Hepatitis C Virus Elimination: An Achievable Goal

Posted on February 12, 2024 by Andrew Talal

This entry is part 9 of 16 in the series Mar 2024

Louisiana and Washington, states with significant differences in sociodemographic characteristics, public health policies, and health rankings, provide models for screening, surveillance, treatment, and funding for other jurisdictions pursuing hepatitis C elimination by 2030.

Twenty-first century healthcare breakthroughs do not always reach those who need them most. That has been the case with treatment for hepatitis C virus (HCV), a leading cause of chronic liver disease, cirrhosis, and death. HCV is an infectious disease that is now almost universally curable with direct-acting antivirals taken for 2 to 3 months, but only 35% of eligible individuals received them during the first ten years they were available (2013-2023). Young people and those on Medicaid are even less likely to receive treatment for HCV.

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It is challenging to identify individuals with HCV because patients are typically asymptomatic for years and often do not receive a diagnosis until liver damage is advanced and may be irreversible. More than half of people infected with HCV are unaware of their status. The good news is that many states are developing HCV elimination programs to expand screening, surveillance, and treatment. In our paper, we highlight the first two states to initiate 5-year, funded HCV elimination programs—Louisiana and Washington (Hepatitis C Virus Elimination Programs in Louisiana and Washington: Importance of Screening and Surveillance Systems – PubMed (nih.gov).

As researchers who have observed the tremendous efficacy of direct-acting antivirals, we are confident that increased government funding for elimination programs is critical to achieving the very feasible goal of HCV elimination by 2030.

A Policy Agenda for Hepatitis C

The initial approval of combination direct-acting antivirals in 2013 made the goal of HCV elimination a real possibility. For the first time, HCV elimination is included in President Biden’s budget request to Congress. That funding would expand screening, surveillance, treatment, and awareness. However, the medication access problem persists, and with the opioid crisis, HCV incidence continues to rise.

Louisiana and Washington launched HCV elimination programs in 2019. Washington prioritized HCV elimination in response to the spike in expenditures related to HCV, while Louisiana aimed to improve poor health outcomes. Interestingly, these states fall at opposite ends of the spectrum in health rankings—Washington ranks 4^th while Louisiana ranks 39^th. Additionally, these states have significant sociodemographic, public health, and political differences. Their differing approaches to HCV elimination can be informative for other jurisdictions in the process of planning and implementing their own HCV elimination programs.

Reaching Eligible Individuals

Louisiana and Washington opted to increase Medicaid funding under the Affordable Care Act, which provided additional resources. To expand access to HCV treatment, Louisiana instituted an expenditure cap where it purchases direct-acting antivirals at a discounted rate. When the state reaches the cap, it is entitled to an unlimited quantity of direct-acting antivirals. Louisiana targeted incarcerated individuals and those on Medicaid for treatment, as these populations are highly impacted by HCV. Washington obtained approval from the federal government to negotiate a discounted rate with a manufacturer for direct-acting antivirals. When the state reaches an annual utilization threshold, prescription costs become nominal. Both states also removed prior authorization as a requirement for HCV treatment.

Improving Hepatitis C Screening and Surveillance

Louisiana focused screening and surveillance on incarcerated people and those on Medicaid, while Washington viewed HCV as a statewide issue and monitored surveillance data from an all-payer claims database. Washington initially focused on HCV care in patients who had an established relationship with a provider or were enrolled in its network of syringe services programs. However, Washington shifted its strategy to identify more patients by collaborating with the private sector. In 2023, the Centers for Medicare and Medicaid Services approved Washington’s request to amend and extend its Section 1115 Medicaid Transformation project waiver through 2028. The extension will allow Washington to implement new policies and use federal funds to improve the state’s Medicaid program.

Louisiana and Washington enhanced their surveillance infrastructures by developing task forces, upgrading health information systems, and automating reporting. Both states mandate reporting of acute and chronic HCV cases. Both states expanded screening through partnerships with the Centers for Medicare and Medicaid Services, departments of corrections, opioid treatment programs, syringe services programs, and primary care providers.

State-tailored Approaches to Hepatitis C Elimination

From 2019-2022, 5591 individuals had initiated treatment in Washington, while 1642 incarcerated individuals had initiated treatment in Louisiana. Both programs can serve as models, not only for many other jurisdictions that are pursuing HCV elimination, but also for the nascent federal elimination plan. Both states provide important lessons with Louisiana taking a targeted approach, focused on incarcerated individuals and those on Medicaid. Washington, on the other hand, took a more inclusive approach, attempting to reach and screen a much wider pool of its citizens.

It will be instructive to continue to monitor HCV elimination activities in these and other jurisdictions, as described in our paper (Hepatitis C Virus Elimination Programs in Louisiana and Washington: Importance of Screening and Surveillance Systems – PubMed (nih.gov)). Congressional approval for the much-needed HCV elimination funding that President Biden has requested, in addition to providing more funding at the state level, as Louisiana and Washington have done, will be critical to achieving HCV elimination by 2030.

Co-author Acknowledgement

We would like to acknowledge and thank our co-authors, who are from various jurisdictions and provided valuable insight and data related to hepatitis C elimination programs in the United States. Drs. Tyson, Mizroch, and McCall and Ms. Britton represented the Louisiana Department of Health, while Drs. Sullivan and Zerzan-Thul and Mss. Birch and Fliss represented the Washington State Healthcare Authority. Drs. Kapadia, Gonzalez, and Shapiro are from Weill Cornell Medicine, while Dr. Wethington is affiliated with Cornell University. Drs. Lloyd and Franco are from the University of Alabama at Birmingham. Finally, Drs. Talal and Dharia are from the University at Buffalo.

About the Author

Andrew Talal: Andrew Talal, MD, MPH, is Professor of Medicine at the University at Buffalo and is a physician-scientist, practicing hepatologist focusing on hepatitis C virus (HCV) especially among substance users. He served on the New York State HCV elimination task force and is a co-investigator on an NIH study of factors leading to HCV elimination.