By Zach Krauss, PharmD and Sarah Leupold, PharmD
Hepatitis C Virus (HCV) is a viral infection that causes liver inflammation, sometimes leading to serious liver damage. It is primarily spread through contaminated blood, such as through the use of shared drug needles, sexual contact, or childbirth. HCV is a major public health concern, with an estimated 71 million people worldwide living with the virus. It can be a silent disease, with many people unaware that they have it until they have significant liver damage.(1-3)
Although HCV can be a burdensome disease, the treatment landscape has drastically changed in the last 10 years, leading to efficacious and safe treatment options. The current mainstay of HCV treatment, direct-acting antivirals (DAAs), can cure the infection in the majority of patients with success rates of 95% or higher. In addition, the DAAs are well tolerated, administered orally, and have short treatment durations.(3-5)
In 2020, the U.S. Preventive Services Task Force (USPSTF) updated their Hepatitis C Screening guidelines to include a one-time screening of all adults aged 18 to 79, regardless of risk factors.(6) Prior to this, only adults born between 1945 and 1965, in addition to persons at high risk, were recommended for screening.(7) Given this expansion of screening, more individuals will be found living with HCV, requiring a robust response from the healthcare system to overcome barriers to care. Pharmacists have the potential to play a key role in this response given their increasing presence in the primary care setting and ability to help in many stages of the HCV Care Continuum.(8)
Figure 1: HCV Care Continuum Graphic (8)
The HCV Care Continuum is a term used to describe the steps that must be taken to prevent, screen, and treat HCV. Currently, there are many barriers that exist due to limited knowledge of HCV among patients and providers, as well as transitions of care challenges that arise with specialist visits. Transitioning HCV care, with proper provider and support staff training, from specialty to primary care solves many of these challenges and allows for better care of our patients.
Primary prevention, the first aspect of the continuum, is heavily focused on risk and harm reduction in at-risk populations. Barriers to primary prevention include lack of syringe access programs and untreated mental health and substance use disorders. This creates an opportunity for pharmacists in a primary care clinic to create services for clean syringe exchange and referral to appropriate mental health services. People who inject drugs (PWID) have a seroprevalence anywhere from 10-70% and it is essential to acknowledge that active or recent drug use is not a contraindication to HCV treatment of any kind.(9)
Early testing, diagnosis, and chronic infection identification is important to ensure management is carried out before extensive damage occurs. Barriers include poor awareness surrounding testing options, inadequate health insurance, and disruptions in transition of care to an HCV specialist. Primary care provider education and prompt patient follow-up to any positive cases within the patient’s primary care setting can speed up the time to treatment initiation.
Treatment is an essential step in the continuum to prevent long-term complications of HCV. Barriers to treatment include lack of prescription coverage and high treatment cost, inexperience with treatment options and prescribing, and low HCV provider reimbursement. This stage is where pharmacists can play a vital role. By implementing a collaborative practice agreement, pharmacists have the ability to complete a pre-treatment assessment and regimen determination. This can include an assessment of drug interactions, laboratory evaluation, and treatment selection based on patient characteristics. In addition, an HCV specific visit can be scheduled with the patient to counsel on their regimen and address any concerns, which can increase their chance of adherence and follow-up. Lastly, pharmacists have the knowledge to complete prior authorizations or patient assistance program applications to eliminate the barrier of cost.
Finally, sustained viral response (or HCV cure) is our end goal of the Care Continuum. Once a patient is cured, it is essential for providers to prevent reinfection by educating on harm reduction, such as avoiding alcohol and drugs as well as getting vaccinated for hepatitis A and B.
Overall, pharmacists and the rest of the primary care team have the opportunity to play a vital role in the management and treatment of HCV by ensuring that patients receive the appropriate medication, education, and monitoring. By working closely with patients and other healthcare professionals, pharmacists can improve the outcomes of HCV treatment and reduce the burden of this disease on individuals and society.
1. Hepatitis C. Centers for Disease Control and Prevention. 2019. Accessed May 11, 2023. https://www.cdc.gov/hepatitis/hcv/index.html.
2. Hepatitis C FAQs for Health Professionals. World Health Organization. 2021. Accessed Mary 11, 2023. https://www.who.int/hepatitis/topics/hepatitis-c/faq/en/.
3. Hepatitis C in Primary Care. American Academy of Family Physicians. Accessed May 11, 2023. https://www.aafp.org/afp/topics/view/22081.
4. Hepatitis C: Diagnosis and Treatment. American College of Gastroenterology. Accessed May 11, 2023. https://gi.org/topics/hepatitis-c/.
5. Hepatitis C Antiviral Therapy. American Association for the Study of Liver Diseases. 2021. Accessed May 11, 2023. https://www.hcvguidelines.org/full-report/antiviral-therapy-chronic-hepatitis-c.
6. U.S. Preventive Services Task Force. Final Recommendation Statement: Hepatitis C Virus Infection in Adolescents and Adults: Screening. Accessed January 10, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/hepatitis-c-screening.
7. U.S. Preventive Services Task Force. Final Recommendation Statement: Hepatitis C: Screening. Accessed January 10, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening-2013.
8. Zhou K, Fitzpatrick T, Walsh N, et al. Interventions to optimise the care continuum for chronic viral hepatitis: a systematic review and meta-analyses. Lancet Infect Dis. 2016;16(12):1409-1422. doi:10.1016/S1473-3099(16)30208-0.
9. Key Populations: Identification and Management of HCV in People Who Inject Drugs. Infectious Disease Society of America website. Accessed January 10, 2023. https://www.hcvguidelines.org/unique-populations/pwid.
Zach Krauss, PharmD
Class of 2023
Cedarville University
Sarah Leupold, PharmD
PGY1 Community Pharmacy Resident
Rocking Horse Community Health Center
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