Canada unlikely to hit 2030 hepatitis C elimination target: Study

Policymakers need to think beyond screening, treatment, researchers say

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by Steve Bryson, PhD |

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An illustration shows a close-up view of the hepatitis virus.

Current screening and treatment strategies won’t allow Canada to eliminate new cases of hepatitis C by 2030, a population modeling study found.

That’s the goal set by the World Health Organization (WHO).

“We are not likely to reach the WHO goal of eliminating HCV by 2030 if screening and treatment are the only focus for policymakers,” William W.L. Wong, PhD, the study’s senior author and associate professor at the University of Waterloo’s School of Pharmacy, said in a university press release.

Modeling showed that working to reduce transmission risk among people who inject drugs, instead of focusing on more aggressive screening and treatment strategies, may help Canada reach WHO’s targets, the researchers said.

“We need to screen for the disease earlier and encourage harm-reduction strategies be put in place,” Wong said. “If patients do not change high-risk behaviors, such as sharing needles, [hepatitis C virus] re-infection can be high even after they were cured the first time.”

The modeling study, “Feasibility of hepatitis C elimination by screening and treatment alone in high-income countries,” was published in the journal Hepatology.

Most countries underinvest in elimination plans, researchers say

The hepatitis C virus (HCV), the cause of hepatitis C, is spread by contact with infected blood or other bodily fluids, mostly by people sharing needles to inject drugs or by contaminated medical equipment. Hepatitis C can cause chronic liver inflammation and serious liver damage, with the potential to cause liver cancer.

Several highly effective medications, known as direct-acting antivirals, or DAAs, have become available for hepatitis C. Based on this, the WHO set a goal to eliminate hepatitis C as a worldwide health issue by 2030.

Elimination was defined as 80% fewer new chronic hepatitis C cases, treatment of 80% of hepatitis C patients, and a 65% reduction in HCV-related deaths from 2015 levels.

“Although various high-income countries around the world have committed to achieving these goals, most have underinvested in HCV elimination programming and focus only on developing interventions related to screening and treatment,” the researchers wrote.

Screening and treatment for hepatitis C “decreased significantly during 2020–2021” with the COVID-19 pandemic, the researchers wrote.

Most model-based studies to project HCV elimination have not considered the impact of HCV transmission dynamics, the pandemic, or ongoing immigration from regions where hepatitis C is common, or endemic.

This may particularly affect projections for high-income countries with “high levels of immigration from HCV-endemic regions,” the researchers wrote. Canada is one of those countries.

Wong and his colleagues aimed to predict long-term health outcomes using current hepatitis C policies — which focus on screening and treatment only — and identify ideal screening, treatment, and harm reduction strategies to achieve the 2030 elimination goal.

They developed a model using data from Ontario, Canada, with 12.2 million people to simulate demographic changes, human interactions, and HCV transmission from 2006 to 2030.

They took into account demographic, geographic, and behavioral factors, the natural history of HCV and treatment effectiveness, the impact of the COVID-19 pandemic on screening and treatment, and HCV in general and immigrant populations.

Model uses Sims-like simulation

“Picture a game, such as The Sims, where you build a dynamic population,” Wong said. “Similar to the game, we simulated Ontario’s population, including those with HCV. We looked at how the disease is transmitted and how it moves around the population with different risk activities triggered.”

Using current strategies based on screening and treatment only, or status quo, modeling predicted that incidence, or new cases, of acute hepatitis C in Ontario would slowly decline, dropping by 6.9% from 2015 to 2030.

During the same period, acute hepatitis C incidence would decline by 12.6% using an aggressive treatment strategy, defined as a 90% increase in treated patients over the status quo; and by 15.8% using an aggressive screening and treatment strategy, or a 90% increase in screening and treatment.

Overall, the status quo and the aggressive screening and treatment strategies would not be enough to achieve the WHO target of an 80% reduction in hepatitis C incidence in Canada.

An enhanced harm-reduction strategy, or a 90% drop in transmission risk among people who inject drugs, would lead to an 85.4% reduction in acute hepatitis C incidence, from 30 cases per 100,000 people in 2015 to 4.4 cases in 2030.

Harm reduction most effective all around

Similar findings were observed for chronic hepatitis C incidence. Harm-reduction strategies were the most effective, reducing the incidence rate by 67.2%, from 28.7 cases per 100,000 people in 2015 to 9.4 cases in 2030. This “was also attributed to its effectiveness in reducing the number of reinfections after recovery,” the team wrote.

Chronic hepatitis C prevalence, or established cases, would be reduced by 57.6% with the status quo, by 65.1% with aggressive treatment, by 71.3% with aggressive screening and treatment, and by 70.9% with enhanced harm reduction. Using either aggressive screening and treatment or enhanced harm reduction, the prevalence may drop to fewer than 250 cases per 100,000 people by 2030.

An aggressive screening and treatment strategy would be more effective, by nearly 10%, than the status quo at reducing new cases of advanced liver disease due to chronic hepatitis C. This aggressive strategy would also be the most effective at reducing the number of liver-related deaths due to chronic hepatitis C, lowering the figure by 72.9%, from 6.4 cases per 100,000 people in 2015 to 1.7 cases in 2030.

Further analyses showed that HCV transmission had the greatest impact on the predicted incidence of chronic hepatitis C in 2030, and the number of patients who started DAAs had the most considerable impact on the predicted liver-related death by 2030.

“With extensive scale-up in screening, and treatment, the mortality target may be achievable, but the target for preventing new [chronic hepatitis C] cases is unlikely reachable, highlighting the importance of developing enhanced harm-reduction strategies for HCV elimination,” the researchers wrote.

Such strategies may include distributing clean needles, reducing sharing of drug-use equipment, and targeting other high-risk exposures, they noted.