Abstract
The success of direct-acting antiviral therapies for chronic hepatitis C virus (HCV) infection led the World Health Organization to set elimination targets by 2030. For the United States to achieve these benchmarks, public health responses must target high-risk populations, such as people who inject drugs (PWID), a group with high rates of HCV incidence and low rates of treatment uptake. To evaluate potential improvements in the HCV care cascade among PWID, focusing on improved testing, treatment uptake, and access to harm reduction. This decision analytic model used a differential equation-based dynamic transmission model based on data from New Hampshire, an illustrative state with a large number of PWID and limited HCV treatment infrastructure. Surveillance data through 2020 was used for model parameterization, and the final analysis was conducted in May 2021. Model forecasts of chronic HCV cases and advanced-stage HCV outcomes from 2022 to 2045. A total of 6 scenarios were tested: (1) the base case, (2) improved harm reduction, (3) improved testing, (4) improved treatment, (5) improved testing and treatment, and (6) improved testing, treatment, and harm reduction. All scenarios with improved testing, treatment uptake, and/or access to harm reduction were associated with decreases in forecasted HCV prevalence and HCV-associated mortality compared with the base case. Improving harm reduction, testing, and treatment individually were forecast to reduce prevalence of HCV in 2045 from 69.7% in the base case to 62.8%, 45.7%, and 35.5%, respectively. Combining treatment and testing improvements was associated with a 2045 prevalence of 0.3%; adding harm reduction improvements was associated with further reductions in prevalence forecasts (to 0.2%), with fewer total treatments (10 960 vs 13 219 from 2022-2045). In this modeling study, no single intervention was projected to achieve World Health Organization HCV elimination targets. Scenarios with improvements in both testing and treatment were associated with a prevalence of less than 3% by 2030 and achieved elimination targets. Adding improvements in harm reduction was associated with faster reductions in prevalence and fewer treatments.
Highlights
IntroductionAn estimated 2.4 million people in the United States live with chronic hepatitis C virus (HCV), and HCV-associated deaths are higher than the 60 reportable infectious diseases combined.[1,2] The development of direct-acting antivirals has dramatically improved our ability to treat HCV, and the World Health Organization (WHO) proposed 2030 HCV elimination targets, including an 80% reduction in new chronic infections and a 65% reduction in mortality from 2015 levels.[3]
An estimated 2.4 million people in the United States live with chronic hepatitis C virus (HCV), and HCV-associated deaths are higher than the 60 reportable infectious diseases combined.[1,2] The development of direct-acting antivirals has dramatically improved our ability to treat HCV, and the World Health Organization (WHO) proposed 2030 HCV elimination targets, including an 80% reduction in new chronic infections and a 65% reduction in mortality from 2015 levels.[3]Despite this progress, incident HCV cases continue to increase in the United States.[4]
All scenarios with improved testing, treatment uptake, and/or access to harm reduction were associated with decreases in forecasted HCV prevalence and HCV-associated mortality compared with the base case
Summary
An estimated 2.4 million people in the United States live with chronic hepatitis C virus (HCV), and HCV-associated deaths are higher than the 60 reportable infectious diseases combined.[1,2] The development of direct-acting antivirals has dramatically improved our ability to treat HCV, and the World Health Organization (WHO) proposed 2030 HCV elimination targets, including an 80% reduction in new chronic infections and a 65% reduction in mortality from 2015 levels.[3] Despite this progress, incident HCV cases continue to increase in the United States.[4] The continued spread of HCV is primarily a consequence of injection drug use; injection-related transmission is responsible for most new HCV cases.[5] to reach WHO goals, treating people who inject drugs (PWID) is a priority. Previous studies have identified barriers that PWID face in the HCV care cascade, including low screening rates, low treatment uptake, and ongoing risk of reinfection.[6,7,8,9,10] Interventions aimed at addressing these issues include improved HCV screening, improvements in keeping patients linked to care, and improved access to harm reduction services, such as syringe service programs (SSPs) and medication-assisted treatment (MAT).[11,12] These interventions are typically implemented at the state level, and state policies on HCV surveillance, Medicaid reimbursement, and access to harm reduction may affect the success of these efforts.[13,14,15]
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