Hepatitis C and the Growing Public Health Concern

The Prospects for Hepatitis C Control and the Challenges of Health Care Reform

The U.S. Centers for Disease Control and Prevention (CDC) estimates that between 2.7 and 3.9 million Americans are living with chronic hepatitis C viral infection (HCV) and the incidences of expected new cases could overburden an unprepared health system, creating a serious public health concern. It is the most widespread blood borne infection in the country, but it need not remain so due to advances in screening and early treatment. However, contradictions between the recommendations of professional organizations and Medicaid reimbursement practices in most states make it difficult for individuals with HCV to access treatment.

At the 2014 US Conference on AIDS, the Department of Health and Human Services's Corinna Dan noted that our prospects in the fight against HCV have vastly improved due to "the confluence of updated viral hepatitis screening recommendations, advances in hepatitis C treatment, new opportunities for viral hepatitis services afforded by the Affordable Care Act (ACA), and growing awareness among both healthcare providers and the public about the scope of the impact of viral hepatitis in the U.S."[1]

New treatments for HCV have reduced detrimental side effects and the length of treatment; among them, sofosbuvir can achieve a cure for HCV in up to 90% of those who take it over a course of a treatment regimen that may be as short as 12 weeks. Combining HCV screening with other primary and preventive services, such as HIV screening, increases the availability of testing while social marketing can increase public awareness of the virus. Implementation of the Affordable Care Act and other aspects of current health care reform could greatly improve access for HCV treatment as well as improve adherence and treatment completion rates. However, in spite of the increased access to health care under the ACA and significant outcomes of early treatment, not all states reimburse sofosbuvir treatment for HCV under their Medicaid programs. Of the 42 that do, 74% (31 states) limit treatment to those with advanced stage liver disease (advanced fibrosis or cirrhosis), which, according to the study's authors, may violate federal Medicaid law.[2] As health care reform continues, providers and advocates will need to develop a persuasive body of empirical evidence on the benefits of aggressive and early HCV treatment.

Addressing HCV could improve other critical public health issues associated with the vulnerable HCV population. HCV is associated with several behavioral and emotional risks, including alcohol and substance use, depression and stigma (especially internalized and socialized anti-gay stigma and homophobia). The CDC's surveillance of HIV/HCV coinfection indicates that approximately 25% of all persons infected with HIV are also infected with HCV; and, HIV/HCV coinfection is estimated to be between 50% and 90% among HIV-infected injection drug users.

Community-based organizations, health centers, and behavioral health providers all have important roles to play in the fight against HCV, and there are tools to help us with this public health mission. 

To track change and understand the epidemiology of HCV, the CDC relies upon reporting of new cases from the field and provides state-by-state guidance on reporting requirements for viral hepatitis (A, B, and C).  A booklet and electronic resource of HCV treatment guidelines is published jointly by the American Association for The Study of Liver Diseases, the Infectious Diseases Society of America, and the International Antiviral Society. It is updated regularly to reflect fast changes in the field and provides a summary of evidence, recommendations for testing and linkage to care, guidelines on when and in whom to initiate HCV therapy, an overview of cost and reimbursement for HCV treatment, a clinical management tool for acute HCV infection, and important resources. The report's key recommendations include making HCV widely available and targeted based on population risk, and that "treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies owing to comorbid conditions." These guidelines and other sources provide an excellent start for advocacy on HCV treatment reimbursement and addressing the public health challenge.

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[1] Corinna Dan, "USCA 2014: Viral Hepatitis in the Spotlight for the First Time," AIDS.gov Blog, October 6, 2014, at https://blog.aids.gov/2014/10/usca-2014-viral-hepatitis-in-the-spotlight-for-the-first-time.html, accessed September 15, 2015.

[2] Barua S, Greenwald R, Grebely J, Dore GJ, Swan T, Taylor LE, Restrictions for Medicaid Reimbursement of Sofosbuvir for the Treatment of Hepatitis C Virus Infection in the United States, Ann Intern Med 2015;163(3):215-223.