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The Challenge of Eliminating Hepatitis C Virus in the United States

A mini-symposium held on October 8, 2017, at ID Week 2017 in San Diego, California addressed the challenges faced in eradicating hepatitis C virus (HCV) infections globally, with 2 speakers focusing on the considerable challenges faced domestically. Both agreed that, while daunting, the World Health Organization (WHO) timeline can be met, with federal government buy-in, ongoing vigor in identifying people who are infected with the virus, and with the revamping of the drug licensing process to encourage the availability of the needed medications for those who are not on the usual radar of companies.

In May 2016, WHO published a report outlining a timeline to achieve the global elimination of HCV by 2030. This ambitious goal demands heavy-lifting from the global community, including the United States.

As a first response, the National Academies of Sciences, Engineering, and Medicine (NASEM) authored a report released about 6 months ago that outlined the recommendations to eliminate HCV in the United States by 2030. Shruti Mehta, PhD, MPH, Johns Hopkins Bloomberg School of Medicine, Johns Hopkins University, Baltimore, Maryland, who was one of the authors of the report, offered her perspectives on the issue.

“The NASEM recommends a 90% reduction in the incidence of hepatitis C by 2030, relative to 2015. This represents a reduction from 35,000 to 2730 cases per year. What is needed to achieve this? Aggressive treatment, with the treatment of everyone, regardless of their disease stage, and aggressive case finding and diagnosis, with 110,000 cases per year through 2020, 89,000 cases per year from 2020 to 2024, and 70,000 cases per year from 2025 to 2030,” she said.

Diagnosis and cure must keep the same pace with time, even as the cases become more challenging to identify as the prevalence of the disease declines and the infected become less visible. Concurrently, prevention efforts need to be in place. It’s a huge challenge. But, there’s a huge payoff. “The same levels of diagnosis and treatment would reduce mortality from hepatitis C in 2030 by 65 percent relative to 2015, and avert 28,800 deaths in the United States by 2030,” said Dr. Mehta.

This is not something that can be achieved at a local or state level. The highest level of the federal government needs to coordinate the elimination effort. “Elimination will require coordinated action from various federal and state government agencies, high political support, and financial support. The leadership of a single office would help ensure efficient and harmonious work,” said Dr. Mehta.

The Centers for Disease Control and Prevention (CDC) need to be a leader in monitoring the prevalence of HCV and hepatitis B virus (HBV). Reliable data on new infections, morbidity, and mortality are a critical component of tailoring the response. Not all state/local health departments have sufficient resources. As well, CDC needs to support studies geared towards clarifying the prevalence of the disease. Surveillance alone, such as through national surveys like the National Health and Nutrition Examination Survey (NHANES), will not be sufficient. One suggestion from the NASEM report is to integrate HCV antibody and RNA testing into existing serosurveys, including in incarcerated individuals.

Another absolute “must” is intervention in the form of expanded access to syringe exchange and opioid agonist therapy. The recent upsurge in the prevalence of HCV has been driven in large part by people who live in rural settings without ready access to syringe exchange facilities and walk-in medical assistance. Part of the expanded access is the recommended removal of restrictions in current public and private health plans that are not medically indicated and the availability of directing-acting antivirals to all chronic HCV infected person. “There have been multiple demonstrations that treating regardless of disease stage is cost-effective,” noted Dr. Mehta.

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