Since 2020, the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention (CDC) have recommended that all adults get screened for hepatitis C (HCV), a bloodborne virus that is 10 times more infectious than HIV and has been estimated to affect between 2.4 and 4.7 million people in the United States.
This recommendation is an update to CDC guidelines from 2013, which previously advised only those at risk for infection be screened, along with one-time testing for everyone born between 1945 and 1965. Chief among those highlighted as being at risk were baby boomers because the test for detecting HCV did not exist until 1990, and earlier standards for hygiene in clinical settings were found to have contributed to numerous transmissions.
Guideline changes to screen all adults for HCV come in response to ongoing rampant infection rates—for instance, novel diagnoses increased by 3.5 times between 2010 and 2016, particularly among younger white people who inject drugs and live in rural areas. Increasing rates of HCV infection were also shown to affect women ages 15 to 44.
The High Costs of Late Detection
What makes this particularly troubling is that 80% of people who have acute HCV infections are asymptomatic; 70% of those with acute HCV will develop chronic HCV infection, which, if left untreated, will likely result in devastating liver disease, liver failure, or hepatocellular carcinoma, the most common type of liver cancer and a leading cause of cancer-related death. Equally alarming, the CDC found that in 2018, only 61% of people diagnosed with HCV reported having ever been told they were infected. That is the reason HCV is widely known as “the silent killer” among medical professionals, because for many people, by the time it is detected, their liver is so ravaged by scar tissue that their only recourse is direct-acting antiviral (DAA) treatment, and potentially a transplant.
And while the eight-to-12-week regimen antiviral cure for HCV can cost as much as $81,000 for patients without insurance coverage, the average cost for a liver transplant and related care in the U.S. can run as high as $575,000. Additionally, finding a donor can be difficult, and, even at the best of times, when a match is found, extensive evaluations are mandated to ensure compatibility and reduce the possibility of organ rejection. Due to the current demand for liver transplants, a 2015 study on the future pricing structure of liver transplantations found that the cost will likely increase by 33% over the next 10 years. These exorbitant costs are a major reason why screening all adults for HCV is crucial.
Michigan’s Commitment to Screening and Reducing Stigma
Unfortunately, due to the COVID-19 pandemic, health care services for HCV, like many other conditions, continue to experience interruptions. According to a study published this May in the American Journal of Preventive Medicine, compared to figures from 2018 and 2019, HCV antibody testing in April 2020 had decreased by 59%, with a rebound to a 6% reduction by July 2020. HCV RNA-positive results fell by 62% in March 2020 and remained 39% below the baseline by July 2020—while treatment prescriptions decreased by 43% in May, 37% in June, and 38% in July from the two previous years.
Had intravenous drug use—the primary method of HCV transmission—remained stable during the pandemic, there would not be as much cause for concern. Unfortunately, a recent CDC report revealed that 13% of Americans said they started or increased substance use, including injection drug use, to cope with the pandemic.
It comes as good news then that, with vaccinations allowing society to slowly reopen, some states are taking precautions to ensure that HCV screenings receive the robust attention they deserve. In Michigan, where more than 100,000 people have been diagnosed as living with HCV, Gov. Gretchen Whitmer has worked with the state health department’s chief deputy director for health, Joneigh Khaldun, M.D., M.P.H., to encourage all adults to get tested.
What started in April 2021 with the launch of a new initiative—“We Treat Hep C”—to expand provider capacity for testing and treatment so that both become normalized evolved into the month of May being declared Hepatitis Awareness Month across the state.
Part of the awareness month rollout included making information about the virus widely available and encouraging specific groups to request the HCV blood test from their health care provider. These listed groups included:
- All adults, at least once in their lifetime
- All women during each pregnancy
- All persons with recognized conditions or exposures, regardless of age
- All persons with ongoing risk factors (routine periodic testing)
A key component of “We Treat Hep C” was making an antiviral treatment for HCV, Mavyret (glecaprevir/pibrentasvir), available without requiring prior authorization for health insurance coverage, after the drugmaker agreed to a discount for the state’s Medicaid and Department of Corrections. If that drug is found unsuitable or “clinically inappropriate” for a particular patient, other antivirals will still require testing and prior authorization.
In her statement about the initiative, Khaldun said, “It is crucial that all Michiganders receive hepatitis C virus testing at least one time in their life, and more frequently if they are in an at-risk category.” She also affirmed that HCV is curable and that the state has committed itself to making treatment accessible to residents in need.
Insurance Restrictions Still Pose Barriers to Access
As is true across the nation, in Michigan, baby boomers and people aged 18 to 39 have the highest rates for HCV infections. Among the younger generation, this corresponds with the group’s significantly higher reported rate of intravenous drug use.
According to the state’s plan on eliminating HCV, the proportion of all chronic infections that were among adults younger than 40 increased from 22% in 2010 to 41% in 2019. The report’s existing data found that 80% of people who tested positive for HCV in 2019 “reported [having] a history of ever injecting drugs.” According to the CDC, Michigan has some of the most vulnerable counties of all states in the U.S. for HCV infections through intravenous drug use. Following a request for assistance from the state’s health department in 2016, the CDC determined that “Michigan is experiencing an increase in viral hepatitis or HIV infections due to injection drug use.”
In addition to that request, the state was able to increase funding to support syringe-service programs and harm reduction plans through prevention block grants provided by Substance Abuse and Mental Health Services Administration’s (SAMHSA) State Opioid Response program. That support allowed agencies in the state that were receiving funding for syringe access to increase from four to 27.
Of the 6,036 novel chronic HCV diagnoses reported in 2019, 2,847 or approximately 46% of them occurred among residents living in predominantly Black areas of the state, including the city of Detroit and Wayne, Oakland, and Macomb counties. This tracks with a historic pattern of reduced services made available to Black communities.
As part of the action plan for eliminating HCV, Michigan has committed itself to collecting detailed data to ensure that specific communities are receiving the assistance that they need, while investing in community-based interventions that work to reduce stigma and increase engagement, as well as collaborating with clinicians to ensure accessibility.
Numerous models and academic objectives are also listed within the call-to-action’s strategies. But what stands out from the data is the emphasis that has been placed on insurance. According to a study published in 2018 in the Journal of the American Medical Association (JAMA) on the prevalence of HCV infections across the U.S., Michigan ranks seventh in the nation. If that ranking is to decrease, so must barriers to insurance and linkage to care. Figures from Michigan’s elimination plan reveal that between 2018 and 2019, use of antiviral treatment for HCV decreased by 40%. This decrease was attributed to Michigan Medicaid’s sobriety and prescriber restrictions, which have now been targeted for removal in order to improve treatment outcomes. Additionally, the plan found that 75% of physicians and providers surveyed out of 132 responded that they would be open to treating HCV if insurance hurdles involving the virus were removed.
As with any treatment program, policies must be shaped to help the populations they profess to serve where they are, rather than where the architects would like them to be. Because HCV is predominantly spread through intravenous drug use, that means that mandating sobriety will prevent those who are in need—people who are living with drug dependencies—from accessing care.
By focusing on providing care to all, without stigma, Michigan is establishing an effective treatment model informed by harm reduction and compassionate care, rather than penalizing vulnerable populations. With consistent support and review of progress, this plan shows promise for eliminating HCV across the state.