More aggressive HCV screening, treatment strategies needed to meet WHO 2030 targets

Universal screening of all adults and improved treatment rates are needed to achieve WHO goals designed to eliminate hepatitis C as a public health threat by 2030, according to a study presented during the Liver Meeting Digital Experience.

The WHO targets include a 90% reduction in HCV incidence and a 65% reduction in mortality, as compared with 2015 baseline numbers, by 2030. The organization also set diagnosis and treatment goals, including 90% diagnosis of patients with chronic HCV and 80% treatment of treatment-eligible patients by 2030, Madeline Adee, MPH, from Massachusetts General Hospital, noted during a presentation of the data.

According to National Health and Nutrition Examination Survey data, which reflects the household-based population, the cascade of care for HCV has improved over time, with more people becoming aware of their status and more people receiving treatment. However, in looking at non-NHANES data, which represent non-household-based populations, such as people in prison or experiencing homelessness, the numbers are much worse.

Under the status quo, Adee said, the picture is unlikely to change substantially by 2030.

Models and projections

To help inform screening and treatment policies that would move the United States closer to achieving the WHO 2030 goals, Adee and colleagues projected future HCV disease burden in all 50 states using a previously validated mathematical model. The model includes information on patient demographics, HCV disease progression, HCV screening, therapeutic advances and access to health care, including insurance coverage.

The researchers obtained estimates of new incidence cases of HCV infection from CDC reports through 2016. When state-level estimates were unavailable, they created estimates using the national rate and applied it to the state population.

For years 2017 to 2028, Adee and colleagues projected trends in HCV incidence by assuming that annual incidence continues to trend upward at the same rate observed between 2006 and 2016. From 2029 onward, they assumed that rates will stabilize and remain flat.

To evaluate HCV prevalence, they developed estimates from NHANES as a starting point and supplemented those with survey data from prisons.

“We wanted to look at different combinations of screening and treatment strategies and rates, so we started with the status quo screening and treatment,” Adee said.

The status quo for screening was 9% annually among the baby boomer birth cohort and treatment rates varied based on insurance status, with a 50% annual treatment rate among the insured population and a 10% treatment rate among the uninsured population. Treatment rates for incarcerated individuals varied by state.

The researchers also assessed two other treatment strategies in which treatment rates were higher in all populations. The first included an 80% treatment rate among the insured population and a 20% treatment rate among the uninsured and incarcerated population and the second included 80% treatment annually for all population in their model.

“We also wanted to see what would happen if we increased the screening, so we looked at all the same treatment strategies under elimination target screening, which means that this is the screening rate needed to achieve the WHO goals for diagnosis coverage,” Adee said.

Benefits of universal screening, improved treatment rates

After examining the two screening scenarios — the status quo and universal screening in each state with a varying annual rate — the researchers found that universal screening is needed to meet the elimination goals for diagnosis coverage in all states.

They found that under the status quo screening scenario, most states were about 10 to 20 percentage points below the diagnosis coverage targets, Adee said, noting that an annual screening rate ranging from 9% to 15% in each state, with a national mean of 9.8%, is necessary to achieve the WHO goal of at least 90% diagnosis coverage by 2030.

Data also showed that all treatment strategies, including the status quo, 80% treatment annually for the insured population and 20% for the uninsured/incarcerated populations as well as 80% treatment annually in all populations, resulted in meeting the WHO 2030 treatment coverage goal. However, the treatment strategy used made a substantial difference in mortality, Adee said.

Unfortunately, the study results suggest that no states can meet the WHO target of a 65% reduction in liver-related deaths by 2030. Nevertheless, the treatment strategy that is coupled with universal screening can still have a significant impact on death, according to Adee.

For instance, status quo treatment results in minimal reduction in deaths, with a national mean reduction of only 9% by 2030. However, an average 17% reduction in liver-related deaths in the U.S. can occur with the strategy that includes 80% treatment among the insured population and 20% among the uninsured population. Even more significant improvements, including an approximately 40% reduction in some states, can be seen with the implementation of 80% treatment for all, Adee said.

“We need to implement universal screening of all adults in different subpopulations to meet the target of 90% diagnosis by 2030. Policymakers need to implement programs that can increase the uptake of universal screening in different populations,” Adee said.