How to Achieve Hepatitis Elimination

Eliminating hepatitis B and C can be done, experts agree. And this week, a new report from the National Academies of Sciences, Engineering, and Medicine answers that thorny follow-up question: How?

Elimination is no small task.  Hepatitis kills more people than HIV, road traffic injuries or diabetes, explained Brian Strom, chair of the committee that completed the study.  But two developments nevertheless make elimination possible.  First, a vaccine for hepatitis B now exists.  Second, direct-acting antiviral treatments for hepatitis C now offer patients a 90 percent cure rate.

Changing Policy, Saving Lives

Meeting these goals requires major policy shifts.  Eliminating hepatitis B means vastly improving vaccination rates.  National Academics committee members noted during a Tuesday webinar that only about one-fourth of adults above age 19 are immunized for hepatitis B.  The public effort is not as widely coordinated and successful as, for example, the push for flu vaccines.

For hepatitis C, elimination requires removing key access barriers:

Prior authorization. At present, health plans commonly use prior authorization to ration treatment and limit medication expenses.  But the approach is ironic from a public health perspective.  As committee members explained, patients with the most advanced liver damage are rarely the same patients actively transmitting the disease.  Treating only the sickest patients, therefore, leaves other community members vulnerable.

Prescriber restrictions. The report also questions restrictions on which health care providers can treat hepatitis C patients.  In some cases, health plans stipulate that only specialists can prescribe curative treatment, a “bottleneck” that committee members say hurts patients in rural and underserved areas. The report suggests building up primary care physicians’ capacity to treat hepatitis B and C in primary care settings.

“Public and private health plans should remove restrictions that are not medically indicated,” Storm summarized, and offer curative treatment to patients who need it.

The report also encourages the Centers for Disease Control and Prevention to work with states on identifying the most appropriate settings for advanced treatment.  Incarcerated people bear a disproportionate burden of viral hepatitis, making the criminal justice system “an opportunity,” the committee argued, to vaccinate, test and treat hepatitis.  At present, however, only about one percent of prisoners receive treatment for hepatitis C.

Cost Challenges

Eliminating hepatitis B and C could be expensive, though delaying mass treatment would carry its own costs.  The report predicts “tens of thousands of deaths and billions of dollars in wasted medical costs” if policymakers don’t work to eliminate the diseases.

To mitigate costs, the report suggests a voluntary negotiation whereby six innovator pharmaceutical companies bid to sell a hepatitis C cure license to the government for use in neglected markets – such as prisons or the Medicaid system. Committee members compared the arrangement to the government purchasing patents for night vision goggles used by the military or for banking software used by the U.S. Department of the Treasury.

The National Academies are private, nonprofit institutions that provide independent analysis and advice to inform public policy decisions related to science, technology, and medicine. Committee members served pro bono for their work on this report.

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