Photo Credit: Mohd Azrin
Vincent Lo Re III, MD, MSCE, discusses efforts to eliminate the hepatitis C virus in the United States and how to overcome remaining barriers.
“It is rare to consider the elimination of any infectious disease,” Vincent Lo Re III, MD, MSCE, and colleagues noted in Clinical Infectious Diseases.
However, in the case of the hepatitis C virus (HCV), highly effective direct-acting antivirals (DAAs) and the development of point-of-care HCV RNA tests led to a national goal to end HCV infection in the United States. Toward that goal, the American Association for the Study of Liver Diseases (AASLD)/Infectious Diseases Society of America (IDSA) HCV Guidance Panel was formed to create evidence-based recommendations for screening, treating, and managing HCV.
Dr. Lo Re, a member of the panel, and colleagues published the commentary in Clinical Infectious Diseases to examine the factors that have held back progress toward HCV elimination, potential solutions that may allow for the elimination of HCV, and the role of the AASLD/IDSA panel in achieving it. Dr. Lo Re spoke with Physician’s Weekly (PW) to discuss the commentary.
PW: What prompted this work?
Dr. Lo Re: In the mid-2010s, a new set of oral, direct-acting antiviral therapies for treating chronic HCV began to be released into the market. These were formulated combinations of once-daily antiviral drugs for 8 to 12 weeks. They revolutionized how we treated HCV. They had very tolerable therapies that offered more than a 95% chance of cure, which for the first time raised the possibility that elimination (not necessarily eradication), in the sense of reducing its prevalence and incidence to that below a public health problem, became possible. In 2016 and 2017, the National Academies of Science, Engineering and Medicine convened a committee for the elimination of hepatitis C, in addition to hepatitis B, and this expert committee endorsed the idea and the possibility of eliminating hepatitis C. If it weren’t for the COVID-19 pandemic, our national hepatitis C guidance panel likely would have gotten behind elimination sooner. We on the national guidance panel felt it was an ideal time to further lend our expertise.
Could you summarize your paper’s major points?
We highlight what the current barriers to HCV elimination are, and then we focus on what we consider the obstacles that have hindered progress toward HCV elimination. We talk about the potential solutions that have opened the path, and we specifically identify how the efforts being planned by our guidance panel will help to further the goal of HCV elimination in our country.
The main obstacles are HCV diagnosis, care linkage, and antiviral treatment. From a diagnosis standpoint, there’s still a sizable proportion of people in this country who are undiagnosed and unaware of their infection. We have to develop approaches to enhance HCV screening and diagnosis, particularly in populations that have been hard to reach, such as those who are uninsured, underserved, incarcerated, or people who formally or currently inject drugs. If you cannot identify individuals who are diagnosed, you can never get them into care and ultimately treat them.
Another significant issue is ensuring that barriers to access to HCV care are overcome. If you look at the data on the dispensing of hepatitis C direct-acting antivirals to people living with HCV, it’s quite low.
Some of these access issues are due to the challenges of diagnosis, but there are also issues of insurance providers that have put barriers up against reimbursement for HCV treatment, requiring, for example, attestation of abstinence from substances prior to HCV treatment or enrolling in a substance use program. Other insurers have required the treatment be performed exclusively under a specialist. Those restrictions stigmatize people living with HCV, discourage them from seeking hepatitis C care, and can delay HCV treatment or prevent it altogether.
What changes could help eliminate HCV?
One of the ways that we could help the field and the community at large is to synthesize research that could advance elimination efforts, such as point-of-care HCV RNA tests, approaches to monitor elimination metrics and ways to decentralize hepatitis C care outside of specialist care. We could also expand access to HCV management and treatment in other nontraditional settings, such as primary care practices, correctional facilities, substance use treatment programs, mobile health services, or telehealth programs.
Is there anything else you’d like to mention?
I don’t think that there are enough specialists in this country who will be able to treat the 2.7 million persons estimated to have chronic HCV in this country by the World Health Organization’s goal of elimination by 2030.
Providing information through our national hepatitis C guidance website, which is online at www.hcvguidelines.org, is a way for us to make valuable inroads and make providers comfortable with managing hepatitis C.
