Steven Tyska, MD; Ryan P. Westergaard, MD, PhD, MPH
More than one year into the worst public health crisis of our lifetime, there is hope for an end to the deadly COVID-19 pandemic, even as significant challenges remain. While these challenges have demanded most of our recent attention, there is another epidemic that we must not neglect—an epidemic with a cure. Hepatitis C virus continues to spread in Wisconsin and in the United States, infecting a new generation, even as curative treatment has become simple to prescribe and barriers to treatment have been removed. We have the means to eliminate hepatitis C as a public health threat and need only the will to do so. We hope that May 2021, Hepatitis Awareness Month, will mark the beginning of a concerted effort to identify all who are infected and to cure them.
In another paper published in WMJ, Koepke and colleagues describe findings from a survey of Wisconsin family physicians to gauge their familiarity with hepatitis C treatment recommendations and awareness of recent changes in Medicaid policies designed to facilitate widespread access to hepatitis C cure.1 The results were striking—the vast majority of family physicians were not aware, for example, that Wisconsin Medicaid now allows nonspecialists to prescribe hepatitis C treatment and does not restrict access to hepatitis C drugs for patients with no evidence of liver fibrosis or cirrhosis. Consequently, very few primary care providers have ever prescribed antiviral drugs to their patients with hepatitis C, missing valuable opportunities to prevent liver disease and stop the spread of the virus in our state.
These results are not surprising. Many physicians practicing today trained in medicine during an era when hepatitis C was described as a “silent epidemic” largely affecting older Americans from the Baby Boomer Generation. In the past, hepatitis C treatment consisted of injectable, interferon-based regimens that had high levels of toxicity and low cure rates. Treating hepatitis C required close monitoring by experienced subspecialist providers, and successful cure was achieved in only a minority of highly selected and motivated patients.
Two historic shifts occurred during the past decade that now demand we approach the hepatitis C epidemic differently. First, we have experienced a revolution in antiviral therapy, with the proliferation of direct-acting antiviral drugs (DAA) with high levels of effectiveness and tolerability. Hepatitis C can now be reliably cured with once daily, single-tablet regimens containing DAAs that are effective against all known genotypes of hepatitis C and require only an 8- or 12-week duration of treatment. Second, the epidemiology of new hepatitis C infections has shifted dramatically toward younger adults who inject drugs, fueled by the persistent epidemic of opioid and methamphetamine use disorder. Curing hepatitis C is now a public health imperative, not only because of the need to prevent severe liver disease in older adults but to prevent transmission of the virus among some of the most vulnerable members of our community.
When the modern era of hepatitis C treatment began in 2011 with the approval of the first DAAs, they were at first not widely available. The high cost of the initial hepatitis C antivirals necessitated prioritization of treatment to those most affected by the infection and those most likely to benefit from the treatment. Insurance companies and state Medicaid programs refused to cover hepatitis C treatment for most patients, except for those whose degree of liver fibrosis placed them at high risk for liver failure and the need for transplantation. Sobriety criteria were developed in an attempt to identify those who may fail to benefit from treatment due to continued drug and alcohol abuse. Furthermore, the daunting decision regarding who should receive this lifesaving treatment and who should not was appropriately relegated to gastroenterologists and infectious disease specialists who were better able to apply complex treatment guidelines and keep up with rapidly evolving science.
In the intervening decade, DAAs have become ever more affordable, simpler to prescribe, and can easily be prescribed in outpatient, primary care settings. Modeling studies have recently suggested that universal testing and treatment of all US residents, similar to the well-accepted paradigm for addressing the HIV epidemic, would, in fact, be a cost-effective national strategy.2 Given these developments, we have a historic opportunity to eliminate hepatitis C as a public health threat. Rarely have opportunities like this arisen, where a simple change in clinical practice can have such a profound effect on morality and mortality. We just need to test and treat. As of March 2, 2020, the US Preventive Services Task Force recommends that all adults aged 18 to 79 should be screened for hepatitis C.3 Primary care providers should be at the forefront of this screening effort and should primarily manage the care of their patients with hepatitis C who do not have complicated liver disease.
The Wisconsin Department of Health Services has taken a number of steps in the past few years to improve screening and access to hepatitis C treatment. In July 2019, the Division of Medicaid Services eliminated all sobriety and liver disease severity restrictions for prescribing hepatitis C antiviral medication and removed the requirement that these medications be prescribed by a specialist. In 2020, the requirement for prior authorization for these medications was removed for fee-for-service Medicaid patients as well. BadgerCare Plus patients in HMOs are equally entitled to these medications without more restrictive criteria.
Another state agency, the Wisconsin Department of Corrections, has shown important leadership in combatting the hepatitis C epidemic in the state. For the past several years, the department has universally screened all incarcerated adults for hepatitis C and has implemented treatment protocols to offer curative treatment to all who need it. Universal testing and treatment is the necessary approach to eliminating hepatitis C as a public health threat. People who are cured can no longer infect others, making our state healthier and safer. We wish to recognize with gratitude this valuable contribution to public health made by our colleagues in the Department of Corrections and encourage all health care organizations to follow this example.
Hepatitis C elimination is an attainable goal and, thanks to the paper by Koepke et al,1 we now understand several challenges we face in its pursuit. Primary care providers can and should offer their patients screening and treatment for hepatitis C. With education and support from the Wisconsin Department of Health Services, we envision a future where hepatitis C screening and treatment is a routine part of primary care practice—that is, until it no longer needs to be.
- Koepke R, Akhtar WZ, Kung VM, Seal DW, Salisbury-Afshar E, Westergaard RP. Hepatitis C treatment knowledge and practice among family medicine physicians in Wisconsin during the current hepatitis C epidemic.” WMJ. Published online May 26, 2021.
- Barocas JA, Tasillo A, Eftekhari Yazdi G, et al. Population-level outcomes and cost-effectiveness of expanding the recommendation for age-based hepatitis C testing in the United States. Clin Infect Dis. 2018;67(4):549-556. doi:10.1093/cid/ciy098
- US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and dults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(10):970–975. doi:10.1001/jama.2020.1123