwanda); Stephen Locarnini (Doherty Institute, Australia); Susan Best (National Serology Reference Laboratory, Australia). Systematic reviews: Jennifer Cohn (Médecins Sans Frontières, Geneva, Switzerland)(Team leader); Claudia Denkinger (Foundation for Innovative New Diagnostics, Geneva, Switzerland)(Team leader); Berit Lange (Center for Chronic Immunodeficiency & Division for Infectious Diseases, Medical Department II, University Hospital, Freiburg,Germany); Rosanna Peeling (London School of Hygiene and Tropical Medicine, London, UK)(Team leader); Shevanthi Nayagam (Imperial College, London, UK); Joseph Tucker (UNC Project-China, University of North Carolina, USA); Predictive modelling: Benjamin Linas (Boston University School of Medicine, Boston, USA)(Team leader); John Parry (Public Health England, London, UK); Values and Preferences Survey: Elena Ivanova (Foundation for Innovative New Diagnostics, Geneva, Switzerland); and Teri Roberts (Foundation for Innovative New Diagnostics, Geneva, Switzerland). Feasibility Survey: Niklas Luhmann and Julie Bouscaillou (Médicins du Monde, Paris, France) and Azumi Ishizaki (WHO). WHO Steering Committee and other staff, Philippa Easterbrook, Anita Sands, Stefan Wiktor, Rachel Baggaley, Cheryl Johnson, Willy Urassa Rachel Baggaley, Willy Urassa; Azumi Ishizaki, Judith van Holten, Stefan Wiktor, Yvan Hutin, Hande Harmanci, Taner Jonathan Bertuna, Fabian Ndenzako, Nicole Simone Seguy, Nick Walsh, Fabian Ndenzako, Susan Norris.

WHO Guidelines on hepatitis B and C testing

WHO Guidelines on hepatitis B and C testing Dr. Philippa Easterbrook Global Hepatitis Programme World Hepatitis Summit Nov 2017 Sao Paulo, Brazil Outline of presentation Key recommendations of 2017 WHO