A National Strategy for the Elimination of Hepatitis B and C Phase Two Report (2017) / Chapter Skim
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Such loss of life comes at a cost to society, both directly, through the expense of treatment, and indirectly, through the loss of adults in their prime; viral hepatitis culls most heavily from the 45 to 64 age group. It is therefore surprising how relatively little public or scientific attention viral hepatitis has garnered.
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They were joined in phase two by the American Association for the Study of Liver Diseases, the CDC Division of Cancer Prevention and Control, the Infectious Diseases Society of America, and the National Viral Hepatitis Roundtable.
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It suggested considerable public health benefit to combining aggressive case finding with unrestricted treatment for chronic hepatitis C In such a scenario, the total number of viremic cases would drop 85 percent and annual deaths from chronic HCV infection would drop 65 percent by 2030 (relative to 2015)
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The elimination strategy described in this report may have particular need for such leadership, given its emphasis on reaching people who inject drugs and novel strategies to finance medicines for Medicaid beneficiaries and prisoners. PUBLIC HEALTH INFORMATION Chronic hepatitis B and C are both clinically silent in most patients.
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Measuring mortality due to viral hepatitis could be improved by attention to cancer registries. A classification system that captures liver cancer etiology would improve understanding of the burden of HBV infection and HCV infection.
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If states supported hepatitis B vaccination to the same level as seasonal influenza vaccine, great improvements could be made in hepatitis B immunization. The relative success of seasonal influenza immunization is partly a matter of making vaccination convenient, especially for hard-to-reach patients, including homeless people and substance users.
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The precise viral load threshold for antiviral therapy is not clear, but all HBsAg+ pregnant women should have early testing so that they and their doctors can weigh the pros and cons of antiviral prophylaxis. Recommendation 4-2: The Centers for Disease Control and Preven tion, the American Association for the Study of Liver Diseases, the Infectious Diseases Society of America, and the American College of Obstetricians and Gynecologists should recommend that all HBsAg+ pregnant women have early prenatal HBV DNA and liver enzyme tests to evaluate whether antiviral therapy is indicated for prophylaxis to eliminate mother-to-child transmission or for treatment of chronic active hepatitis.
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Recommendation 4-3: States and federal agencies should expand access to syringe exchange and opioid agonist therapy in accessible venues. Evidence indicates that syringe exchange programs neither encourage new users nor increase drug use among clients.
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Delaying treatment only increases a patient's risk of cirrhosis, liver cancer, and death. There are also consequences to society, as failure to treat chronic HCV infection creates a reservoir for transmission.
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Recommendation 5-2: The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America should partner with primary care providers and their professional organiza tions to build capacity to treat hepatitis B and C in primary care. The program should set up referral systems for medically complex patients.
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A system of the same breadth and flexibility would go far to reaching marginalized viral hepatitis patients. While building a parallel program comparable to Ryan White might not be feasible, outreach activities for viral hepatitis could be built onto existing Ryan White programs, using separate funding for HIV-negative people.
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As discussed in the previous section, it might be most efficient to use another discretionary program, the Ryan White Act, to reach viral hepatitis patients with overlapping risk factors for HIV. Any modifications to the Ryan White Act should make it clear that services for viral hepatitis patients should supplement the program's main goal of supporting treatment for poor and uninsured HIV patients.
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The voluntary nature of this process guarantees the drug company reasonable compensation; the patent holder has the option to walk away if the price is too low. Furthermore, the government would license the patent only for use in those populations for whom the government buys and access is limited, such as prisoners and Medicaid beneficiaries.
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Mechanistic research questions include the immune response and curative therapies for HBV and vaccine for HCV, as well as rapid diagnostic tests and new treatments for fibrosis, cirrhosis, and liver cancer. Implementation research questions include how to manage substance use in prisons and ways to reach key populations, as well as novel strategies for harm reduction, better understanding of networks of drug users, and prevention of injection drug use.
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