November 7, 2018 / All Stories

HCV elimination: the next frontier

Ending the public health threat of hepatitis C means going beyond medicine.

Defying dogma

Viruses can't be cured.

That’s what Andreas Pangerl was taught in medical school.
“The dogma was, it just wasn’t possible,” says Pangerl, senior medical director, hepatology, AbbVie. “There wasn’t a single example of specifically curing a viral disease. We could prevent some through vaccinations, like with smallpox or polio, try to stimulate the immune system, but when it came to specifically treating a viral disease there was no option… even in HBV or HIV, the moment you go off therapy, the virus could come back. ”
But here he sits, discussing what it will take to eliminate a viral disease, hepatitis C (HCV), on a global scale.
Pangerl has witnessed the evolution of HCV, events that occurred in an unbelievably short time span. Approximately 30 years after researchers first identified the hepatitis C virus, the majority of those infected with the disease can achieve a virologic cure,* and the World Health Organization has now set a goal for elimination of HCV as a public health threat for the year 2030 – less than twelve years from now. 

The scientific achievement of beating a virus at its own game (in only 30 years, no less) is ample cause for celebration. Yet for those trying to eliminate HCV, the journey is just beginning. Because that old medical school dogma was partly true: maybe viruses can be cured* after all, but they aren’t easily eliminated.

Beyond medicine

On the surface, the problem of elimination seems straightforward. There’s a known disease, a simple way to diagnose it, and effective treatments.

But HCV can be asymptomatic for years. Public health campaigns around the world have effectively reached some demographics of patients (for example, in the United States, campaigns directed at the “baby boomer” generation have helped reduce the disease in older Americans), but now the virus disproportionally affects people within the prison population and those who use drugs.9,10 In other words, HCV involves an unaware, infected population that may not have access to or trust for the medical establishment.

“We have to recognize that a lot of the people to whom we have the privilege of providing care are living on the margins of society," says Dr. Brian Conway, an infectious disease specialist in Vancouver, Canada. “There are many who are infected with HCV who might be watching the news, and see an advertisement to get tested and get treated and will respond to it. But there are so many others who don't fit that mold, perhaps millions of active drug users who are living with hepatitis C, for whom a different approach is needed. We need to reach them, too." 
Getting these harder-to-reach patients diagnosed and treated requires out of the box thinking that marries public health, sociology, logistics and medicine.
“Now, we can seriously talk about elimination,” Pangerl says. “But that means our collective scientific consciousness needs to move on from reporting of clinical data to the challenge of elimination.”

Targeting the missing millions

The first step to making a medicine is finding a target: you must understand the molecular mechanism of a disease, and then seek out a way to intervene with that process.
To play their part on the path to eliminating HCV, AbbVie’s health economics and outcomes research (HEOR) scientists are looking for targets of their own – ways to find  the “missing millions” of people infected with undiagnosed or untreated HCV.
Even when testing efforts are successful, those testing positive don’t always end up getting treated, due to systemic and psycho-social barriers. So Steven Marx, director, HEOR, AbbVie and his team looked for a way to better understand if the missing millions were actually missing, or just not getting the care they needed.
“In the United States, we had limited information from a geographic standpoint about how many people had been tested and treated,” Marx says. “The data we did have varied from state to state; a lot of it was outdated and before recent outbreaks in several areas.”
Looking at data gleaned from the lab reports of over 17 million people tested for HCV in the United States, Marx’s team began developing a system that could identify pockets of untreated patients down to the three-digit zip code.
“Using machine learning, we came up with a way of predicting, with very high probability, whether patients who had been tested had received care,” Marx says. “We wanted to have a way of collecting this data and sharing the results with the HCV community at large … not only can this information help identify the need for an improved care cascade in specific areas, but it can also help clarify ‘what good looks like’, and ‘where good is’ in terms of reaching the missing millions in our country.” 

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One at a time

Since health systems around the world face disparate challenges, there likely isn’t a one-size-fits-all strategy that can lead to worldwide elimination. Finding replicable strategies that work across populations with similar characteristics could be helpful, Pangerl says.
“What works well as an elimination strategy in an American prison may not work well in a homeless shelter in Germany,” he explains. “But let’s say someone with a prison population in a different country can see how that American prison successfully approached their problem – then, they can look at what was done and replicate it.”
This is the philosophical argument behind the concept of micro-elimination, where efforts are made to treat every last person living with HCV in a smaller, more targeted group. It may not seem like the fastest way to achieve the WHO goals for 2030, but the hope is that this type of customized approach may allow public health experts to address the societal barriers that make elimination so difficult.  In other words, it’s not just about eliminating HCV, but figuring out how to do so in a sustainable, scalable way.
To help accomplish this goal, AbbVie is launching several micro-elimination projects around the world, funding and eliminating hepatitis C in smaller settings, with the goal of replicating elsewhere.
“Eliminating the disease is of course an incredible goal for those in the medical field; it’s the pinnacle of public health. But thinking of that one patient at a time, for me, is really important,” Pangerl says. “It’s not just a number. It’s about changing that one additional life.” 
*In HCV, cure means that the virus is undetectable 12 weeks or more after completing treatment. This is also known as a “sustained virologic response”, or SVR. (Source: U.S. Department of Veteran Affairs)

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Raquel Powers
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