For months, community advocates have been battling state Medicaid requirements for hepatitis C treatment. Many state Medicaid programs invoke stringent restrictions, often requiring evidence of severe fibrosis or drug and alcohol abstinence for extended periods of time.
A recent article from Philadelphia painted a picture of the crisis:
“Drugs are so expensive that state Medicaid contractors have felt forced to gamble. They bet that a patient’s’ disease will progress slowly. They wager that pharmaceutical companies will gradually lower prices in the face of competition. They take a chance that people with hepatitis C will not infect others.”
Taking that chance is dicey, as an estimated 80% of new HCV infections occur among people who inject drugs (PWID). Researchers have estimated that transmission of hepatitis C through sharing drug equipment is ten times more efficient than that of HIV and, unfortunately, very common. With the onset of new direct-acting antiviral (DAA) treatment, many believed the end of HCV was in sight. However, treatment of active drug users has remained unacceptably low for a constellation of reasons.
At the systemic level, the infrastructure involved in the HCV cascade of care remains woefully deficient, with programs struggling to establish protocol for assessment, linkage to care, and treatment. At the practitioner level, perceptions about poor adherence, substance use, and potential reinfection have been used as reasons for withholding therapy.
With these barriers in place, it seems insurmountable to achieve HCV elimination, which was deemed feasible in the U.S., without widespread treatment of active drug users. A recent study cautions that the impact of continued Medicaid restrictions would increase costs for ill patients and delay elimination efforts.
However, a model exists that focuses on the nature of infectious disease transmission to bolster the argument for treating drug users: treatment as prevention.
Treatment as prevention acknowledges that people living with an infectious disease have the potential to transmit that disease to others. To prevent other infections from occurring, they focus treatment efforts on those most affected to protect the greater community from exposure.
Many researchers have taken to mathematical modeling to understand the impact treatment as prevention for active drug users with new DAAs. These arguments provide a compelling case for the efficacy of HCV treatment as prevention.
Intense scale-up of DAA treatment will be easier to implement and have greater impact than interferon, as the all-oral medications require shorter treatment duration and less complex monitoring. A 2016 study found that treating drug users with moderate fibrosis had the greatest impact on reducing HCV mortality and burden of end-stage liver disease. A 2015 study urged treatment as prevention could further decrease the impact of the HCV epidemic, and warned that without proper HCV treatment and scale-up, the disease could remain a substantial public health threat for many years.
Interestingly enough, the research does not suggest a massive scale-up of treating drug users in absentia of other programs. Most studies clearly advocate for a comprehensive approach to create an effective HCV cascade of care. Alone, harm reduction methods such as opioid substitution therapy (OST) and syringe service programs (SSPs) are necessary but insufficient to fully eliminate HCV among drug users.
Instead, researchers advocate for a combination of services—such as increased access to HCV testing, highly effective treatment, and harm-reduction programs—working in concert to decrease the burden of HCV in drug users.
As we consider the toll HCV takes on drug users in our communities, we must be proactive in our treatment access efforts. As the opioid epidemic facilitates continued hepatitis B and C infections, we must advocate for aggressive treatment as prevention efforts to achieve elimination.
NVHR believes everyone deserves access to curative hepatitis C treatment. One of our current efforts we are proud to announce is the launch of our new Hepatitis C Treatment Access Page!
This page contains extensive information for patients, providers, and advocates seeking resources for hepatitis C treatment access. We hope you will use this compilation of template letters, news articles, research, and resources to ensure that everyone who desires a cure for their hepatitis C has access to it.
These resources are also an excellent tool to argue for treatment as prevention. We hope they are of use to you!
Emily Stets is the Program and Policy Associate at the National Viral Hepatitis Roundtable (NVHR), a national coalition dedicated to ending the hepatitis B and C epidemics in the United States.