Expert Columnist post for the Hepatitis Policy Project at the O’Neill Institute for National and Global Health Law
Written by Richard J. Wolitski, PhD, Director, and Corinna Dan, RN, MPH, Viral Hepatitis Policy Advisor Office of HIV/AIDS and Infectious Disease Policy, Office of the Assistant Secretary for Health, Department of Health and Human Services
Viral hepatitis poses a serious threat to the health of millions of Americans from all walks of life. It accounts for more deaths in the United States than all other reportable infectious diseases combined. New infections are on the rise across the country as a result of injection drug use that has been driven by the opioid crisis that is gripping communities across the country. The severity of this problem was recognized by the editors of the American Journal of Public Health in what is certain to become an iconic cover. The February 2018 issue features an in-your-face cover image of a man injecting drugs into his scarred and scabbed arm. It is disturbing. It forces you to take notice, and it is not easy to forget.
Although the image is shocking for the cover of a journal, the editor’s choice to put this topic front and center is not. What is surprising is that has taken so long. New hepatitis C (HCV) infections have been increasing since 2009 and new hepatitis B (HBV) infections have remained stable or increased slightly after declining for more than three decades. The increase in new infections among young adults has resulted in increases in HCV transmission from pregnant women to their infants. Almost every one of these HCV infections could have been prevented; each new infection represents a failure of health care providers and health care systems.
We are losing ground in the battles against viral hepatitis despite the fact that we’ve made important scientific advances in prevention, care, and treatment. Vaccination against HBV infection is highly effective, but until recently required 3 doses. A new vaccine recently approved by the FDA can be delivered in two doses, which could increase the percentage of persons who are fully vaccinated against HBV. HCV can now be cured with an 8 to 12 week course of once daily oral medication that is more than 95% effective if taken as prescribed and has few the side effects. We cannot cure HBV infection at this time, but antiviral treatment can lower the amount of virus, prevent disease progression, and may prevent sexually transmission to others.
Why have we been backsliding in recent years, instead of moving forward? It’s not that we do not have the tools needed to get the job done. It’s not that we haven’t used these tools effectively. It’s not that we do not have a vision or a plan. We have had a national plan addressing viral hepatitis since 2011. CDC and other HHS agencies have put forward their own plans that are aligned with the National Viral Hepatitis Action Plan that include efforts to monitor, prevent, and treat new and existing cases. These plans also address the need to expand diagnosis, care, and treatment of viral hepatitis, especially among groups that have been most heavily affected. These plans lay out strong, science-based frameworks for mounting effective, comprehensive actions to combat viral hepatitis. The National Academies of Science, Engineering, and Medicine (NASEM) convened a panel of experts from around the country to assess what it would take to eliminate viral hepatitis as a public health threat in the United States by 2030. Their 2016 and 2017 reports concluded that that viral hepatitis elimination is possible with existing prevention and treatment methods. It is important to keep at least two things in mind about their conclusions: (1) elimination is not the same as eradication of these infections—prevention, care and treatment would all still be needed for years to come, and (2) that achieving the goal of elimination will require “considerable will and resources.”
We strongly support the goal of eliminating viral hepatitis. It is the goal that we are all ultimately working to achieve. We also believe it is important to set realistic expectations for policy makers and to set performance targets that are achievable. We must make the best possible use of available resources and leverage technology, partnerships, policy changes, and other approaches that have the potential to result in lasting, sustainable viral hepatitis programs that are not dependent on one type of funding for their survival.
A key to the long term success and sustainability of viral hepatitis efforts is greater integration into existing health care services in ways that support the client in making the best possible choices he or she can and having access to the most appropriate and most effective services and programs that will keep them healthy. We believe that this can be accomplished by taking a patient-centered approach- considering the health threats that each person faces and developing a plan that allows that client to access both preventive health care and treatment for existing illnesses.
But creating and sustaining change cannot stop there. The changes also have to make sense to the people who are footing the bill. They need a return on their investment such as reducing health care costs, serving more people in need, increasing profit, recognition of innovation, or feeling good about helping others. If a change is not reinforced by a resultant benefit, it doesn’t stand a chance of being sustained.
There are clear benefits of greater integration and colocation of HIV, viral hepatitis, STD, TB, substance use disorder treatment, overdose prevention, comprehensive syringe services, primary health care, housing and employment services. In many cases, behaviors place people in situations where they are at increased risk for multiple physical and mental health problems. Many of these problems do not occur independently of each other. They are often intertwined with each other and affect the social and economic well-being of individuals, families, and communities. Understanding the needs of the individual and what’s important to them can support a more holistic approach to health and wellness that meets people where they are at, addresses their most critical needs—the ones that most endanger their immediate health and well-being, and helps them identify their own lasting solutions in novel ways that are feasible, self-reinforcing, and habit forming.
Actions speak louder than words. Actions are the foundation of what’s required to turn around the negative viral hepatitis trends that we have been seeing in the data, in our communities, and too often within our own families and among our friends. We need to choose our actions wisely and focus on the things that are in our power to change or that can support others to take necessary actions when we cannot. Among the things we can influence, we need to choose those that will provide the greatest benefits to the greatest number of people.
A key objective for us is to promote an accurate understanding of the magnitude of the problem of viral hepatitis, its severity, the challenges, the solutions, and what it would take to achieve the vision of the National Viral Hepatitis Action Plan.
A goal without a plan (that is feasible and implemented) is just a wish.
— Antoine de Saint-Exupéry (paraphrased)
The opinions expressed in this blog are the writers’ own and do not necessarily represent the official policy of the Department of Health and Human Services.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.