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State of the Hepatitis C Virus Care Cascade, USA, Gobally
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21 July 2020 - David L. Thomas, M.D.
US Cascade
The United States is a high‐income country with a modest disease burden, access to curative oral treatments since 2014, no hepatitis C elimination plan, an opioid epidemic, and little public health response. With the approval of safe oral treatments in 2014, HCV treatment uptake rose sharply in the United States and was associated with a decline in the number of persons with viremia and HCV‐related mortality.7 Moreover, HCV elimination appears to be likely in some subpopulations, such as veterans and within some Native American settings where uniform testing and treatment was implemented and funded. However, by the end of 2018 in the United States, one review projected that there were still 2.71 million persons with ongoing HCV infection out of a total of 4.29 million who were once infected; 50% to 60% were aware of their diagnosis, and 1.58 million had already been successfully treated (Fig. 4).7-10


There remain many impediments to HCV elimination in the United States, where HCV treatment has declined since 2016. Low treatment update reflects a spectrum of residual challenges, including limited testing and awareness of infection, lack of concern about HCV infection among some already diagnosed, and obstacles to receiving treatment, including refusal of some states to pay for treatment for Medicaid recipients. The price of treatment in the United States has dropped significantly but remains the reason that many barriers to treatment are sustained. Chief among those is corrections, where 10% to 20% of the remaining infected persons may be at any one time. Individual states are responsible for those costs, as well as the cost of treating persons with low income. Solutions such as the “Netflix” subscription plan that fixes the total cost and incentivizes (rather than punishes) states to test and treat are being tested. Individual factors, such as competing priorities and distrust of traditional medical providers, cannot be overestimated as well, because studies have shown that even free same‐day treatment is occasionally not accepted. In addition, HCV incidence in the United States continues to increase due to the opioid epidemic, which occurs in rural regions of the country where public health outreach is limited.11 Thus, although harm reduction services prevent HCV infection, there is no obvious way to distribute them (the way they are currently provided) to all of the areas where they are needed.
HCV treatment is an incredible tool, but one that is effective only when coupled with testing, linkage, and preventive services. This situation is not unlike what exists with malaria, tuberculosis, and HIV. With each of those, well‐funded global public health responses have been necessary to deliver treatment to those in need and to achieve elimination. It will be the same for HCV.

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