Why Is HCV a Problem?
Today, approximately 2.4 million people are living with hepatitis C virus (HCV) in the United States. The number of new infections increased by 50% between 2017 and 2020, exacerbated by injection drug use associated with the opioid epidemic. Injection drug use increases the risk of transmission of blood-borne diseases such as HCV. Only 54% to 69% of antibody-positive cases are diagnosed, and even fewer are treated. The World Health Organization (WHO) and CDC have declared their intention to eliminate HCV by 2030, which means reducing new infections by 90% and mortality by 65%. As the cost of curative direct-acting antivirals (DAAs) drops and Medicaid programs continue to remove access restrictions, more resources are needed to prioritize prevention, screening, and linkage to care. Addressing this complex public health challenge in the U.S. requires continued action from a variety of stakeholders.
Current HCV Elimination Efforts
HCV prevention efforts across the U.S. have been scarce and inconsistent. Many existing prevention strategies focus on harm reduction related to injection drug use, with some states and localities successfully implementing syringe services programs (SSPs) and mail distribution of harm reduction supplies. In other countries, novel, targeted micro-elimination models among high-risk groups, such as men who have sex with men (MSM) and people living in carceral facilities, have been shown to reduce HCV incidence and prevalence, but have yet to be broadly implemented due to legal restrictions in the United States. While harm reduction is a vital component of HCV prevention, it does not address the need to reach all people who need to be diagnosed and connected to treatment.
To increase screening and diagnosis rates, guidelines now recommend once-in-a-lifetime screening for all adults. Studies have also shown that reflex testing, which simplifies the standard two-step testing process into one visit, increases the rate of confirmed diagnoses — yet providers and testing labs have not yet adopted reflex testing as standard protocol due to potential concern or inertia in deviating from the “gold standard” testing approach.
Despite efforts by Medicaid programs to remove access restrictions, HCV treatment rates among Medicaid beneficiaries are approximately half the rates among commercially insured patients. Continued advocacy efforts by the State of Hep C and Hep ElimiNATION projects have drawn attention to this issue in recent years. Though some states have adopted innovative payment models (IPMs) to help control costs while expanding access, they have not been shown to have made a significant impact on improving treatment rate. Researchers suggest that removing Medicaid access restrictions has been more effective at increasing treatment rates among diagnosed patients. However, there remains a need to improve testing and linkage to care to increase diagnosis rates and, ultimately, treat more people living with HCV.
Minimal monitoring approaches to treat HCV have also produced similar outcomes to the standard approach, suggesting that simplifying treatment may be a helpful way of reducing drop-off rates. As the cost of treatment becomes less of a challenge, HCV elimination efforts need to increase identification of undiagnosed and untreated people living with HCV, while continuing to expand treatment access and national and state-level surveillance.
HCV Elimination Policy Recommendations
Federal and state lawmakers, agencies, health and corrections departments, providers, and health plans can and should take further action to improve HCV elimination efforts.
At the national level, hepatitis C elimination goals should be supported with adequate funding towards prevention, testing, and linkage to treatment. Congress should also pass federal legislation to legalize the use of federal funds for SSPs in prisons, which have a high burden of HCV.
In states that have not yet done so, expanding Medicaid is a critical method of increasing access to HCV care for low-income adults. Lawmakers and Medicaid programs should ensure treatment access controls are reasonable and equitable between both fee-for-service and Managed Medicaid populations. States receiving funds from opioid lawsuit settlements should direct those resources to HCV elimination to close gaps in funding compared to other diseases.
State and local health departments can also prioritize HCV elimination by developing goal-oriented HCV elimination plans, expanding testing locations outside of primary and specialty care, and using IPMs to control spending on DAAs while increasing access. Corrections departments should implement opt-out HCV screening for all new inmates and leverage micro-elimination models to reduce transmission and supply timely treatment.
Provider organizations should encourage screening and testing by implementing best practice alerts or protocols to increase compliance with once-in-lifetime screening guidelines. Loss to follow-up can be minimized by using reflex or point-of-care RNA testing to reduce the number of visits required to receive a diagnosis. Insurers should also facilitate a streamlined approach to treatment by covering the full dose of DAA treatment at the first visit and supporting the minimal monitoring treatment approach, which is as effective and safe as the standard protocol and may increase likelihood of treatment completion and cure.
To improve surveillance and monitor progress towards elimination goals, the CDC should provide standardization and oversight to state surveillance activities and work towards building a national database. CDC should also educate Congress and the Biden administration on the importance of national HCV surveillance, which would dovetail with the administration’s public health priorities. State lawmakers should similarly allocate increased funding towards HCV data collection and management. Health departments should proactively work with state lawmakers to prioritize such funding efforts.
These recommendations were created with a pragmatic approach in mind: no single organization or authority can eliminate HCV alone. Success lies with the combined action of all levels of government, private organizations, and advocates working to improve case-finding, streamline the care cascade, and facilitate treatment access.