A Deadlier Disease
Deaths per persons in the United States have dropped by 22% since 1990,
a study published in April of this year found. But how people are dying is also constantly changing—sometimes at a more severe rate.
Though cardiovascular disease, diabetes, Alzheimer’s, and others have remained among the greater drivers of mortality, other conditions have spread like wildfire in just less than 3 decades. Among them, opioid use disorder (OUD) mortality has raised by 447.3%, and liver disease due to hepatitis C by 75.4%.
With the rise of these conditions also came the fall of previously-feared epidemics: HIV/AIDS, a public health crisis and the 13th-leading cause of death in 1990, killed fewer Americans in 2016 than 50 other conditions. Access to highly-efficacious antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP), and a growing understanding of how and when to test at-risk patient populations have made HIV a good example of clinical response to a growing disease.
It’s one doctors and policy-makers could do well to apply to hepatitis C and OUD—2 diseases that are linked by more than just increased prevalence. Hepatitis C is a significant risk factor for people who inject drugs. As a study published in the journal Addiction this year reported, 8.5% of the 71 million-plus individuals with hepatitis C worldwide had recently injected drugs prior to their diagnosis. Among all people with recent injection drug use living with hepatitis C globally, half come from just 4 countries: Russia, China, Brazil, and the United States.
With the boom of drug use-related cases has come a new target population for hepatitis C care: adolescents and young adults—once shadowed in the national push for improved Baby Boomer screening—are in need of help.
It’s why the continually improving benefits of direct-acting antivirals (DAAs) have become something of a moot point to Global Liver Institute president and chief executive officer Donna Cryer, JD: it’s not benefitting a group of patients facing an epidemic.
“Looking at 2018, our biggest negative was the increasing rate of younger people contracting hepatitis C because of the opioid use crisis,” Cryer told MD Magazine®. “Seeing that wave increase was so sad.”
Missing Patients
Indeed,
a study presented at the IDWeek annual meeting this October confirmed clinicians’ inability to get marketed DAAs to younger hepatitis C patients. Investigators from the Boston Medical Center reported that—in a pool of about 269,000 teenaged and young adult patients in 19 states over 5 years—just 2.5% were tested for the disease. Among those coded with having history of drug use, still only 8.9% were tested. And among patients with an OUD diagnosis, 35% were tested for hepatitis C.
The majority of cases, noted lead author Rachel L. Epstein, MD, MA, were missed opportunities. “And even when drug use is identified, there’s a belief that youth are less likely to test positive for hepatitis C, which isn’t necessarily the case as we show in our study,” she said.
Another Boston-based study on hepatitis C prevalence in young drug users (aged 22-30 years) published this year found that diagnosed patients who had not been prescribed or had taken DAAs faced barriers in the stigma surrounding the “average patient,” their healthcare provider interactions, the expectation of illness severity required for treatment, and the lack of incentives available for drug users in need of hepatitis C care.
When interviewed, some young adults implied they were treated as addicts or “junkies” by their provider, rather than an at-need patient with a deadly infection. These negative interactions perpetuate the belief that therapies are unavailable to drug users.
But maybe there’s something to that perception. DAAs, while close to 95% in efficacy rates, are severely costly—investigators have reported a 12-week regimen totaling between $50,000 to $100,000. Additionally, more than one-third of chronic cases are denied treatment coverage by insurers, a recent study found. In commercially insured patients, coverage is denied more than half the time (52%).
Some insurance denials are based on the same perceptions that were found to plague doctor-drug user patient interactions, including the belief the disease hasn’t progressed severely enough to warrant DAAs.
The combination of limited screening, stigmas attached to victims of a drug epidemic, and an out-of-reach cure illustrate a vicious cycle of hepatitis C spreading through young Americans. As the average US patient becomes younger and less reached, goals of national eradication currently held by other countries seem unfeasible.
Cryer theorized it could help to actually have an eradication goal, though.
“We’re very much outliers in the international health community by not having an elimination goal now that we have a cure,” Cryer said. “This could be the public health success story of our generation, but we really need the administration to come behind us and step up, and help us achieve the goal.”
Hitting Goals
A blueprint has been laid out by the likes of Australia,
which reported it could reach hepatitis C elimination in the next 10-15 years. Australia was among the first countries to provide funding for broad DAA access in 2016—albeit with stipulations based on patient parameters such as drug use. But another contributor to their elimination pursuit is the country’s screening rates. About 81% of patients with chronic hepatitis C have already been diagnosed, investigators noted.
Research has proven that a universal hepatitis C screening policy would be cost-effective—regardless of DAA costs or disease stage—due to the benefits of early detection and care. One study evidencing the benefits also surmised universal screening would reduce stigma surrounding the disease and its most susceptible patients in the US. Rush University Medical Center specialist Nancy Reau, MD, told MD Mag the biggest hurdle would then be access to therapies.
“Given the current climate in the US, where access to care is unstable, it seems unlikely that this could be a serious discussion,” she explained.
Cryer wants it to be a discussion. Organizations such as the National Academy of Medicine—which she noted has previously recommended hepatitis C elimination goals for the US—would also like it to be a discussion. But still, challenges persist.
It may do well to focus on smaller-scale success. In 2018, the same year of newfound concern for injection drug use and its deadly comorbidities, Louisiana answered the problem. The state proposed a plan to expand access to DAAs with a fixed payment method that would ensure Medicaid and uninsured patients have access to sofosbuvir (Sovaldi) in the immediate time of their diagnosis.
This innovative public health initiative, Cryer argued, is the most positive news in hepatitis C care this year. She’d like to see more initiatives like it in 2019.
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