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Invited Commentary
Public Health
May 6, 2020

Elimination of Hepatitis C Virus Infection in Canada—It Is Achievable, But Is the Rest of the World Ready to Join in the Effort?

Author Affiliations
  • 1Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
JAMA Netw Open. 2020;3(5):e204355. doi:10.1001/jamanetworkopen.2020.4355

Pharmaceutical innovations with highly effective direct-acting antiviral (DAA) regimens over the past decade have created the opportunity for society to rid itself of chronic hepatitis C virus (HCV) infection, and organizations have worked to develop eradication strategies.1,2 The ability to achieve this public health goal will require various stakeholders to work together to ensure widespread implementation of multiple efforts, including promotion, screening, treatment uptake, monitoring, and prevention.1,2

Binka et al3 use modeling techniques to assess Canada’s ability to meet the World Health Organization (WHO) elimination targets by 2030.2 The authors report the potential outcomes associated with different treatment strategies to reach HCV-associated liver morbidity and mortality targets by using a Markov model that incorporates country-level infection prevalence, diagnoses and incidence, disease progression, and treatment uptake and effectiveness. Despite some limitations in their approach, the authors provide an informative model to aid the Canadian government in decision-making while it attempts to address this disease burden.

One potential consideration for the modeling of HCV elimination may be the consequences of treatment success for high-risk behaviors associated with HCV infection. Research that was recently conducted in a Swiss cohort study of individuals with HIV found that DAA treatment uptake was potentially associated with reductions in HCV incidence, but these improvements were counterbalanced by new infections in populations in which high-risk behaviors were not reduced.4 An unintended consequence of a new highly effective treatment for a communicable disease is the potential for high-risk behaviors to increase, as some at-risk patients may not fear a curable disease enough to adhere to recommended preventive strategies.5 While this unintended consequence should not discourage policy makers from investing in preventive or therapeutic strategies, it does require additional considerations to ensure overall program effectiveness. As the Public Health Agency of Canada launches a multipronged approach to educate, screen, treat, and monitor current and potential patients with HCV infection, it may have to swim upstream against a current of reinfection if high-risk behaviors increase.

International travel and tourism may create additional challenges for a single-country elimination strategy. In 2018, Canadians made approximately 27.7 million trips to the United States and another 10.3 million trips to other countries around the globe.6 Further complicating matters, approximately 300 000 immigrants settle within Canada annually.7 Binka et al3 use incidence assumptions that result in a reduction in new infections by using data from the Public Health Agency of Canada and expert consensus. If the source for a proportion of these new infections were outside of Canadian jurisdiction (owing to travel abroad or from foreign visitors), then the actual reduction may be limited. Foreign disease exposure combined with potential behavioral changes could challenge the disease incidence assumptions derived from previous estimates. This exposure may be something that the Public Health Agency of Canada plans to monitor and update accordingly. The resources and effort required to update the inputs of an existing model are substantially lower than the investment in building the initial model represented in this publication. Changes in infection incidence after implementation would be valuable information for other governments or private payers who are interested in disease eradication.

Any single country may invest substantially in eliminating HCV, but if their neighbors in the global community do not address HCV infection, then it will be difficult to reach country-specific elimination goals. The costs incurred by the Canadian government to cure HCV infections that are associated with viral exposure in the United States may be something to consider during larger commerce and trade negotiations. A Canada free of HCV should help leverage greater public health actions in the United States and beyond.

As countries negotiate pecuniary contributions for joint efforts associated with peacekeeping, environmental protection, or other causes, investments made to reduce communicable diseases may be germane to the discussion. We are a global society, and our policies need to reflect that. As the Canadian government moves forward with public health efforts, simultaneous foreign relations efforts should be conducted to encourage an international movement. Given our proximity and the frequency of travel between citizens of the 2 countries, a joint US-Canadian effort would go a long way toward ensuring the success of this initiative.

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Article Information

Published: May 6, 2020. doi:10.1001/jamanetworkopen.2020.4355

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Mattingly TJ II. JAMA Network Open.

Corresponding Author: T. Joseph Mattingly II, PhD, 220 Arch Street, 12th Floor, Baltimore, MD 21201 (jmattingly@rx.umaryland.edu).

Conflict of Interest Disclosures: Dr Mattingly reported receiving personal fees from Bristol-Myers Squibb, G&W Laboratories, the Massachusetts Health Policy Commission, and the National Health Council outside the submitted work.

Strom  BL, Buckley  GJ, eds.  A National Strategy for the Elimination of Hepatitis B and C: Phase Two Report. National Academies Press; 2017.
World Health Organization. Global Hepatitis Report, 2017. World Health Organization; 2017. Accessed March 26, 2020. https://apps.who.int/iris/bitstream/handle/10665/255016/9789241565455-eng.pdf;jsessionid=29B7A15D0CAC3F44351DB12E2669E858?sequence=1
Binka  M, Janjua  NZ, Grebely  J,  et al.  Assessment of treatment strategies to achieve hepatitis C elimination in Canada using a validated model.   JAMA Netw Open. 2020;3(5):e204192. doi:10.1001/jamanetworkopen.2020.4192Google Scholar
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