Hepatitis C treatment in US declined from 2015 to 2020

From a height of more than 164,000 in 2015, the number of people treated with direct-acting antiviral (DAA) therapy for hepatitis C has steadily declined, reaching a low point during the COVID-19 pandemic, according to a study from the Centers for Disease Control and Prevention (CDC) presented this week at The Liver Meeting.

"Reaching more people with hepatitis C testing and treatment is critical to saving lives and preventing transmission of this deadly, but curable, infection," the CDC stated in a press release.

The CDC estimates that around 2.4 million people in the United States were living with hepatitis C virus (HCV) during 2013 to 2016. Over years or decades, chronic hepatitis C can lead to serious complications including liver fibrosis, cirrhosis and liver cancer. Most people with hepatitis C can be cured, but not enough of them are being screened and treated, and some 40% are unaware of their status.

Eyasu Tehale of the CDC and colleagues used prescription claims data to estimate the number and characteristics of people receiving treatment since the approval of the first next-generation DAAs in the US at the end of 2013.

According to the IQVIA prescription claims database, a total of 843,329 people initiated DAA treatment from 2014 to 2020. This is an undercount, as the data do not include all retail, mail order and long-term care pharmacies or the Veterans Affairs health system. About 60% were men. Information on race/ethnicity was missing for more than two-thirds of the cohort, but among those with available data, more than two-thirds were White, about one in five were Black, about 10% were Latino and about 2% were Asian.

Reflecting the shift in the US hepatitis C epidemic to a younger population in conjunction with the ongoing opioid crisis, the proportion of treated people who were born between 1945 and 1965 fell from nearly three-quarters in 2014 to less than half in 2020. Similarly, the proportion of claims paid by commercial insurers or Medicare (coverage for seniors) decreased over time, while claims paid by Medicaid (coverage for low-income people) increased from 9% in 2014 to 29% in 2020.

Overall, 60% of prescribers were specialists, but as hepatitis treatment became simpler over time, it was increasingly managed by other providers. In 2019 and 2020, about half of prescriptions were written by primary care providers, nurse practitioners or physician assistants. In 2020, the most commonly prescribed regimens were sofosbuvir/velpatasvir (Epclusa) and glecaprevir/pibrentasvir (Maviret), at about 45% each, distantly followed by sofosbuvir/ledipasvir (Harvoni).

Just over 109,000 people were treated in 2014, as DAAs availability increased. This rose to more than 164,000 in 2015, reflecting a backlog of people awaiting simpler and more effective treatment. Between 114,000 and 134,000 people were treated each year from 2016 to 2019. But the number fell to approximately 84,000 in 2020, the first year of the COVID-19 pandemic.

While about 120,000 people, on average, have been treated each year, this is well below the 260,000 people the National Academies of Science and Medicine estimates would need to be treated annually in order to eliminate hepatitis C as a public health threat by 2030.

The CDC noted that while some barriers to care have come down, new challenges have emerged. Since 2015, many states have removed policy restrictions that prevented people from accessing treatment, and the cost of HCV medications have fallen thanks to competition, negotiated discounts and innovations such as subscription models. But some state Medicaid programmes still impose barriers, including restrictions on the type of providers who can manage treatment, requirements for sobriety and requirements for prior authorisation before treatment can begin.

The COVID-19 pandemic has also led to major disruptions in access to hepatitis C testing and treatment, according to the CDC. Routine healthcare services were suspended during lockdowns, some people avoided seeking medical care and prevention services and some syringe service programmes – many of which offer testing and linkage to care – reduced their operations.

At the same time, the opioid crisis continues, leading to an increase in new hepatitis C cases. Acute HCV infections reported to CDC quadrupled from 2009 to 2019, with the steepest rise among younger adults who inject drugs.

"Harm reduction programs and intervention such as syringe services programs and substance use disorder treatment are essential to reduce bloodborne infections, including hepatitis C, among people who inject drugs," the CDC stated. "Connecting people who inject drugs to hepatitis C testing and treatment services is critical to reducing hepatitis C transmission."