U.S. Not on Track to Meet WHO's Hepatitis C Elimination Targets
Key findings
- According to a modeling-based study, 52% of people infected with the hepatitis C virus (HCV) in the U.S. in 2018 were aware of their diagnosis, and 37% had been cured
- Projections for 2030 are that 62% of HCV-infected people in the U.S. will be diagnosed, and 49% will be cured
- World Health Organization targets for 2030 are for 90% of HCV-infected people to be diagnosed and 80% to be treated
- Recommended measures include more aggressive screening, improved access to direct-acting antivirals and support for young people who inject drugs
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Direct-acting antivirals (DAAs) that can cure infection in people with the hepatitis C virus (HCV) became available in 2014. Two years later, the World Health Organization (WHO) launched a global strategy to eliminate HCV, with the goals of diagnosing 90% of infected people and treating 80% of eligible patients by 2030.
As a framework for monitoring progress toward those goals, the WHO defined a cascade of HCV care: testing, diagnosis, treatment and cure. The National Academies of Sciences, Engineering and Medicine soon adopted a similar strategy for the U.S.
Jagpreet Chhatwal, PhD, assistant professor at Harvard Medical School and senior scientist at the Mass General Institute for Technology Assessment, Qiushi Chen, PhD, research fellow, and Emily D. Bethea, MD, associate clinical director of liver transplantation, and colleagues recently used computer modeling to estimate the current and future HCV care cascade in the U.S. In Alimentary Pharmacology & Therapeutics, they report much progress but also warn that the WHO goals are in jeopardy.
Model and Study Design
The researchers previously developed the Hepatitis C Disease Burden Simulation (HEP-SIM), a state-transition model that simulates the trajectory of HCV disease in the U.S. It has been validated with multiple clinical studies and nationwide surveys, including the National Health and Nutrition Examination Survey (NHANES), which is conducted regularly.
Modeling in the current study took into account the changes over time in HCV screening policies, incidence of infection, treatment recommendations and uptake of treatment. The researchers projected the HCV care cascade for 2011 (when the first DAAs became available), 2018 (study year) and 2030 (the target year for HCV elimination).
WHO set a target for the percentage of patients who should be receiving treatment by 2030, but this study went farther and projected the percentages who would be cured (have sustained virologic response).
Overall HCV Care Cascade
Diagnosed
- 2011: 41% of HCV-infected people were aware of their HCV diagnosis
- 2018: 52%
- 2030: 62%, well below the WHO and National Academy targets
Cured
- 2011: 12%
- 2018: 37%
- 2030: 49%
NHANES vs. Non-NHANES Populations
Populations not surveyed for the NHANES include incarcerated and homeless people, active-duty military, nursing home residents and immigrants from most countries.
Diagnosed
- 2011: 47% of NHANES populations vs. 30% of non-NHANES populations
- 2018: 59% vs. 36%
- 2030: 70% vs. 45%
Cured
- 2011: 17% vs. 0.7%
- 2018: 52% vs. 5%
- 2030: 65% vs. 18%
Baby Boomers vs. Non–Baby Boomers
The model projected that if current conditions continue, by 2030 the number of viremic baby boomers will decrease to 609,000, but the number of viremic non–baby boomers will increase to 1.27 million. The increase will be driven primarily by injection drug use associated with the opioid epidemic.
Diagnosed
- 2011: 42% of baby boomers and 41% of non–baby boomers
- 2018: 58% vs. 44%
- 2030: 79%, driven by the new guidelines for screening, vs. 45%, essentially no change in non–baby boomers
Cured
- 2011: 11% vs. 13%
- 2018: 40% vs. 33%
- 2030: 66% vs. 32%, a widening gap
Sensitivity/Scenario Analysis
The researchers also evaluated how varying the assumptions in the model would affect the HCV care cascade:
- One-time screening of all adults from 2019 onward: The 2030 diagnosis rate would increase from 62% to 77%
- Increase in treatment uptake to 400,000 patients per year from 2019 onward: No impact
- Drop in HCV incidence to four million from 2019 onward: No substantial impact
- Combination of the above scenarios: The diagnosis rate would increase from 62% to 82%, and cure rates would increase from 49% to 62%
More Aggressive Efforts Needed
Thus, even the combined scenario would be inadequate to reach the target of having 90% of HCV-infected people diagnosed by 2030. More aggressive efforts are needed to increase uptake of HCV screening and improve access to DAAs, both at the national level and in high-risk subpopulations such as prisoners.
Controlling the rising incidence of HCV will also be critical, particularly among young people who inject drugs. Reducing the transmission of HCV will require scaling-up harm reduction strategies such as providing more needle exchanges and improving access to opioid agonist therapy.
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