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About 2.4 million people in the United States have hepatitis C virus (HCV) infection, and an estimated 66,700 acute infections occurred in 2020. American Indian and Alaska Native (AI/AN) people are hit hardest: in 2020 they had the highest rates of acute HCV infection (2.1 per 100,000) and of HCV-related death (10.17 per 100,000).
CDC
The program
Cherokee Nation is the largest AI/AN nation in the U.S., spanning 14 counties in Oklahoma with more than 450,000 registered citizens. Cherokee Nation Health Services (CNHS) is the largest tribally run health system in the country, caring for over 100,000 AI/AN people in 11 facilities.
In 2015, CNHS launched an HCV elimination program built on:
- universal HCV screening;
- a larger primary care workforce trained in HCV;
- harm reduction services.
Treatment used interferon-free, all-oral direct-acting antivirals.
Five years on
CNHS analyzed de-identified records from November 1, 2015, to October 31, 2020. 1,423 people were diagnosed with HCV (a detectable HCV RNA test). 61.1% were male and 38.3% female; 13.3% had advanced liver disease or cirrhosis.
The cascade of care
| Step | People | Share of all diagnosed | Share of the step before |
|---|---|---|---|
| Diagnosed | 1,423 | 100% | — |
| Linked to care (seen by an HCV-trained provider) | 1,227 | 86.2% | 86.2% |
| Started treatment | 871 | 61.2% | 71.0% |
| Returned for the cure test 12 weeks after treatment (SVR12 visit) | 702 | 49.3% | 80.6% |
| Cured — virus undetectable 12+ weeks after treatment (SVR12) | 698 | 49.1% | 99.4% |
Cascade of care, Cherokee Nation Health Services, November 2015–October 2020. CDC
Of the 871 who started treatment, 800 (91.8%) finished it. Of 98 people who finished treatment but didn't return for the 12-week test, 40 had already shown no detectable virus before that test was due. They are likely cured, but because they were tested too early to rule out a relapse they don't strictly meet the definition, and aren't counted as cured.
The gap: starting treatment
Linking people to care worked. Getting them onto treatment didn't go as well — and given how effective direct-acting antivirals are, most who did start were probably cured. The authors see several reasons for the gap:
- Oklahoma Medicaid didn't cover hepatitis C treatment for people with little or no liver scarring (fibrosis scores F0 or F1) until 2018.
- Every payer required prior authorization, so weeks or months could pass between evaluation and getting the medicine.
- Some payers required a specialist to evaluate the patient or to be consulted on the prescription — more delay.
Some people likely fell out of care while waiting.
What's next
The CNHS program can serve as a model for other health systems serving AI/AN people — but reaching elimination means closing the gaps at every step, above all the delay in getting hepatitis C medicines. For CNHS, starting treatment should be the priority. Research is needed on barriers to linkage, starting and finishing treatment, and returning for the cure test among AI/AN people, and on ways to overcome them.
Limits
- One tribal health system — results may not apply elsewhere.
- Standard ("consensus") cascade definitions were used, so the numbers aren't directly comparable with CNHS's earlier published cascades.
- Care received outside CNHS was missed, which may undercount outcomes.
- COVID-19 overlapped the last seven months and may have cut visits, treatment starts and lab tests.
Sources
Based on Essex W, Feder M, Mera J, "Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program — Cherokee Nation, Oklahoma, 2015–2020," MMWR volume 72, number 22, Centers for Disease Control and Prevention; a work of the United States government in the public domain.
Licence : CC0 1.0 (domaine public) · Adapté de www.cdc.gov
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