The Hepatitis C Care Cascade: From Diagnosis to Care and Treatment in British Columbia

At the PAN Fall Conference, we learned from Dr. Lianping (Mint) Ti about short-course direct-acting antiviral (DAA) drugs for hepatitis C (HCV). These well-tolerated drugs have demonstrated cure rates of 95% and have been available in British Columbia (BC) since 2014, but their dispensation has been limited to individuals with advanced liver disease due to their high cost.

Findings from a recently published paper on the population level cascade of care for HCV in BC demonstrate the need for greater access to liver care and treatment for individuals living with HCV. According to Dr. Naveed Janjua and his colleagues, data from the BC Hepatitis Testers Cohort (BC-HTC; click here for more information about the cohort) indicates that as of 2012, only 32% percent of the 54,902 people diagnosed with HCV in BC had accessed liver care. Of these diagnosed individuals, only 12% had initiated treatment for hepatitis C and only 7% had achieved a sustained virologic response, defined as an undetectable HCV RNA level measured twelve weeks after completing treatment.

It is also important to note that Janjua and his colleagues estimate that as of December 31, 2012, 18,301 residents of BC were HCV antibody positive but undiagnosed. While it may seem surprising that an estimated 25% of HCV infections in BC are undiagnosed, Janjua et al. cite a 2011 paper by Maxim Trubnikov and colleagues from the Public Health Agency of Canada that suggests 20–44% of HCV infections in Canada are undiagnosed. These statistics illuminate the need for a testing strategy to reach those who are undiagnosed and, as a result, unlinked to care.

Janjua et al.’s findings on the cascade of care for people living with both HIV and HCV also demonstrate the need for accessible interventions. While HIV and HCV co-infected individuals are 6% of the 52,902 people diagnosed with HCV in BC, they are 10%, or 957 people, of the group of people accessing liver care. Of this 10%, however, only 5%, or 408 people, have ever been dispensed treatment. These numbers demonstrate that about 50% of individuals in the co-infected group fall off the cascade of care between these stages, highlighting the gaps that exist between a positive HCV diagnosis and retention in care and treatment.

Fortunately, options for treatment are about to become more accessible for individuals living with HCV in BC, Ontario and Saskatchewan. In February 2017, the BC Ministry of Health announced that thousands of British Columbians living with hepatitis C will have better access to treatment as a result of negotiations brokered by the pan-Canadian Pharmaceutical Alliance (pCPA) to improve the costs of these drugs for the BC, Ontario and Saskatchewan governments. Starting around March 21, 2017, physicians in BC can apply on behalf of their patients for coverage to a set of more effective HCV drugs.

In March 2018, coverage restrictions related to disease progression will be lifted completely and BC PharmaCare will provide coverage for any British Columbian living with chronic hepatitis C regardless of the type or severity of their disease. In their paper, Janjua and his colleagues explained how access to drugs such as these are “expected to be a game changer in preventing progressive liver disease.”

We can only hope that access to these better-tolerated drugs will help close the gap between diagnosis, care, and treatment for individuals living with HCV in British Columbia, Ontario and Saskatchewan. As Janjua and his colleagues remind us, “for these drugs to have major population-level impact on morbidity and mortality, screening efforts must reach undiagnosed individuals, diagnosed individuals must be linked with care and people remain engaged with care to be assessed for and receive treatment.”

Questions? Feedback? Get in touch!
Heather Holroyd, Community Based Research and Evaluation Projects Contractor
[email protected]