The availability of direct acting antivirals (DAA) — a revolutionary, curative treatment for hepatitis C infection — makes national elimination of the hepatitis C virus (HCV) an attainable goal. However, a new analysis from the Centers for Disease Control and Prevention (CDC) reveals concerning declines in the number of people in the U.S. who actually initiated DAA treatment for hepatitis C from 2015 to 2020.

Approximately 164,247 people received treatment in 2015, and slightly over half that number — or about 83,740 people — received treatment in 2020. Reductions in 2020 were somewhat expected given the visceral impact of the ongoing COVID-19 pandemic. Related disturbances including stay-at-home orders, reduced operation of syringe service programs (SSPs), and patient avoidance of healthcare settings likely contributed to poor utilization of HCV services during this time.

In 2015, the National Academies of Science and Medicine estimated that treatment of at least 260,000 people annually is necessary to achieve the U.S. goal of eliminating hepatitis C by 2030. Yet, from 2014 to 2020, our nation has only managed to treat about 120,000 HCV infections annually.

Barriers to Treatment: Funding, Linkage to Care, and Coverage

The U.S. needs to prioritize increasing funding for hepatitis awareness programs, screening, and linkage to care. Without timely identification, diagnosis, and coordinated care management, individuals living with HCV are unable to move forward in acquiring lifesaving treatment. This was demonstrated by a recent qualitative study published in the Harm Reduction Journal which found that HCV patient participants perceived there to be both individual and structural barriers regarding linkage to care. Expansion of HCV services to primary care settings and co-location of HCV treatment within substance use treatment programs were recommended to improve access.

Similarly, we must address issues regarding treatment cost and coverage. The cost of HCV treatment has generally decreased with market competition and innovative state payment models. However, many states continue to uphold discriminatory Medicaid policies that inhibit patients from accessing prompt treatment. These barriers include requiring patients to reach an advanced stage of liver damage before being eligible, restricting patients with a history of alcohol and/or substance abuse, allowing only certain specialists to prescribe treatment, and requiring prior authorizations. Vulnerable populations — including minority communities, individuals battling sobriety, people who inject drugs (PWID), rural communities, and LGBTQ+ communities — are disproportionately impacted by these policy barriers. States that persist in upholding these policies undermine national efforts to provide effective treatment that not only cures HCV, but also reduces the spread of infection and the risk of severe liver damage.

Compounded Effects of the Opioid Crisis

The ongoing opioid epidemic has only inflamed the issue of hepatitis C in the United States. PWID often do not receive treatment for HCV; perceived stigmatization is a major barrier, especially since abstinence from substance use is sometimes an insurance prerequisite to treatment initiation. It is imperative that policy efforts consider injection drug use and hepatitis C as interrelated public health burdens, rather than mutually exclusive epidemics. Recent research published in Clinical Infectious Diseases demonstrated that concurrent initiation of opioid agonist therapy with HCV treatment produced high rates of sustained virologic response (SVR) in study participants, as well as reductions in drug use and risk behaviors that could potentially result in reinfection or other negative outcomes. This study highlighted that withholding or delaying HCV treatment due to lack of sobriety is unsubstantiated — something that should be a major policy consideration.

An analytical modeling study published in the Journal of the American Medical Association (JAMA) also provided telling insights on the efficacy of improving testing, treatment uptake, and access to harm reduction services for PWID. The model utilized 2020 surveillance data from New Hampshire, a state with a significant population of PWID and limited HCV treatment infrastructure. Forecasts showed that concerted efforts prioritizing testing and treatment for PWID were associated with a decreased prevalence of HCV and achievement of elimination targets. Supplementing these efforts with harm reduction strategies, such as enrolling patients in syringe service programs and medication-assisted treatment, reduced the time and number of treatments required to attain HCV elimination.

Looking Ahead

The U.S. needs to be more proactive in making lifesaving DAAs readily accessible, especially for vulnerable populations. Elimination of viral hepatitis remains an ambitious, but attainable goal. Intervention at multiple levels of the hepatitis C care cascade — from diagnosis, to treatment, to mitigating the risk of reinfection — is essential to create measurable changes that will support nationwide HCV elimination efforts.

Malki De Silva is an extern at the O’Neill Institute and a 2022 Public Health Practice & Policy MPH candidate at University of Maryland’s School of Public Health.