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Remaining challenges in HCV elimination
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February 12, 2021 Jnl of Hepatology
Camelia Capraru
Jordan J. Feld
AASLD: AUTOMATED VIRAL HEPATITIS (HCV AND HBV) SCREENING: LESSONS ON EXPANSION & SUSTAINABILITY AMIDST THE COVID-19 PANDEMIC - (12/21/20) NJ
AASLD: ELIMINATING HEPATITIS C: A COMPREHENSIVE PROGRAM OF DIGITAL CASE FINDING AND LINKAGE TO CARE ACROSS A LARGE URBAN HEALTHCARE SYSTEM - (11/13/20) NYC
AASLD: Early phase implementation of routine opt out hepatitis C testing in the Philadelphia jail system - (11/28/20) Philadelphia
AASLD: Provision of Hepatitis C Care in a Federally Qualified Health Center during the COVID-19 Pandemic - (11/13/20) Philadelphia
AASLD: A hospital free of Hepatitis C: Hepatitis C virus screening program in an Emergency Department of a tertiary hospital of a high-income country. (Preliminary results) - (11/16/20)
AASLD: Treatment As Prevention: Addressing HCV in Persons Who Inject Drugs (PWID) - (11/28/20)
AASLD: POINT-OF-CARE HEPATITIS C TESTING AND TREATING STRATEGY IN PEOPLE WHO INJECT DRUGS IN HARM REDUCTION AND ADDICTION CENTERS FOR HEPATITIS C ELIMINATION - (11/19/20)
The remarkable advances in HCV therapeutics have raised the prospect of elimination of HCV as a public health threat. However, many remaining barriers must be overcome to achieve this ambitious goal. The emergence of the global COVID-19 pandemic has unfortunately created additional challenges that will likely slow global progress towards elimination.
Before even considering those with HCV infection, a major focus needs to be on prevention. Without the near-term prospect of an HCV vaccine, reducing incidence requires a major focus on harm reduction for people who inject drugs (opiate agonist therapy, needle syringe programs, supervised injection sites) as well as avoidance of iatrogenic infection. Emerging data support treatment as prevention as an additional tool to decrease new infections but this requires active case-finding and early treatment in hard-to-reach populations.
A high proportion of those living with HCV remain unaware of their infection. Increased awareness and targeted screening strategies based on local epidemiology are critical to increase diagnosis rates. Acceptance of screening requires destigmatization of HCV among the public and in health care settings. Simplification of the diagnostic approach is also required. The standard paradigm of antibody testing followed by HCV RNA testing risks losing people before diagnostic confirmation or treatment initiation. The cost of HCV RNA testing surpasses the cost of a full course of therapy in many low- and middle-income countries, adding a major additional barrier. Increased use of point-of-care antibody testing followed by reflex HCV RNA, ideally delivered by peer workers without the need for phlebotomy at sites where treatment can be immediately initiated, would greatly reduce loss to follow-up and drop-offs in the cascade of care.
Even after diagnosis, significant drop-offs before treatment initiation are a consistent finding globally. Patient and provider restrictions on access, as well as the cost of therapy, continue to be major barriers. Use of pangenotypic regimens following very simplified guidelines allow for task-shifting to reduce the need for specialists and increase treatment capacity. Increased access to high quality generic medications is critical in low-income settings. Ideally low barrier treatment with minimal or no monitoring can be co-located with other services. Development of long-acting injectables as has been done for HIV could be transformative, allowing for immediate treatment (and cure) at the time of diagnosis.
After cure, those with advanced liver disease require ongoing surveillance for hepatocellular carcinoma. Improved tools for risk stratification could greatly enhance the efficiency of surveillance. Those at risk of reinfection require continued access to harm reduction services, bringing the cascade full circle back to prevention. Development of a vaccine is likely required for true global eradication.
The COVID-19 pandemic has exaggerated challenges at every step in the cascade of care from reduced access to harm reduction services to delayed treatment initiation.
Strategies to improve retention across the continuum of care exist. However, implementation of good practices requires coordinated efforts specific to the local epidemic. Countries/regions on track for elimination have clear action plans developed with strong community engagement, leading to critical political buy-in. Hopefully, the major public health challenge we currently face will not hamper our efforts to achieve the major public health triumph of eliminating HCV by 2030.
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