Hepatitis C Control and Elimination: What Are We Missing?

Hepatitis C (HCV) is a viral infection that, if left untreated, can slowly evolve into cirrhosis, hepatocellular carcinoma, and kidney failure, among other complications. In the last two decades, with the arrival of direct-acting antivirals (DAAs), the prognosis has been transformed, and the global community has moved closer to the goal of elimination. This is defined by the World Health Organization (WHO) as a 90% reduction in the incidence of infection, and a 65% reduction in mortality by 2030, with at least 90% of people diagnosed and treated.

However, despite these advances, other challenges persist that hinder the elimination of hepatitis C globally, and we’re still finding obstacles in population subgroups. Being able to identify them properly could advance steps towards elimination. Nevertheless, the overall burden of HCV has decreased compared to previous years, thanks to the availability, safety and tolerability of high-efficacy DAAs. However, prevalence and incidence remain uneven across regions and populations, with those populations at higher risk and with less access to diagnoses and treatments representing a significant proportion of untreated cases.

And while the elimination or effective control of HCV is feasible in clinical terms, it requires intensifying diagnosis efforts, access to treatments, and the prevention of new infections.

Challenges

Underdiagnosis remains a barrier, with up to 40% of people with HCV not knowing they’re infected. Late detection with inconsistent screening in high-risk populations, such as specific cohorts with barriers, include those who use substances, patients with comorbidities (HIV, co-infections), the elderly, and vulnerable populations. These in turn present challenges in adherence and managing comorbidities (those who use injectable substances, patients in low-cost outpatient treatments, migrants, and people in correctional systems or prisons).

The lack or limitation of robust epidemiological vigilance weakens the ability to identify outbreaks, assess the impact of interventions, and make the appropriate policy adjustments. In addition, limited access to DAAs in low- and middle-income countries, along with high costs, supply chains and health policies, can affect the availability of treatments. These factors, combined with the rules for approving processes and medications, can delay the start of treatment. Also, we cannot forget that the stigmatization and marginalization that comes with the diagnosis associated with hepatitis C can reduce the demand for tests and treatment, which in turn leads to a decrease in the prevention of new infections. In terms of public health, there’s also a need for expanded testing in high-risk settings, needle exchange programs, dependency treatments, and vaccinations for hepatitis A and B, where appropriate. Unfortunately, this is an area that has historically had limitations, given that federal funds or programs do not subsidize or endorse this practice.

On the other hand, we’re aware that in other countries, hepatitis C competes with other priorities in the public health system, especially where there are limited resources. In Puerto Rico, the reality is different, given that in our public health system, we fortunately have the resources and programs aimed at controlling and eliminating HCV, including medical plans, which collaborate to achieve this feat, we are one step away from achieving it with the necessary support and socio-political action.

So, what gaps need to be closed in order to make progress in identifying and treating HCV?

• We must expand and simplify targeted universal screening in high-risk settings, with rapid testing and immediate access to treatments within an agile framework and without administrative barriers, using the pan-genotypic treatments available to the greatest number of people in the earliest stages of the disease.
• Integrated care approaches must be implemented. This includes “attestation at the door” models and multicomponent care that combines diagnoses, treatments and the management of comorbidities in those populations at higher risk of community transmission.
• Education and stigma reduction is essential in getting people to seek those aids and resources while empowering the general community to request the relevant tests in frank discussions with their medical providers, while standardizing the training of medical and paramedical personnel in performing the necessary antibody and reflex tests (Reflex PCR Test).
• It’s important to maintain robust monitoring and surveillance in order to establish real-time data systems that allow for alerting and interpreting possible breaches and epidemic outbreaks, and directing efforts for immediate proactive interventions.

While, thanks to direct-acting pan-genotypic antivirals the elimination of hepatitis C is clinically achievable, it depends on the removal of structural barriers such as unequal access and availability, insufficient diagnoses of unconfirmed serological antibody tests, treatments, and limitations in prevention and vigilance. Integrated care approaches that combine screening, accessible treatments, patient-centered care, and health system sustainability are essential for the control and elimination of hepatitis C and to get closer to WHO’s target for 2030. Collaboration among governments, communities, NGOs and the private sector will be decisive in achieving truly effective global elimination.