Hepatitis C in the United States: One Step Forward, Two Steps Back

ABSTRACT

Despite not having a vaccine for HCV, the availability of curative direct-acting antiviral agents (DAAs) led the National Academy of Sciences, Engineering, and Medicine in 2017 to conclude that HCV could be eliminated as a public health problem in the United States if considerable will and resources existed to do so.1 HCV INFECTION AND THE INJECTION DRUG USE EPIDEMIC In the current issue of AJPH, Holtzman et al. from the Centers for Disease Control and Prevention document the changing epidemiology of acute HCV in the United States between 2010 and 2018 (p. 949). The fact that injection drug use is now the major driver of HCV transmission in the United States indicates that any program to eliminate or even control HCV in the absence of a vaccine must directly address treatment of substance use disorders. Because injection of opioids was found to be the major cause of injection drug use-related acute HCV incidence during that period, specifically addressing the treatment of opioid use disorder (OUD) and integrating infectious disease prevention and treatment services with addiction services are critical to eliminating or controlling HCV infection in the United States. Harmreduction services such as syringe service programs have helped to curb the epidemic of not only HCV but also HIV infection.2 Importantly, use of medication to treat OUD (e.g., buprenorphine, methadone, extended-release naltrexone) has been shown to reduce transmission of HCV and HIV as well as lead to cure of HCV and increased viral suppression among individuals with HIV infection.36 HCV reinfection is also uncommon among persons who inject drugs on opioid agonist therapy.7 A recent report from the National Academy of Sciences, Engineering, and Medicine that evaluated opportunities to improve OUD and infectious disease services outlined a series of recommendations that undoubtedly could impact the HCV epidemic.8,9 Among them was the elimination of prior authorization policies and removing the X-waiver requirement to prescribe buprenorphine, which would make the effective opioid agonist medications to treat OUD more accessible and available to all who need them.