Hepatitis C elimination: challenges with under-diagnosis and under-treatment

Abstract

Hepatitis C infection has affected 189 million people globally and more than 4 million in the US. Owing to remarkable advances in the therapeutic sphere, essentially all infected patients can be expected to achieve cure. This provides an unprecedented opportunity to eliminate the risk of complications from hepatitis C and to reduce the spread of the virus to others. To achieve this, a streamlined cascade of care from diagnosis to treatment may be enacted. Although great strides have been made, under-diagnosis and under-treatment remain major hurdles.

Keywords: PWIDs; baby boomers; cure; direct-acting antivirals; screening.

Figure 1.. Countries with a higher burden of chronic hepatitis C virus (HCV).

Twenty-eight countries account for 80% of viremic HCV infections. Six countries carry 50% of the global hepatitis C burden: China, Pakistan, India, Egypt, Russia, and the US .

Figure 2.. Hepatitis C virus (HCV) cascade of care.

Of the 3.5 million Americans estimated to be infected with HCV, 50% have undergone anti-HCV testing, the first step in the cascade of care. Next, confirmation testing for viremia (HCV RNA testing) is needed. Once infection is confirmed, linkage with a provider who is expert in HCV treatment is needed (primary care or specialist) and additioal steps include testing for HCV genotype and staging of liver disease. Once treatment is prescribed, there are additional steps to get the medication approved and the patient to complete the treatment. As shown, there are multiple points along the cascade of care where interruption can occur, leading to decreased numbers of persons achieving HCV cure . Current HCV elimination efforts are focused on reducing gaps along the cascade of care.

Figure 3.. Hepatitis C virus (HCV) cases in young adults versus baby boomers in the US.

To date, baby boomers have been the birth cohort with the highest prevalence of HCV infection. However, as cases related to the opioid epidemic increase among young adults, this is changing. Via state-level reports of HCV cases, the seroprevalence of HCV among baby boomers from 50 to 69 years of age was compared with those of young adults from 20 to 39 years of age, and the 2016 US Census population was used to determine the proportion of the population which was HCV-positive in each age category. Eleven states had higher rates of HCV in young adults than baby boomers, and four additional states had roughly equivalent numbers of young adults and baby boomers . CDC, Centers for Disease Control and Prevention.

Figure 4.. Rating of US states in terms of access to hepatitis C virus (HCV) treatment, 2017.

A report from the National Viral Hepatitis Roundtable and Center for Health, Law and Policy Innovation at Harvard Law School found that most Medicaid programs restrict access to HCV treatment. More than half the programs received a “D” or “F” rating, indicating that severe restrictions to HCV therapy exist. In addition, restrictions on who can prescribe HCV treatment exist in all but 14 states. Adapted from sources: https://stateofhepc.org/wp-content/uploads/2017/10/State-of-Access-Infographic.pdf and https://stateofhepc.org/wp-content/uploads/2017/10/Prescriber-Infographic.pdf.