Canadian Association for the Study of the Liver (CASL) 2015 Winter Meeting
CASL 2015. Abstract A22. Feasibility of Hepatitis C Virus Disease Elimination in Canada Within Two Decades.
R. Myers(10), M. Krajden(4), A. Ramji(5), K. Peltekian(6), K. Kaita(7), P. Marotta(8), S. Borgia(2), S. Shafran(9), M. Bilodeau(1), M. Swain(10), H. Shah(3), J. Feld(3), C. Estes(11), H. Razavi(11), M. Sherman(3)
1. CRCHUM, Montréal, QC, Canada; 2. McMaster, Hamilton, ON, Canada; 3. University of Toronto, Toronto, ON, Canada; 4. BCCDC, Vancouver, BC, Canada; 5. GIRI, Vancouver, BC, Canada; 6. Dalhousie, Halifax, NS, Canada; 7. University of Manitoba, Winnipeg, MB, Canada; 8. UWO, London, ON, Canada; 9. University of Alberta, Edmonton, AB, Canada; 10. University of Calgary, Calgary, AB, Canada; 11. CDA, Louisville, CO.
Background: The burden of hepatitis C virus (HCV)-related sequelae is increasing in Canada.
Aims: To examine the impact of novel antiviral regimens on disease burden and explore the feasibility of HCV disease elimination from Canada within the next two decades.
Methods: Using a system dynamic model, we quantified the HCV-infected population in Canada (2014-2035). 36 age/gender-defined cohorts were tracked to define HCV prevalence, complications and mortality. Baseline assumptions, transition probabilities and SVR rates were extracted from the literature, and the availability of novel treatments (Rx) was based on expert opinion (2016: all-oral Rx for G1-3; 2018: pan-genotypic all-oral Rx). In the ‘base case', only patients with ≥F2 fibrosis were treated and no increase in Rx uptake over current levels (3,600 patients/yr) was assumed. Additional strategies modelled a stepwise increase in Rx due to the availability of novel agents (2015: 7,200 patients/yr; 2016-17; 10,800; and 2018-35: 20,000) and different fibrosis restrictions (≥F0, ≥F1, ≥F2 and ≥F3). Finally, a ‘progressive strategy' with a gradual decrease in fibrosis threshold (≥F2 until 2018; ≥F1 until 2022; ≥F0 from 2022-35) was modelled. A sensitivity analysis examined the impact of Rx volume increases (1- to 6-fold increase in Rx rates) on outcomes. The primary endpoint was disease elimination (>95% reduction in HCV infections, decompensated cirrhosis, hepatocellular carcinoma [HCC] and liver-related deaths).
Results: In 2014, we estimated 250,859 HCV-infected cases in Canada including 2,171 with decompensated cirrhosis, 802 with HCC and 824 liver-related deaths. In the base case, 174,941 viremic cases will remain in 2035 (30% decline from 2014), but increases in decompensated cirrhosis (32% [n=2,866]), HCC (108% [n=1,667]) and liver-related deaths (84% [n=1,516]) will be observed. The five selected strategies of increased Rx uptake could eliminate HCV-related complications by 2035; to achieve a dramatic decline in HCV prevalence, strategies limiting fibrosis restrictions would be needed. However, the ‘progressive strategy', treating those with more severe liver disease first, was most efficient in achieving elimination of infections and complications. Above 10,800 patients/yr, all Rx scenarios resulted in similar declines in morbidity and mortality by 2035.
Conclusions: With the availability of novel antiviral regimens, elimination of HCV infections and hepatic complications from Canada within two decades are achievable.
CARE Faculty Canadian Perspective:
This study is incredibly important Canadian work. Treating HCV in small numbers will not impact the overall public health burden of the disease according to several analyses, but how much HCV we should be treating in Canada is unknown. This paper provides practical policy approaches to possibly eliminate HCV from Canada, with the best approach being one that treats patients with more advanced fibrosis today, then expanding to patients with less advanced disease. Coupled with creative methods to amortize the costs of HCV meds, this strategy really could work. Of course, HCV will never be eliminated with treatment alone, but a sizeable advance could be made in reducing the complications of this curable infection with a ‘progressive strategy’.
- CARE Liver Disease Faculty