This is the sixth installment in my series on progress toward the elimination of Hepatitis C infection and disease. Read more about Hepatitis C in part one, part two , part three, part four, part five, and part six.
Three years ago, Egypt and the United States had approximately the same number of people infected with chronic hepatitis C. The hepatitis C burden in Egypt was also three to four times higher per capita than in the United States. Today, the situation is very different. Egypt has been certified by the World Health Organization to be virtually free of the disease. The United States, however, still carries the same burden despite having the resources to eliminate hepatitis C (Figure 1). In the previous story, we saw how Egypt’s 100 Million Healthy Lives program achieved country wide elimination by demonstrating the will and organization to do so, as well as finding a way to cover the costs. Unfortunately, the United States seems to lack those same tenets. Recently, the current administration took a major step forward and laid out a historic $11 billion plan to eliminate hepatitis C in the United States within five years.
The $11 Billion Dollar Plan
The barriers that the United States faces to eliminate hepatitis C are comparable to the barriers that Egypt faced. The United States must also demonstrate a strong will to eliminate the disease, organize its infrastructure and resources, and find ways to lower the high costs of diagnostics and drugs. The success of Egypt’s 100 Million Healthy Lives campaign provided an excellent model for creating a hepatitis elimination plan, and in March of this year, the current administration revealed its Nation Hepatitis Elimination Program. Outlined in the government budget for fiscal year 2024, this five year and $11.3 billion plan is a declaration of the United States’ willingness to eliminate hepatitis C. It establishes a cohesive effort that brings together all facets of the healthcare delivery system including state governments, federal agencies, and community health providers.
The National Hepatitis Elimination Program plan outlines four main objectives that aim to “increase access to curative medications and expand implementation of complementary efforts such as screening, testing, and provider capacity.” These objectives are designed to tackle all three of the main elimination barriers: the will, the organization, and the cost.
Unlike Egypt, the United States doesn’t have a national health service and as a result, there isn’t a standardized protocol for surveilling, identifying, and treating hepatitis C. Even with the CDC’s universal testing guidelines, 40% of the United States’ population is unaware of their infection status until severe, often irreversible liver damage occurs. This is partially due to the lack of coordination among states. While some states may possess the will and the resources necessary to inform their populations about hepatitis C testing and treatment, others might not demonstrate the same urgency or have the resources to reach its entire population. The first tenet of this program addresses this by prioritizing finding ways to reach and engage people, especially those in marginalized communities. In addition to nationwide media campaigns, telehealth is a promising outreach tool. It allows providers to remotely reach individuals who would otherwise not have access to information about preventive measures and the importance of getting tested.
The next step of the program is to test the population. Currently, the diagnostic process for hepatitis C includes both an antibody test and a PCR test that can require multiple provider visits over several weeks to get a diagnosis. This can be a deterrent for individuals to get tested. One way the National Hepatitis Elimination Program plans overcome this barrier is by increasing the availability of point of care diagnostic tests. As we’ve seen with COVID-19, at home or local point of care testing is a highly effective way to quickly screen a mass number of people and identify individuals who need treatment. Europe, in fact, already has such a test which can readily be employed in the United States. Much like the call to action we observed with COVID, making information, and testing widely accessible is critical to the success of a nationwide elimination campaign.
The curative ability of direct acting antivirals is a modern medical miracle, but the high costs of the drugs make it widely unavailable, especially for those who are incarcerated or on Medicaid. Due to the high financial barrier, many health insurance providers require proof of liver damage or sobriety to cover the cost of treatment with direct acting antivirals. As a result, only about a third of individuals with active hepatitis C infections receive treatment within one year of diagnosis. This not only prevents many marginalized individuals access to life saving treatment, but also prevents pharmaceutical companies from making money off drugs that very few can afford to use. The National Hepatitis Elimination program proposes a subscription model solution, also known as the “Netflix” model, that benefits both parties. In a subscription model, states pay a pharmaceutical company a lump sum for free access to their hepatitis C drugs for a specific population. This model was piloted in Louisiana in 2019 and regarded as a success as the Louisiana state government was able to drastically expand access to hepatitis C treatment for its Medicaid and incarcerated populations. If deployed on a national scale, the subscription model can help insurers lower coverage costs and provide life saving care to all that need it.
The final pillar of the National Hepatitis Elimination plan is to reignite research for a hepatitis C vaccine. While direct acting antivirals are highly effective at curing hepatitis C, they do not prevent reinfections. In conjunction with a national awareness and prevention campaign, however, a hepatitis C vaccine would reduce the rate of both new and recurrent infections. This key step not only addresses the current hepatitis C endemic but can also prevent future waves of infection.
Through the four major pillars of the program, the National Hepatitis Elimination Program addresses the will, organization, and cost barriers that hinder elimination of hepatitis C in the United States. The plan outlines a cohesive effort among many stakeholders to create a cascade of identifying and curing those with hepatitis C—an endeavor that will save billions in future healthcare costs. So why does the program need five years and $11 billion? The United States’ program must reach nearly three times the population as Egypt and has many start-up costs including lump sums for pharmaceutical companies, a nationwide awareness campaign, vaccine research, and labor costs. Although the scale of the National Hepatitis C Elimination program may seem daunting, it is worth it. We know it is possible to eliminate hepatitis C in the United States, and now that there’s a plan, we just need to put it into motion.
It is also worth noting that the 100 Million Healthy Lives campaign not only screened the entire population over 12 for hepatitis C, but also for diabetes, hypertension, and obesity. Egypt’s national public health service also offered free treatment for diabetes and hypertension and free counseling for obesity. We can only hope that the United States achieves similar efficiency in disease screening such as screening women for breast and cervical cancer.