Eliminating Hepatitis C Requires Commitment

In just 35 years, hepatitis C virus (HCV) has gone from unidentified to a disease targeted for elimination as a public health threat. The Viral Hepatitis National Strategic Plan for the United States: A Roadmap to Elimination’s vision for the country is, “a place where new viral hepatitis infections are prevented, every person knows their status, and every person with viral hepatitis has high-quality health care and treatment and lives free from stigma and discrimination.” This is an admirable and technically possible goal given the availability of cost-effective, well-tolerated, oral treatments that cure more than 95 percent of HCV cases in only eight to 12 weeks; broad testing recommendations; and a clear understanding of how HCV spreads. Nevertheless, the nation is a long way from realizing this vision. Although there have been successes in HCV care and prevention, it will take a strong commitment to treatment and harm reduction to meet national goals.

About HCV Infection and Treatment

HCV is a blood-borne, infectious disease that can spread through use of unsterile injection, tattoo, or piercing supplies; to an infant during pregnancy or birth; infected blood products or organ transplants; and, rarely, sexual contact. HCV infection has two phases, acute and chronic. Acute hepatitis C occurs in the first six months after a person is exposed to HCV and about 25-40 percent of people recover without treatment. For the other 60-75 percent, the infection becomes chronic, which eventually leads to liver damage, scarring, or cancer. Estimating the number of people living with HCV is difficult because the infection is often asymptomatic until liver damage occurs. That said, between 2017 and 2020, an estimated 2.2 million Americans had HCV. People ages of 55-64 account for more than half of people living with HCV; however, people ages of 20-49 account for the most new infections.

Treating and detecting HCV early prevents liver damage. This is one reason why the U.S. Preventative Services Task Force and Centers for Disease Control and Prevention recommend testing all adults at least once in their lifetime, in addition to during each pregnancy, if applicable. For those who test positive, treatment is easier than ever. In 2013, direct-acting antiviral (DAAs) medications were approved, simplifying curative HCV treatment. Although DAAs were originally quite expensive, the cost of these medications has decreased significantly as innovation has delivered new formulations spurring free-market competition between drug manufacturers. Now, sticker price for the medications that cure HCV is about $25,000, but averages $11,000-$17,000 after pharmacy discounts, patient assistance programs, and manufacturer-funded price concessions. Treating HCV can save $57,000 to almost $200,000 per patient depending on the severity of existing liver damage.

Preventing New HCV Infections

Even though HCV is now curable, preventing infections is still the best course of action. Since HCV is most commonly transmitted through injection drug use with unsterile supplies, interventions targeted toward people who inject drugs (PWID) can be highly effective prevention programs. Syringe services programs (SSPs), where people who use drugs can access sterile injection supplies and return used syringes, are vital to slowing the spread of HCV and other infectious diseases. A 2024 study of PWID in rural New England found that the rate of HCV among people living far (more than 10 miles) from an SSP was 19 percent higher than among people living within one mile. Unfortunately, SSP access is difficult for many Americans who use drugs. One study found that 80 percent of 18-29 year olds with HCV lived far from an SSP and more than 2200 additional SSPs would be needed to provide uniform access.

SSPs offer more services than just syringe exchange—they often also offer supportive services, connection to treatment, and importantly testing for infectious diseases. Testing this population is so important that the American Association for the Study of Liver Disease and the Infectious Diseases Society of America recommend that SSPs and substance use treatment programs offer routine, opt-out, HCV screening to their participants and link those who test positive to treatment. Overall, according to one estimate, the United States will not eliminate HCV until 2050 without increasing harm reduction services, HCV testing, and treatment rates. Not only will this prolong individual suffering, it will cost the health system $49.2 billion over 10 years.

One hesitation about treating people with HCV, especially those who continue engaging in activities that carry a high risk of infection, is reinfection. Although a HCV infection can occur multiple times, evidence shows that about 80 percent of PWID who become reinfected do not progress to chronic HCV. Interestingly, a paper that analyzed results from 38 HCV studies, found that reinfection rates were lowest among PWID and about 2.5 times higher among men who have sex with men and people in custodial settings, with both groups experiencing higher than expected rates of HCV. Regardless, the risk of reinfection highlights the need for frequent testing for members of at-risk populations. Reinfection risk should not be a reason for withholding treatment.

Micro-Elimination Programs

One strategy for decreasing HCV rates is starting with micro-elimination in specific populations. The benefits of this strategy is that it can seem more attainable and successful implementation can build political will to expand HCV elimination programs. In 2014, the Department of Veterans Affairs (VA) set out to cure the roughly 170,000 veterans with chronic HCV under their care. The program, which enjoyed the support of Congress and other stakeholders, treated 116,000 veterans by March of 2019. This success was possible because of the VA’s robust HCV surveillance systems, theory-based implementation strategies, and an approach that allowed for rapid clinical system redesign and innovation. This example demonstrates how government-funded systems can adapt and reach more individuals with HCV.

Some states have also introduced HCV micro-elimination plans. Louisiana and Washington entered flat-rate, “subscription” arrangements with different pharmaceutical manufacturers in July 2019. Although neither program has been evaluated yet, there is preliminary data. In Louisiana, the state paid a set amount annually for five years, no matter how much HCV medication it used. Louisiana estimated that at least 40,000 residents had HCV. As of May 31, 2024, 16,345 residents who were insured through Medicaid or were confined to the state correctional system were treated. In its first quarter, the program treated 5.5 times more people than in the previous quarter. Washington’s “Hep C Free” initiative aims to eliminate HCV by 2030. Washington’s program has not released data beyond the beginning of 2022, but from the agreement’s start to 2022, the state treated 5,403 people. In both cases, decreased health care utilization during the COVID-19 pandemic likely negatively affected the programs’ implementation.

Conclusion

HCV can result in considerable costs to health systems and individual wellbeing. Fortunately, HCV testing and treatment have become much less complex and costly, making eliminating HCV an attainable goal. Success stories offer real-world evidence of this possibility and provide blueprints for elimination in other systems with high rates of HCV. Although free-market forces have decreased treatment costs, there are enough people with HCV who use publicly funded health care systems that states can explore pursuing flat-rate arrangements with manufacturers to decrease costs more. Combining increased treatment opportunities with prevention strategies offers governments the best chance of controlling HCV in their jurisdictions. HCV is a conquerable infectious disease if health systems commit to elimination efforts.