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Paving the Way to HCV Elimination

Oluwaseun Falade-Nwulia, MBBS, MPH

Associate Professor
Division of Infectious Diseases
Johns Hopkins University School of Medicine
Division of Infectious Diseases
Johns Hopkins Hospital
Baltimore, Maryland

Oluwaseun Falade-Nwulia, MBBS, MPH, has no relevant conflicts of interest to report.

View ClinicalThoughts from this Author

Released: October 14, 2019

The WHO has called for elimination of hepatitis C as a public health challenge by Year 2030. Milestones to achieving this goal include diagnosing HCV in 90% of people with the infection and treating HCV in 80% of those eligible for treatment.

Despite the availability of effective HCV therapies with cure rates of more than 95%—and the added benefit of disrupting HCV transmission—HCV treatment rates are significantly lower than those required for HCV elimination.

How do we change the tide and begin to make some progress toward HCV elimination? Here is a summary of some of the points I will discuss at a symposium in Boston on November 11.

People who inject drugs (PWID) represent a key population with the potential to sustain the HCV epidemic through continued transmission and, thus, should be targeted for HCV treatment. Several studies have shown the effectiveness of HCV therapies regardless of substance use status. However, multilevel barriers to HCV linkage persist for PWID:

  • At the patient level, misinformation about HCV and its treatment and the stigma related to substance use and HCV infection hinder linkage to care and limit patient interactions with the healthcare system
  • At the provider level, misguided concerns about reinfection risk and adherence to HCV therapies
  • At the system level, limited HCV treatment sites and restrictions on access to HCV therapy

Patient-Level Pathways
At the patient level, innovative strategies are needed to increase engagement in care for PWID. Patient navigation programs guide patients through the care continuum and can include insurance assessment, counseling, and enrollment assistance and facilitation of primary care provider acquisition, visits with the primary care provider, and appointments with specialists.

These programs have been shown to have a positive impact on HCV treatment uptake. Peer support by others who have experienced substance use may be particularly effective at linking and supporting PWID through HCV treatment. Other strategies involve HCV testing and linkage to HCV treatment in settings where PWID feel comfortable, potentially including sites where they currently access other services.

Provider-Level Pathways
For many cases, trained nonspecialists can independently provide HCV treatment. For the more complex cases, nonspecialists in community-based settings may benefit from specialist support, either through partnerships for discussion and referral or ongoing collaboration using telemedicine platforms such as the ECHO Model.

It is critical to integrate harm reduction such as access to syringe programs and opioid agonist treatment—interventions with proven effectiveness to reduce HCV infection and reinfection—into HCV care.

System-Level Pathways
Given the proven success of nonspecialist treatment of HCV, colocalized care that integrates HCV treatment into substance use disorder treatment programs, public health clinics, syringe service programs, community-based organizations, and other sites providing services to PWID has the additional benefit of reducing barriers to HCV treatment.

Innovative payment models at the system level may also improve treatment uptake. These can include public–private partnerships, such as the model recently implemented in Louisiana and Washington in which the states pay a flat fee for unlimited drugs to treat people who are in prison and Medicaid patients. Models such as these ensure access to HCV treatment for vulnerable populations.

Treating HCV by Treating Opioid Use Disorder
Taking a different approach, the path to engaging PWID with HCV may be through the Drug Addiction Treatment Act of 2000 and the Comprehensive Addiction and Recovery Act of 2016, which permit individual healthcare providers to receive a waiver to provide office-based treatment for opioid use disorders with buprenorphine.

Buprenorphine for treatment of opioid use disorders in primary care and nonaddiction care settings has been proven to be effective in reducing opioid use, reducing all-cause mortality, and increasing HCV treatment engagement in PWID. Therefore, for patients linking to care at HCV treatment sites, simultaneous buprenorphine and HCV treatment prescriptions with subsequent linkage to care in the community for ongoing substance use disorder treatment may improve HCV care outcomes.

Every step of the HCV care pathway requires optimization, especially for populations likely to sustain the HCV epidemic through ongoing transmission. It will take all of us—individuals infected with HCV and their peers and support systems, medical care providers across different settings, researchers, public health practitioners, the judicial system, and the government—to develop and implement the innovative solutions required to pave the way to HCV elimination.

Your Thoughts?
Which aspects of HCV care do you think are critical to reach our goal of HCV elimination? Please tell us your thoughts in the comment box below. Then, please join me and my colleagues, Paul Y. Kwo, MD, and Manal F. Abdelmalek MD, MPH, for a CME/MOC-certified symposium in Boston on November 11, where we will discuss these and other topics related to advances in liver health. If you can’t be there in person, you can register to attend a live simulcast from your home or office.

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