- Researchers project that Canada could eliminate hepatitis C as a public health threat by 2030
- Mathematical models show that this can be achieved with high rates of diagnosis and treatment
- Study authors cautioned that a hepatitis C resurgence could occur if treatment rates decline
Exposure to hepatitis C virus (HCV) can lead to this virus infecting the liver. Chronic HCV infection causes persistent inflammation within the liver that slowly degrades this vital organ. If HCV is undiagnosed and untreated, the liver becomes chronically inflamed. In turn, chronic inflammation causes healthy liver cells to be replaced with useless scar tissue in a process called fibrosis. As the amount of scar tissue accumulates, the liver is less able to function and complications ensue, including severe fatigue, internal bleeding, serious abdominal infections, kidney injury and liver failure. The presence of scar tissue within the liver also increases the risk for liver cancer.
Treatment then and now
Treatment for chronic HCV infection used to consist of regular injections of interferon-alpha for between 24 and 48 weeks. This treatment was modestly effective at curing HCV, but it came at the cost of highly unpleasant side effects. However, over the past six years in Canada and other high-income countries, all-oral medicines gradually became available for HCV treatment. These medicines, called direct-acting antivirals (DAAs), have revolutionized HCV treatment due to their potency—with cure rates of 95% or greater. In some cases, people can be cured after eight consecutive weeks of treatment. DAAs are generally well tolerated.
Helping people get access to HCV testing and treatment
The World Health Organization (WHO) has encouraged countries to develop plans to bring about the “elimination” of HCV as a public health threat by 2030. By elimination, WHO means for countries to scale up offers of HCV testing and treatment such that the number of people newly infected each year falls drastically by 2030. Before embarking on such a program, it is helpful to develop computer simulations to explore different approaches to HCV elimination goals.
Scientists at the British Columbia Centre for Disease Control in Vancouver and at universities in Montreal, Toronto, Sydney (Australia) and Colorado (U.S.) have cooperated in an important study that sought to assess different rates of intervention in Canada’s HCV epidemic. This multinational team developed a computer simulation that found it is indeed possible to bring about the elimination of HCV in Canada by 2030. Their study provides a path for policy makers and ministries of health to move forward to help greatly reduce HCV in Canada.
However, for elimination to occur on schedule or even ahead of the 2030 deadline, sustained investment in HCV awareness, access to testing, offers of and engagement in care and treatment, and continued expansion of mental health and harm reduction services are needed.
HCV elimination
WHO encourages countries to take measurable steps toward HCV elimination. Such steps include reducing the rate of new infections each year by 80% and reducing HCV-related deaths by 65% by 2030. For this to happen, countries must understand the drivers of new cases of HCV infection and make HCV testing and treatment more accessible. If the path to elimination is successful, WHO expects that by 2030 90% of people with chronic HCV will have been diagnosed and 80% of people diagnosed will have been offered, accepted and successfully completed treatment.
The simulation
The study team used a mathematical model that had previously been validated for assessing trends in HCV infections in a large population. Canadian data were obtained from various databases and publications.
At the start of their simulation, the scientists estimated that there were about 180,000 people with chronic HCV infection and about 12,000 people have initiated treatment for this infection in Canada.
Results
The scientists found that it was possible for Canada to eliminate HCV as a public health threat by 2030. For such an outcome to occur, they estimated that each year, starting in 2018, more than 10,000 people would have to be treated for HCV.
The scientists note that maintaining a high rate of HCV testing and treatment would have a broad range of benefits to individuals with HCV as well as to society. Such benefits include a large reduction in the number of people with HCV, fewer serious complications (that require expensive medical care) and many lives saved. As there would be fewer people with HCV in the long term, there would also be fewer cases of HCV that are spread in the future.
The scientists cautioned that for these good outcomes to occur it is important to maintain momentum in the rollout of HCV testing and treatment in the coming decade.
Possible challenges
The study team acknowledged that “maintaining high treatment uptake rates [over the coming decade] to achieve HCV elimination in Canada may prove challenging.” They pointed out that in the recent past in Australia there was an initial and large increase in the number of people who were treated for HCV followed by a substantial decrease. The scientists suggested that this surge of people who sought treatment occurred because they had deferred treatment until they could access DAAs (subsidized treatment was initially heavily rationed in Australia).
If momentum in HCV testing and treatment in Canada were to falter, not only would Canada not meet HCV elimination targets by 2030, but there is the possibility of a “resurgence of HCV-associated morbidity and mortality given the persistent risk of viral transmission by individuals with viremic HCV infection.”
Securing the future
To help maintain momentum toward HCV elimination by 2030, the scientists made the following statement:
“It is important that public health policies and programs be implemented to support the testing and diagnosis of an adequate number of individuals with HCV infection to meet and exceed annual treatment targets and to keep individuals with HCV infection engaged in care and committed to disease prevention [after they have been cured].” Specifically, the scientists stated that such programs “may include initiatives to raise awareness” of the following:
- the need for HCV screening and diagnosis
- the adverse health outcomes associated with untreated HCV infection
- the availability of publicly funded HCV treatment
Awareness of the above-mentioned points needs to be done among “key at-risk groups,” the scientists stated.
The scientists also provided other suggestions to help Canada achieve the 2030 elimination goals, including the deployment of the following:
- a variety of care models and HCV testing technologies
- simplified HCV testing and treatment processes
- expansion of settings for HCV management and healthcare professionals who are trained in HCV management
- improvement of patient connections to care through the use of more accessible resources, such as peer navigators and the integration of addiction and HCV care
Limitations and future directions
All simulations have limitations and the current simulation could be refined. Nevertheless, this effort is a very good one to help maintain Canada’s momentum toward HCV elimination. Analyses in other countries have found that HCV treatment is cost effective, as it substantially reduces future costs associated with complications of HCV infection. The scientists suggested that a future project could be to estimate the costs of scaled-up HCV testing and treatment so that Canada’s provinces and territories can set budgets appropriate to ensuring HCV elimination by 2030.
Resources
Canadian trends in hepatitis C virus treatment for people co-infected with HCV and HIV – CATIE News
Progress made in the hepatitis C virus cascade of care but more work lies ahead in B.C. – CATIE News
Improved health when treatment for both hepatitis C and opioid use disorder are offered – CATIE News
Assessing the cascade of care for opioid use disorder in British Columbia – CATIE News
Trends in deaths among people with hepatitis C virus in British Columbia – CATIE News
The cascade of hepatitis C virus care in Alberta – CATIE News
–Sean R. Hosein
REFERENCE:
Binka M, Janjua NZ, Grebely J, et al. Assessment of treatment strategies to achieve hepatitis C elimination in Canada using a validated model. JAMA Network Open. 2020;3(5):e204192.