CDC report highlights the gaps in care of hepatitis C treatment

By Dr. Liji Thomas, MDAug 3 2023Reviewed by Benedette Cuffari, M.Sc.

Hepatitis C virus (HCV) infection affected about 2.4 adult Americans between 2013 and 2016. Without treatment, HCV infection can become chronic and cause progressive liver damage, liver cancer, and death.

Study: Hepatitis C virus clearance cascade — United States, 2013–2022. Image Credit: Jarun Ontakrai / Shutterstock.com

Introduction

The U.S. has its own Viral Hepatitis National Strategic Plan, in which 80% or more of patients with HCV should be cleared of the infection by 2030.

At present, infected patients are treated for eight to 12 weeks with highly effective oral directly acting antivirals (DAA). This regimen should result in viral clearance in 95% of patients; however, periodic monitoring is needed to assess the rate of progress toward this goal.

The HCV clearance cascade refers to the stepwise movement of the infected person who is first diagnosed with HCV, cleared of the virus, and, in some cases, reinfected. The U.S. Centers for Disease Control and Prevention (CDC) has recently developed a five-step cascade, which refers to the progress of any given individual through the process of testing for the virus through viral clearance to reinfection or persistence.

These five steps were identified based on the long-term follow-up of all HCV-positive patients using laboratory data from a single national laboratory over the past decade. Without a proper understanding of how these are being achieved, the HCV elimination strategy cannot be assessed for its efficiency and effectiveness.

Characterizing the HCV clearance cascade is critical for monitoring progress toward national elimination goals, identifying gaps in care and program effectiveness, and prioritizing public health resource allocations.”

The current study published in the CDC's Morbidity and Mortality Weekly Report analyzes the HCV clearance cascade using national testing data between 2013 to 2022. All cases that have been identified at this commercial laboratory since the introduction of DAA for HCV were included in the analysis.

What did the study show?

Of about 1.7 million individuals tested for HCV infection during the period following the introduction of DAA, almost 90% were tested for viral ribonucleic acid (RNA). Viral testing identified about 70% of tested individuals as positive for HCV. About 63% of tests were positive among individuals with commercial insurance as compared to over 80% with unspecified insurance.

The highest infection rates were observed in individuals between 40 and 59 years of age at 43%, with lower rates between 27-29% observed among adults younger or older than this group. About half of the infected individuals were on commercial health insurance, with 25% on other forms of healthcare coverage. About 10% each were on Medicaid and unspecified payor, while 8% were covered by Medicare.

While those on Medicare or commercial insurance achieved 40-45% clearance rates, these rates dropped to 23-31% among people on other Medicaid or unknown payors.

The lowest proportion of cured or cleared, across all age groups, was among those with other payor. The highest proportion of cured or cleared among all age groups and payors was 49% for commercially insured persons aged ≥60 years.”

With half of the individuals with unknown payors being cured of infection, one in ten younger adults between 20 and 39 years of age were likely to be diagnosed with reinfection or persistent infection.

In individuals between 20 to 39 years of age, the rate was as low as one in six among those who have client or self-pay insurance plans. The highest clearance in this payor group of 23% was significantly less than the 29-33% clearance for those on Medicare or commercial payors. This group also had a higher risk of reinfection or persistent infection at 9% as compared to the 7% overall risk.

Even among those who were cleared, 7% of these individuals subsequently exhibited evidence of viremia due to either persistent infection or reinfection. Persistent infection or reinfection denotes the detection of HCV RNA following viral clearance on follow-up.

What are the implications?

These findings reveal substantial missed opportunities to diagnose, treat, and prevent hepatitis C in the United States.”

In the absence of such measures, HCV-infected individuals are likely to develop progressive disease and transmit the virus to others.

This simplified national HCV clearance cascade identifies substantial gaps in cure nearly a decade since [DAA] became available and will facilitate the process of monitoring progress toward national elimination goals.”

These types of analyses allow public health officials to monitor the execution of national strategies for HCV elimination, including universal viral RNA testing, treatment for all, irrespective of insurance type, and risk-based preventive interventions.