Estimating the Year Each State in the United States Will Achieve the World Health Organization’s Elimination Targets for Hepatitis C

Our study, which assessed the progress and timeline for US states to achieve the 2030 WHO HCV elimination targets, suggests that the USA is not on track to meet these targets, as it is projected to achieve HCV elimination by 2037. Our analysis of states that are not projected to meet elimination targets allows for modifications in screening, assessment, and linkage to care. Comprehensive data similar to those used in this study that are regularly updated can be accessed by healthcare providers, policymakers, and payers to view the progress towards elimination in their states (accessed at MappingHepC.com) [25].

In a previous study that utilized similar methodologies and models to project the year of elimination, the estimated year of elimination in the USA was beyond 2050 [16]. The present analysis estimates an earlier year of HCV elimination based on the availability of prevalence, diagnosis, and treatment inputs from two large laboratory datasets. In contrast, the previous study was based on data derived from the Polaris Observatory, which relied on the best available published sources at the time of the study [16]. In the present study, we identified substantial differences between states for the estimated time to HCV elimination; these differences were driven by heterogeneous progress toward meeting the targets set by the WHO for HCV diagnosis, treatment, incidence, and mortality. When assessed at the state level, only 6% of states are on track to achieve overall HCV elimination by 2030 and 35% of states are not expected to meet these targets before 2040. Additionally, we estimated the overall prevalence of patients with active HCV infection (RNA+ patients) in the USA to be approximately 3,063,343, which is a higher estimate than previously reported from the NHANES data (2.3–2.4 million) [3, 26, 29]. The present study utilizes a dataset that combines two large de-identified US laboratory datasets from January 2013 through December 2017, while the NHANES data included data from 2013 to 2016 based on surveys extrapolated to the US population.

Among the individual WHO targets, the goal of reducing new incidences of HCV by 80% appears to be the most difficult to achieve. Only three states (6%) are on track to meet this goal by 2030, while 18 states (35%) are estimated to achieve this goal in 2040 or later. These data indicate that increased efforts are needed to prioritize treatment for all patients with active HCV infection, particularly those at risk of transmitting HCV to others, including those who inject drugs and prisoners [3]. Meeting the WHO treatment target by 2030 is also behind schedule in most states (69%) and the USA as a whole. The annual number needed to treat to meet the treatment target is 173,514 between 2020 and 2030. In five of eight states not projected to achieve elimination before 2050 (Hawaii, North Dakota, Rhode Island, Puerto Rico, and South Dakota), the annual number needed to treat is less than 500, suggesting the annual treatment benchmark in many of these states is low and achievable.

This study highlights the disparity between treatment targets and restrictions and offers an opportunity for states to reconsider barriers to treatment. The National Viral Hepatitis Roundtable (NVHR) report cards provide Medicaid access grades based on restrictions that still exist in each state which may be prohibitive to states meeting 2030 elimination targets [28]. Meeting the treatment target may be hampered by the persistence of treatment restrictions based on liver fibrosis severity in nine states (17%); most of these states had Medicaid access grades of C to F, apart from Maryland (B) and Montana (A−) [28]. Additional restrictions that may impact access to treatment, especially among high-risk groups, include sobriety restrictions in some states with 18 states requiring abstinence for at least 6 months, as well as limited access to healthcare and health insurance among the HCV-infected population [28]. Meeting the incidence and treatment targets will require the removal of these restrictions along with improved linkage to care efforts, especially among those with substance abuse disorders and poor social determinants of health. In support of increased screening, treatment, and improved linkage to care, the CDC, USPTF, and AASLD–IDSA have all provided updated guidance that supports universal screening recommendations. The universal screening guidelines indicate that all adults over the age of 18 years should be screened for HCV [6‐8]. Additionally, AASLD–IDSA recommends that all patients with HCV infection should be treated, regardless of sobriety [7].

In contrast, the WHO elimination targets relating to diagnosis and reduction in mortality are on track for achievement in 2030 or earlier overall in the USA as well as in at least 87% of states. The 2019 National Virus Progress Report estimates the USA has met the 2020 goal to reduce the rate of HCV-related deaths [30]. While it is hard to compare different data sources, the model projections in our study align with that report as the model estimated the USA to meet the mortality reduction target in 2020. Mortality may be the easiest metric to meet by prioritizing (through restrictions) those patients with more advanced fibrosis, in which it would be the easiest to measure a decrease in mortality. Mortality may also be reduced in those patients with more comorbid conditions that are improved by viral eradication. However, it should be noted that the reductions in mortality cannot capture all-cause mortality (i.e., extrahepatic manifestations such as type 2 diabetes, end-stage renal disease, cardiovascular disease, or malignancy) that are also drivers of mortality but are not directly linked to HCV.

There are key barriers that directly contribute to the limited progress in achieving HCV elimination targets. In particular, political will is considered crucial for providing sustained commitment and funding of HCV elimination strategies [16]. An example of a country in which political will exists is Australia, which has an estimated elimination target of 2026, which is earlier than the 2030 WHO elimination target [16]. In the USA there is growing political will as evidenced by recent universal screening guidelines issued by the CDC and USPTF [6, 8] and the CDC has designated May as Hepatitis C Awareness Month to encourage screening of high-risk populations [31]. Sustained political will and policy changes at the federal and state level as well as funding for efforts to reduce HCV incidence and prevalence are required for HCV elimination. Examples of ways the USA could increase public health infrastructure to support elimination efforts include increased federal funding of national surveillance systems, expansion of access to and funding for syringe exchange programs and opioid agonist therapy, and removal of all restrictions to HCV treatment [31]. Treatment restrictions play a role since, in an effort to limit costs, some states have restricted access to treatment based on stage of liver disease [32]. The NVHR report cards highlight the states in which there is the greatest need to reduce treatment restrictions [28]. Stigma and discrimination against people with HCV can also impact access to HCV care [15]. Some states limit access to treatment for those with a history of illicit drug use or alcohol abuse [33]. This is compounded by the high lack of awareness of HCV status among those who inject drugs and the criminalization of drug use in most states [34]. The link between substance abuse and HCV is highlighted by the sharp increase in HCV infections among subgroups of the population who abuse or inject opioids [35]. Syringe exchange programs were previously shown to reduce the rates of HCV infection in New York City [36]. Limited public health and healthcare system resources, especially from government health insurance programs (i.e., Medicare, Medicaid) for screening and diagnosis and treatment, are also a significant barrier to treatment [14, 32]. Despite these barriers, there is evidence suggesting that full access strategies result in cost-savings and are associated with a reduction in the number of patients who progress to more advanced fibrosis or cirrhosis compared with more restrictive strategies [32, 37]. The overall long-term social value generated from increasing access broadly is estimated to be substantial despite the increased short-term costs [38]. However, lifting treatment restrictions based on fibrosis staging or sobriety alone will not allow elimination targets to be met and may require improved linkage to care efforts to cure marginalized and disengaged patient populations.

There are several limitations to this analysis. First, the model assumes that every patient with HCV infection is at constant risk of transmitting HCV, even though HCV transmission patterns and risk factors may vary regionally and depend on the size of the at-risk population in each state [39]. The size of the at-risk population in each state may depend on many factors, including the number of injection drug users, incarcerated individuals, and migrants from areas of high HCV prevalence. Another limitation is that HCV prevalence data prior to 2013 were not captured in our study. Therefore, information is not available for individuals with an HCV RNA+ test prior to this date without subsequent viral load tests. The model also assumes annual rates of treatment and diagnosis remain constant in the future, which may require increased efforts in screening and linkage to care to maintain. However, increased efforts in screening and linkage to care and initiating treatment in new patients may be hampered by the recent COVID-19 global pandemic. In light of the pandemic, HCV treaters have seen a reduction in face-to-face interactions and increases in telehealth visits in the USA and many healthcare providers have seen reductions in new prescriptions, which may be due to patients’ unwillingness to initiate new therapy remotely and a lack of diagnostic testing that prevent diagnosis of new conditions, such as HCV infections [40]. It is anticipated that there may be a long-term impact of COVID-19 on healthcare provider engagement. Despite these challenges that healthcare providers face amid the COVID-19 pandemic, several major liver and hepatology societies recommend that providers should continue treatment of HCV-infected patients with COVID-19 and proceed with treatment in HCV-infected patients without COVID-19 as clinically warranted [41‐46]. Additionally, if there is an indication of a flare-up or reactivation of disease, therapy should be initiated in patients with COVID-19 and chronic HCV who are not already receiving treatment [41‐43, 45, 46]. In patients with COVID-19 and elevated serum liver levels, other etiologies such as HCV should be considered, and these patients should be screened for viral hepatitis, which may highlight a need for increased screening and diagnosis in the USA [41, 43]. Further, the model does not account for risk reduction due to harm-reduction programs or from the prioritized treatment of high-risk groups. The model also does not account for the impact of new treatment options or shortened treatment durations that may become available after 2017. Finally, as with any forecast, the model results and the estimated year of elimination provide directional guidance on potential shortfalls in efforts to achieve HCV elimination and therefore may not exactly match the future trajectories observed in the real world.