The Fight isn't Over Yet: Confronting Barriers to Hepatitis C Elimination
By Nathan Pilkey
This post is part of a series in diverse mediums focusing on the theme “How do we envision equity in global health?”. These submissions are by McGill students who were part of the course, Fundamentals of Global Health, in Fall 2023.
In 2014, the world experienced one of the most foremost advances in medical technology – the development of highly effective direct acting antiviral (DAA) medications for hepatitis C virus (HCV). (1) HCV is one of the most prevalent viral diseases worldwide, and at the time was estimated to infect over 160 million people globally. (2, 3) Prior to the development of DAAs, conventional treatment modalities had limited effectiveness, with drastic and debilitating side effects. In contrast to this, DAAs are highly efficacious, with minimal side effects. The introduction of DAAs has significantly reduced the disease burden of HCV globally, and it is currently is estimated to infect 71 million people worldwide. (2) However, these reductions have not been equitably distributed. A plethora of factors including astronomical cost of treatment, lack of testing, and systemic stigmatization of affected groups has contributed to disease persistence. (3, 4) This piece seeks to summarize the inequities of HCV disease burden and prognosis and proposes three solutions to move forwards in achieving HCV elimination.
HCV is a bloodborne infection and causes chronic viral hepatitis in 85% of infected individuals. HCV infections are present on every inhabited continent, with the greatest disease burden in Northern Africa and Asia. (5) The World Health Organization (WHO) estimates that there are approximately 1.75 million new cases each year. (2) Following the introduction of DAAs, global prevalence has declined to an estimated 71 million chronically infected individuals, nonetheless the WHO estimates that HCV killed 400,000 people in 2019. (2) Chronic infection with HCV leads to liver fibrosis, hepatocellular carcinoma, and liver failure. HCV is the leading cause of liver transplantation worldwide, and in the United States alone was estimated to have an economic impact of 184 billion dollars from 2011-19. (6) Viral transmission is associated with blood transfusions, injection drug use, and high-risk sexual activities.(5) In 2016 the WHO published their first strategy on viral hepatitis, which aimed to eliminate the disease by 2030. (7)
One of the primary barriers to treatment and subsequent HCV elimination is lack of access to testing and minimal public knowledge of the disease. Due to the ‘silent’ nature of HCV infection, which can take up to 20 years for symptoms to occur, it is not commonly recognized by the public as being a disease of concern. In the United States, it is estimated that only 50% of infected individuals are aware of their infection. Of this diagnosed population, only a third have received antiviral intervention. (8) In addition to this, despite being a sexually transmitted infection (STI), HCV is not part of general STI testing panels. Thus, to qualify for HCV testing, specialist care is required, at which point patients are usually presenting with symptoms, and the infection has progressed significantly. Furthermore, many of the groups at high risk of infection, such as intravenous drug users are ostracized by local healthcare systems, further perpetuating the cycle of infection.(9) This lack of testing options, and knowledge of infection prevents people from accessing treatment, and making informed decisions to reduce further disease transmission.
Even once patients have identified they are HCV positive, access to medicines and DAAs to manage infection is another significant hurdle in the path to treatment. A single course of daclatasvir, one of the most efficacious HCV DAAs on the market can cost up to 80,000 CAD, making it a significant barrier to equitable access to treatment. (1, 10) These inequities are not only limited to countries who can afford the astronomical prices of HCV therapeutics, but also other socioeconomically challenged groups in high income countries (HICs). In addition to economic barriers to access, when DAA treatment is covered by government policy, there are stringent requirements and hoops to jump through to actually receive medications. For example, in Ontario, to receive DAAs under the Ontario Drug Benefit, individuals must present two HCV RNA positive tests at least six months apart to prove chronic infection. (4) These initial six months can be crucial for timely pharmaceutical intervention before fibrosis and other pathologies can develop.
In 2016 the WHO set the first goal for the elimination of viral hepatitis by 2030. While many countries are not currently on track to meet this goal, there are some glimmers of hope for eliminating this deadly disease. (2) Globally, incidence of HCV has declined since the program began, and with continued efforts and funding, global HCV elimination can be achieved. Herein, I propose the following measures for the equitable elimination of HCV.
Increased Access to Testing: To eliminate a disease, we must know where it is. Expanding testing capacity and capabilities globally will allow for detection of the virus before presentation of symptoms and subsequent liver damage. Additionally, knowledge of HCV positive status can inform changes to prevent transmitting the disease to others in the community. I also propose the inclusion of HCV in standard STI testing panels. The introduction of these suggestions will identify infected individuals, reduce disease transmission, inform epidemiological interventions, and increase public awareness of the disease.
Safe Needle Exchange Programs: Globally intravenous drug use is the leading cause of new HCV infections, and accounts for 60% of new infections. (2) The majority of these infections are due to the use of unsafe, and contaminated needles. Access to safe injection sites, sterilized syringes, and syringe exchange programs has been shown to significantly reduce the burden of disease in these populations. Safe injection programs have been shown to reduce the spread of other bloodborne infections, and implementation of these programs globally will help to significantly reduce the spread of HCV. (11) Additionally, the destigmatization of injection drug use associated with these programs could help to remove stigma and discrimination for injection drug users to seek medical care.
Universal Healthcare Coverage: The final recommendation for the elimination of HCV is the implementation of universal healthcare (UHC) policies. Adoption of UHC, as outlined by the Sustainable Development Goal 3.8 would allow for fair, equitable, and global access to DAA medication. Additionally, these programs would serve to increase testing and disease surveillance, allowing for more timely intervention, and a more holistic understanding of disease burden and incidence.
In summary, while HCV does cause debilitating disease, the development of novel DAAs has enabled a sustained virological response in upwards of 95% of patients. (1) The introduction of these drugs to the market have revolutionized the outlook for HCV patients. However, due to many systematic and economic factors, global access to these treatments remains limited, with rich HICs representing the majority of patients receiving antiviral treatment. I propose increased access to testing, safe intravenous drug use sites and paraphernalia, and universal health care to reduce the incidence, prevalence, and disease burden of HCV in a global and equitable manner.
References
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11. Hagan H, Jarlais DC, Friedman SR, Purchase D, Alter MJ. Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma syringe exchange program. American Journal of Public Health. 1995;85(11):1531-7.