Meeting the World Health Organization’s (WHO) ambitious HCV elimination targets requires more emphasis on marginalized patients, including patients who inject drugs (PWID) and patients in correctional facilities.
Jason Grebely, BSc, PhD, Associate Professor, Kirby Institute, UNSW Sydney, Australia, and Anne Spaulding, MD, MPH, Associate Professor in the Department of Epidemiology at Emory University Rollins School of Public Health, talked about these groups during Friday morning’s “Navigating the Road to Elimination of HCV in the US” SIG programing.
WHO set a 2030 target of having 90% of those infected with HCV is diagnosed, and 80% of those diagnosed treated, but testing and linkage to care remain inadequate. Dr. Grebely pointed to a study that found a 78% gap between the diagnosis goal and current number of people diagnosed and 98% gap between the treatment goal and actually started on treatment.
People with recent injected drug use, roughly defined as injection within a year, represent about 8-9% of all HCV infections. Four countries — Brazil, China, Russia and the United States — account for more than half of all HCV infections among recent PWIDs. In the United States, about 30% of all infections occur among people with recent injected drug use.
“I think it’s going to be impossible to treat our way out of the HCV epidemic,” Dr. Grebely said. “We will need HCV treatment coupled with harm-reduction programs in order to get a bigger bang for our buck.”
Dr. Grebely cited studies showing that opioid agonist therapy (OAT) and needle and syringe programs (NSPs) reduce the risk of infection by 71%. The key is making sure PWIDs have access to these programs. OATs and NSPs remain inadequate around the world and will require the determination to make policy changes.
Dr. Grebely noted that the current momentum around the drive to eliminate HCV could help spearhead some of the needed policy changes. He also described specific ways hepatologists could help lead the way to eliminate HCV in PWIDs in their own regions, including:
- Encourage partnerships and develop PWID-accessible models of care.
- Implement novel strategies such as on-site and point-of-care testing.
- Advocate for removing restrictions for HCV therapy reimbursement based on fibrosis stage and drug/alcohol use.
- Help educate general practitioners and drug and alcohol care providers about HCV testing and management.
- Push for more harm reduction services.Call for removal of laws restricting NSP access and barriers to OAT provision.
Correctional facilities offer another important avenue to eliminating HCV. Nearly a third of Americans with HCV spend at least part of the year in either a jail or prison, Dr. Spaulding said.
While prison populations remain stable, with most of those incarcerated staying for more than a year, jails have a much higher “churn” factor, Dr. Spaulding said, with more people coming in and out. Many of these people are missed by any household surveys for HCV and without testing and treatment make eliminating HCV almost impossible.
Unless the jail and prison populations are properly accounted for, there can’t be an accurate picture of HCV in the United States. To help determine the true burden, the Emory Center for the Health of Incarcerated Persons and MGH Institute for Technology Assessment launched on Friday hepcorrections.org, a website designed to offer the most accurate estimates of HCV prevalence, treatment and screening at intake among people serving time in state prisons.
“In a perfect world, everybody should be treated,” Dr. Spaulding said. “However, with limited funds, we are only treating a small portion of those who are infected and we’re trying to play catch-up.”