WHO Hepatitis C Elimination Goal Slipping Away

In 2016, shortly following the introduction of direct acting, curative agents, the World Health Organization set a goal of global elimination of HCV by 2030. At the time, it was an ambitious but potentially achievable goal. The WHO, much like the rest of the world, couldn’t have anticipated declaring another pandemic in 2020 and its massive disruptions to screening and care. Now, as the world trudges through limited COVID-19 vaccine access, outbreaks, and variants, public health experts are returning to familiar concerns while still wading through COVID-19 and seeing a worrying trend in the strains caused by the pandemic.

The WHO estimates about 71 million people living with HCV with about 400,000 people dying annually due to liver failure and hepatocellular carcinoma caused by the virus. Despite the WHO’s lofty 2030 goals, those numbers are growing, not decreasing. Unfortunately, that trend isn’t new.

Sarah Blach, of the CDA Foundation in Colorado, recently evaluated and updated modeling from her team’s 2017 projections under the lens of COVID-19 disruptions and the results were startling. Prior to diving into the forecasting data, it’s important to note Blach’s team found HCV screenings and treatment initiation were declining even in high income countries. Prior to COVID-19, only 5 countries out of the 110 included in the 2017 model were on track for their 2030 elimination benchmarks. The model discussion cites both the United States (with a 60% reduction in patients receiving treatment in 2019 compared to 2015) and Italy (with a 35% reduction in treatment initiation from 2018 to 2019). Blach’s modeling team provided estimations considered under a “no recovery” model, “no change scenario” relative to 2019 data (or a 1-year delay in screening and treatment uptake model), and an “escalation” model in terms of efforts to eliminate HCV – particularly among lower-middle income countries. The model found that, if the United States were to resume static screening and therapy initiation efforts at pre-pandemic levels or exceed those goals, between 10,000 and 25,000 cases of hepatocellular carcinoma would be averted from 2021-2030. Though, this model would require treating almost 250,000 people per year in order to reach the 2030 elimination goal – in context, the United States initiated treatment for just 150,000 people in 2019 (also missing the targets for the year by 10,000-20,000).

Blach’s modeling uses the United States as a frequent example because, despite being a high income country, not much in the way of incremental incident infections were expected because the United states does not largely engage in best practices related to (and some would argue “required to”) HCV eelimination (ie. fibrosis requirements related to DAA initiation, care rationing, and restrictions on treatment access for people who inject drugs. The model found under a 1-year universal delay of treatment initiation, no country would achieve HCV elimination by 2030, particularly because the year of delay in treatment initiation doesn’t stop transmission of HCV and considers many lower-middle income countries may experience additional barriers to trust and patient engagement, potentially delaying timely diagnosis for years. Limitations to the model include a universal calculation of delay and local holidays and customs may more readily adapt. The most significant limitation in the model is it does not consider the impacts of increased risk behaviors or decreased access to harm reduction programs. Blach and team use the closing moment to ask policy makers to consider the role of investigating and investing more in HCV screening and treatment efforts in order to not lose critical, fragile ground in the fight against HCV. Given a different study’s conclusions on exactly when particular states in the US might reach their elimination goals with only 3 (Connecticut, South Carolina, and Washington) making it in 2030 and several others’ efforts taking until after 2050. The same study notes, of the states with the most restrictive access to HCV care policies and lack of harm reduction infrastructure, theirs are the ones estimated to take the longest to achieve HCV elimination.

2020 did not hold all bad news for the fight against HCV though. Nature covered 3 of the most impressive study efforts in HCV, with findings presented in 2020 and 2021, which may hold some of the keys to reducing HCV-related deaths and improving other health outcome goals. Egypt’s shift from a national treatment program to a national screening program, amid the treatment program being so successful the need to identify HCV patients more readily, also modeled effective cost savings opportunities as $85 USD per patient to identify an HCV infection and $130 USD per curative course. A Scottish study found particular pharmacies were more apt to identify patients at higher risk of HCV for screening, more likely to successfully initiate treatment, more likely to maintain program of care, and more likely to achieve curative status than more traditional physicians. Lastly, a third paper found – in a limited study - prophylactic therapies could allow countries to expand organ donation access by way of making HCV positive donor material safe to provide for non-sero positive patients. As organ donations are strained, this type of progress could enhance care and outcomes among solid organ transplant recipients.

While there’s promising opportunities on the horizon, we cannot lose sight of the fact 400,000 people a year die HCV-related complications. In a year in which much the of the United States is grappling with understanding the weight of half a million deaths, the global toll of a similar number might get drowned out amid the noise of COVID. We can’t afford to leave behind these noble goals or our global partners in HCV elimination. Like with COVID (and any other infectious disease), it’s not over for any of us until it’s over for all of us. While COVID has gripped the globe and limited access to vaccines makes for a shocking headline, we’re only in the first 2 years of this disease and have made significant, even if unequal, progress. There’s a path. HCV has killed tens of millions over the last 2 decades with equally amazing tools to combat the disease. Yet and still, millions are poised to die due to inaction and lack of sustainable investments to eliminate the virus - in large part because the risks associated with HCV transmission are judged to be “moral ills”. There is no greater ill than standing idly by allowing death to rage through the most vulnerable in any society. COVID may be the mechanism for which we’re having that particular conversation on global equity in this moment and it would behoove us all to remember HCV, a treatable and curable disease, remains a threat.