After reaching a peak in 2015, the number of people treated with direct-acting antiviral therapy for hepatitis C has steadily declined, reaching a low mark in 2020, according to new data from the Centers for Disease Control and Prevention (CDC) presented this week at The Liver Meeting.
Although about 120,000 people, on average, were treated each year from 2014 through 2020, this is less than half of 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 goal of the Viral Hepatitis National Strategic Plan.
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 with direct-acting antivirals (DAAs), but not enough of them are being screened and treated, and some 40% are not aware of their status. Since 2020, the CDC has recommended that all adults be screened for hepatitis C at least once, and women should be tested during each pregnancy.
CDC scientist Eyasu Tehale and colleagues used prescription claims data to estimate the number and characteristics of people receiving treatment since the advent of next-generation direct-acting antivirals. The first DAAs were used with pegylated interferon and ribavirin—the previous standard of care—but by 2014, DAA combinations offered more convenient, shorter and more effective treatment without the side effects of interferon-based therapy.
According to the IQVIA (formerly IMS Health and Quintiles) prescription claims database, a total of 843,329 people in the United States initiated DAA treatment from 2014 through 2020. This is an undercount, as IQVIA does not collect data from the Veterans Affairs health system and does not include all retail, mail order and long-term care pharmacies. Of these, 60% were men. Information on race and 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.
Some notable changes were observed over time. In 2014, nearly three quarters of those treated were baby boomers born between 1945 and 1965, but this fell to less than half in 2020. The proportion of claims paid by commercial insurance or Medicare decreased over time, while claims paid by Medicaid increased from 9% in 2014 to 29% in 2020. These trends reflect a shift in the hepatitis C epidemic to a younger population in conjunction with the ongoing opioid crisis.
Overall, 60% of prescribers were specialists, such as hepatologists. But hepatitis C treatment has become simpler over time, and it can successfully be managed by primary care providers. In 2019 and 2020, about half of prescriptions were written by primary care providers, nurse practitioners or physician assistants and about half by specialists. In 2020, the most commonly prescribed regimens were Epclusa (sofosbuvir/velpatasvir) and Mavyret (glecaprevir/pibrentasvir), at about 45% each, distantly followed by the older Harvoni (sofosbuvir/ledipasvir).
Just over 109,000 people were treated in 2014, as access to DAAs ramped up. 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 through 2019, falling to approximately 84,000 in 2020, the first year of the COVID-19 pandemic.
In a press release about the study, 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. What’s more, medication costs have decreased thanks to competition, negotiated discounts and innovative state treatment models.
However, some state Medicaid programs still impose barriers, such as restrictions on the type of providers who can manage treatment, requirements for sobriety and requirements for prior authorization before treatment can begin.
The COVID-19 pandemic has also led to major disruptions in access to hepatitis C testing and treatment. Routine health care services were suspended during stay-at-home orders, some people avoided seeking medical care and prevention services and some syringe service programs—many of which offer testing and linkage to care—reduced their operations.
At the same time, the opioid crisis continues unabated, 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. Connecting people who inject drugs to hepatitis C testing and treatment services is critical to reducing hepatitis C transmission,” the CDC stated. “Reaching more people with hepatitis C testing and treatment is critical to saving lives and preventing transmission of this deadly, but curable, infection.”