Where is Canada’s plan to eliminate hepatitis C?

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Nine countries – Australia, France, Iceland, Italy, Japan, South Korea, Spain, Switzerland and Britain – are on track toward eliminating hepatitis C by 2030.

Like those countries, Canada signed a pledge to eliminate the debilitating, potentially deadly infectious disease, HCV.

But, unlike those countries, Canada doesn’t have a plan.

So, a group of liver experts, the Canadian Network for Hepatitis C (CanHepC), took it upon themselves to do the work of policy-makers and produce a “Blueprint to Inform Hepatitis C Elimination Efforts in Canada.”

The document presents a no-nonsense menu of options for the prevention and treatment of HCV, with specific recommendations on how Canada can achieve elimination by 2030.

Now it’s up to federal, provincial and territorial governments to act on the advice.

Before getting into the details of what needs to be done, it’s worth reflecting on why HCV has become a global priority.

The hepatitis C virus, a leading cause of liver disease and the need for liver transplantation, was identified only in 1989.

In 2013, HCV became the only chronic infectious disease for which there is a simple, effective cure – one daily pill for 8-12 weeks.

Globally, 71 million people are living with chronic HCV infection, and it kills more than 400,000 people annually.

In Canada, there are an estimated 250,000 people living with HCV. Because the virus eats away slowly at the liver, many people don’t know they’re infected until they have advanced liver disease or liver cancer.

HCV, a blood-borne disease, disproportionally affects a handful of demographic groups:

• People born between 1945 and 1975: This group, primarily baby boomers, make up about 75 per cent of all HCV cases. Many were exposed to the virus unwittingly in the days before sterilization of medical equipment and single-use syringes became the norm. Injection drug use was also quite common in the sixties and seventies, although today’s grandparents aren’t always keen to talk about that;
• Injection drug users are, by far, those most at risk of HCV infection. There are an estimated 172,000 regular injection drug users in Canada, about two-thirds of them are infected, and they account for almost all the new cases. There are also high rates of co-infection with HIV;
• About one-third of all HCV infections in Canada are among immigrants and newcomers, reflecting how common it is globally. Countries such as China, India, Pakistan and Egypt have astronomical rates;
• About one in four prisoners, past and present, have HCV, due to common prison practices such as tattooing and drug injection with unsterilized needles;
• About 5 per cent of men who have sex with men are infected. HCV is not sexually transmitted commonly, but can be when there is exposure to blood;
• Indigenous people have rates of HCV infection about five times higher than the general population – approximately 3 per cent.

The blueprint prepared by CanHepC recommends, quite sensibly, that treatment and prevention efforts be focused on these high-risk groups.

Instead of universal programs, it is suggested that micro-elimination projects be undertaken – in other words, focusing on specific groups with tailored strategies.

For baby boomers, that means stepping up testing to identify those who don’t know they’re infected. It’s also important to train family physicians so they know how to identify and treat hepatitis C.

With injection drug users and prisoners, prevention is key. That means investing in harm-reduction initiatives such as needle exchanges and supervised injection sites. One successful B.C. micro-elimination project treats patients who are in rehab simultaneously for hepatitis C.

Acting on the objectives and targets set out in the blueprint would mean ensuring that 90 per cent of those who are infected are identified and that 80 per cent of them get treatment.

Doing so would reduce HCV prevalence by about 90 per cent, and reduce the need for liver transplants and HCV-related mortality by 65 per cent.

In public-health terms, those are eye-popping numbers. But they are achievable.

Of course, there is a cost. Antiviral drugs such as Epclusa, Harvoni and Daklinza are expensive, with list prices in the $60,000 range for a full course of treatment, but prices are coming down through joint buying.

Because the costs of treating liver disease and transplants are significant, these drugs can be cost-effective, but that means ensuring those who will benefit most from treatment get it.

Treatment has been revolutionized and has created an unprecedented chance to dramatically reduce the harms of HCV, today and in the future.

It’s an opportunity we shouldn’t squander.

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