While medical science has already developed a highly effective cure for the hepatitis C virus (HCV), identifying those with the virus and getting them started in treatment are proving to be the real challenges. It’s one of the most pressing public health dilemmas of our time, and one that could have dire consequences down the road if public health officials in the U.S. and worldwide don’t develop more effective policies and programs.
The HCV cure is remarkably effective. Direct-acting antivirals (DAA) to treat HCV can cure patients in more than 95% of cases, usually within 8-12 weeks, if they stick to the prescription.
Compared to other diseases with many identified patients and no cure, it’s the identification of those in need that is the most daunting task for hepatitis C. In fact, the global prevalence of HCV is estimated to be 70 million cases, and is expected to increase significantly over the next two decades. Dr. David L. Thomas (Director of the Division of Infectious Diseases at Johns Hopkins) covered this issue in a November 2019 presentation to the American Association for the Study of Liver Diseases (AASLD).
A Worsening Crisis
Dr. Thomas presented his “Current State of HCV Care Cascade” as a continuum of four stages: Infected, Diagnosed, Treated and Cured. Since treatment is so effective, these last two, Treated and Cured, are almost the same number, which is the good news. However, he said the first two stages, Infected and Diagnosed, are where public health officials need to turn to make the biggest impact.
The chart above illustrates that one of the world’s most affluent countries is only diagnosing about half of its infected citizenry. At that rate, the U.S. cannot achieve the WHO’s 80% cure target.
“The problem has shifted…to finding the infected individuals, confirming the infection, and then linking them to care,” Dr. Thomas said.
Getting More Patients into Treatment
One area of success for identification efforts has been to strategically target sub-populations with the highest infection rates, including those who are homeless, incarcerated or inject illicit drugs. This last group also has higher incidences of HIV. Dr. Thomas cited a program from the Netherlands which had striking success with comprehensive HCV programs targeting its HIV population. They used an HIV registry and systematic plan to reach 100% of those identified.
Another speaker, Dr. Jonathon Fenke (Director of the Hepatitis C Center at Jefferson University), presented complementary findings to Dr. Thomas’s during the same AASLD Conference in 2019.
“Current screening practices of risk factor-based and birth cohort screening are not adequately capturing all those infected with HCV around the world,” Dr. Fenke said. He believes that more highly-targeted testing of those who are incarcerated, homeless, on dialysis, or seeking acute medical care in emergency departments and hospitals will identify a great number of people infected with HCV.
Evolving Screening Practices
In his presentation, “Novel Test Strategies in HCV Screening,” Dr. Fenke also promoted the need to both test and initiate a cure in a single visit to achieve greater success worldwide.
The standard HCV protocol involves two separate tests and visits, then additional visits for treatment. Dr. Fenke also emphasized the need to adopt novel testing processes not used in the U.S. but accepted elsewhere, such as the PoC (Point of Care) RNA or Cor Ag tests. These would enable a one-step testing process and reduce the number of dropouts in the cascade between initial patient identification and final confirmation of disease.
Public Health Policies Crucial
Dr. Thomas also mentioned the “terrific success” toward elimination of hepatitis C when the public health sector has made a deliberate, concerted effort (versus ad hoc clinical interactions). A thoughtful approach promotes the plan, coordinates among the healthcare providers, and dedicates sufficient funding to achieve success.
Concerted global efforts to address HIV / AIDS have dramatically lowered the rate of HIV infection and mortality. He called for a similar effort for HCV.
“We need a public health-dedicated, coordinated response to drive the treatment cascade around the world,” Dr. Thomas concluded.
Dr. Fenke also called for national political support and the activation of public health programs in countries where HCV has a high prevalence.
Both presenters stressed the need to muster the political will and adopt dedicated public health policies to close the gap between identifying those in need and getting them treated. The cure is there, but only time will tell if the will is there as well.
