Barriers to Treatment of Hepatitis C Virus in the Direct-Acting Antiviral Era
Purpose of review
Hepatitis C Virus (HCV) is a major public health problem in the USA, accounting for more deaths than any other infectious disease. New infections have been on the rise in recent years because of increased parenteral transmission related to injection drug use and the opioid epidemic. Curative treatment for HCV is now available; however, many barriers to treatment still exist.
Direct-acting antiviral (DAA) treatments have been available since 2011 in combination with interferon, and since 2014, as part of interferon-free regimens, and have greatly improved both safety and efficacy and made the prospects of HCV elimination possible. However, due to the initially high cost of these medications, factors related to younger individuals infected through injection drug use, and concerns about adherence and reinfection, access to treatment has been limited. Recent studies have documented barriers along the care continuum and have attempted to address these barriers to make treatment more widely available.
HCV is a curable infection, and an opportunity exists to dramatically reduce the spread and consequences of this chronic infection with highly effective and well-tolerated treatment. Systemic, provider-related, and patient-related barriers have been identified; however, increased education, policy and advocacy, and innovative models of care may address these barriers. Expansion of HCV treatment efforts will need to be sensitive to these barriers.
KeywordsHepatitis C (HCV) People who Inject Drugs (PWID) Barriers Direct Acting Antivirals (DAA)
Compliance with Ethical Standards
Conflict of Interest
Dr. Frenette reports personal fees from Gilead, personal fees from Abbvie, personal fees from Merck, personal fees from Bristol Meyers Squibb, outside the submitted work.
Dr. Ramers reports grants and personal fees from Gilead Sciences, personal fees from AbbVie, personal fees from Merck, outside the submitted work.
Dr. Liu declares that she has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as:• Of importance •• Of major importance
- 1.American Association for the Study of Liver Diseases and Infectious Diseases Society of America. HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. Retrieved February 4, 2019. 2017, from https://www.hcvguidelines.org/evaluate/when-whom
- 2.Arnold R, Manchover H, Wall M, Ahmadizadeh I, Potts W, Himelhoch S. “Why Me?” Understanding the HCV care continuum among people with serious mental illness. Psychiatr Serv. 2018. https://doi.org/10.1176/appi.ps.201700542.
- 6.Bamvita JM, Roy E, Zang G, Jutras-Aswad D, Artenie AA, Levesque A, et al. Portraying persons who inject drugs recently infected with hepatitis C accessing antiviral treatment: a cluster analysis. Hepat Res Treat. 2014;631:481.Google Scholar
- 9.Centers for Disease Control. Retrieved February 4, 2019, from Surveillance for Viral Hepatitis - United States. 2016 https://www.cdc.gov/hepatitis/statistics/2016surveillance/commentary.htm
- 11.Feller SC. Barriers to care identified by patients in opioid substitution clinics and needle exchange programs. In: The Liver Meeting. Abstract 274. Washington DC: The American Association for the Study of the Liver; 2013.Google Scholar
- 13.Grebeley J, Litwin AH, Dalvard O, Gane EJ, Shibolet O, Conway B, et al. Hepatitis C virus reinfection and injecting risk behavior following elbasvir/grazoprevir treatment in participants on opiate agonist therapy: C-EDGE CO-STAR Part B. In: The Liver Meeting. San Francisco, CA: American Association for the Study of Liver Diseases; 2018.Google Scholar
- 15.•Hajarizadeh B, Cunningham EB, Reid H, Law M, Dore GJ, Grebeley J. Direct-acting antiviral treatment for Hepatitis C among people use or inject drugs: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2018;3(11):754–67. This Meta-Analysis provides a snapshot of the current literature on DAA treatment of Hepatitis C in people who use drugs, showing favorable adherence and efficacy figures.Google Scholar
- 17.••Harvard Center for Health Law & Policy Innovation. Retrieved February 4, 2019, from HCV State of Medicaid, 2018. Access: https://www.chlpi.org/wp-content/uploads/2013/12/HCV-State-of-Medicaid-Access-Update-11-8-18.pdf. This resource compiles and frequently updates a state-by-state list of sobriety, provider-type, and fibrosis restr ictions in Medicaid programs.
- 20.Jezequel C, Bardot-Jacquet E, Desille Y, Renard I, Laine F, Lelan C et al. Survival of patients infected by chronic hepatitis C and F0-F1 fibrosis at baseline and after a 15 year follow-up. 50th Annual Meeting of the European Association of the Study of the Liver. 2015; p. S589. Vienna, Austria.Google Scholar
- 22.Kapadia S, Johnston C, Marks K, Shackman B, Martin E. Strategies for improving hepatitis C treatment access in the United States: State officials address high drug prices, stigma, and building treatmetn capacity. J Public Health Manag Pract. 2018. https://doi.org/10.1097/PHH0000000000000829.
- 27.•Ly KN, Hughes EM, Jiles RB, Holmberg SD. Rising Mortality Associated With Hepatitis C Virus in the United States 2003–2013. Clin Infect Dis. 2016;62(10):1287–8. This manuscript describes the surprisingly high rates of Hepatitis Cassociated mortality, particularly compared to HIV, a disease with better funding of research and control efforts.Google Scholar
- 29.••National Academies of Sciences, Engineering, and Medicine. A National Strategy for the Elimination of Hepatitis B and C. Washington DC: The National Academies Press; 2017. This is our National Strategy for elimination of Hepatitis B and C in the United States. Commissioned by the National Viral Hepatitis Round Table and carried out by the National Academies of Sciences, Engineering and Medicine, the report outlines key interventions that will be necessary to eliminate both of these devastating chronic infectious diseases.Google Scholar
- 34.US Department of Health and Human Services. US National Viral Hepatitis Action Plan for 2017–2020. 2017Google Scholar
- 35.van der Meer AJ. Achieving Sustained Virological Response: what’s the impact on further Hepatitis C-related disease? Expert Rev Gastroenterol Hepatol. 2015, May;9(5):559–66.Google Scholar
- 37.World Health Organization. Global Hepatitis Report 2017. Geneva: World Health Organization; 2017.Google Scholar
- 38.•Yehia BR, Schranz AJ, Umscheid CA, Lo Re V III. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9(7):e101554. This manuscript provides a comprehensive view of the Hepatitis C testing and treatment cascade at a moment just prior to the introduction of the DAA's into clinical practice.Google Scholar