A five-year evaluation of the Cherokee Nation Health Services (CNHS) hepatitis C virus (HCV) elimination program found that 86% of people diagnosed with the virus were linked to care and 99% of those who completed antiviral therapy were cured, according to a new report from the Centers for Disease Control and Prevention (CDC). But about 40% did not start treatment, showing that there is still room for improvement in access to care.

“CNHS’s Hepatitis C Elimination Program can be used as a model for other health systems serving [American Indian and Alaska Native] persons; however, barriers to HCV treatment initiation need to be addressed to achieve HCV elimination,” Jorge Mera, MD, of CNHS, and colleagues concluded.

American Indians and Alaska Natives are disproportionately affected by hepatitis C and other types of liver disease. In 2020, these groups had the highest rates of acute HCV infection and HCV-associated mortality, according to the CDC. Higher rates of injection drug use, alcohol use and lack of access to health care in the community are thought to play a role.

In 2015—a few years after the advent of direct-acting antiviral therapy—the Cherokee Nation Health Service, the CDC, the Oklahoma Department of Health and the University of Oklahoma launched an initiative to eliminate hepatitis C in this population, aided by a $1.5 million federal grant. Gilead Sciences, a major producer of direct-acting antivirals, also contributed funding. One of the two largest American Indian tribes in the United States, the Cherokee Nation counts more than 141,000 citizens living on its reservation in northeastern Oklahoma.

The program’s goals are to screen 85% of people who access the CNHS, link 85% of people with current active infection to care, treat 85% of those linked to care and cure 85% of those who start treatment. Strategies include expanding the hepatitis C primary-care workforce; incorporating patient navigators, case managers, community health workers and drug and alcohol counselors; decentralizing hepatitis C care to include outlying clinics; and offering harm reduction, such as medication-assisted treatment for opioid use disorder.

While most hepatitis C efforts initially aimed to test people assumed to be at greatest risk for HCV infection and to treat those with more advanced liver disease, the CNHS program took a universal approach, seeking to screen all adults and treat everyone diagnosed with active hepatitis C as soon as possible. Testing is offered during routine medical and dental care and at emergency care facilities, and children born to mothers with HCV and those who don’t know their status are tested soon after birth. (In 2020, the CDC updated its guidelines to recommend that all American adults should be screened for HCV at least once.)

By 2017, nearly half of the eligible Cherokee Nation population—about 46,000 people—had been tested for hepatitis C, according to an August 2017 update. A 2020 analysis by Mera and colleagues, published in JAMA Network Open, tracked how many people accessed care from November 2015 through August 2017, with cure outcomes through April 2018.

In that analysis, 793 people were found to have active HCV infection, 664 of them (84%) were evaluated for treatment, 394 of those (59%) started therapy and 335 treated individuals (85%) achieved a sustained virological response 12 or more weeks after completing therapy (SVR12), which is considered a cure. At that point, the 85% cure goal was reached, and the 85% linkage to care goal was nearly reached, but screening (44%) and treatment initiation (59%) “required more time and resources,” the study authors concluded.

Now, Mera and his team report updated findings on access to care through October 2020, with cure outcomes through April 2021.

As described in the CDC’s Morbidity and Mortality Weekly Report, five years after implementing the elimination program, 1,432 people have been diagnosed with active hepatitis C. In this analysis, 61% were men, about one quarter each were ages 31 to 40 and 51 to 60—indicating that many would have been missed if screening had been limited to baby boomers—and 13% had already developed advanced liver disease or cirrhosis.

Among those diagnosed, 1,227 people (86%) were linked to care. Of these, 871 people (71%) started antiviral treatment, 800 of them (92%) finished treatment and more than 99% of those who completed therapy and returned for posttreatment testing were cured. While this cure rate is impressive for those who finished treatment, just 61% of all diagnosed individuals started therapy, and only 49% were cured.

“Although CNHS has linked the majority of persons diagnosed with HCV infection to care, and those who returned for the SVR12 visit had high cure rates (99.4%), treatment initiation was lower than expected,” Mera and colleagues concluded. “Future activities should prioritize addressing gaps in treatment initiation after linkage to care and confirmation of hepatitis C cure with SVR12 testing.”

“[A]lthough linkage to care has been successful, treatment initiation continues to be a barrier to achieving HCV elimination within the Cherokee Nation,” the authors wrote in their discussion of the findings. Oklahoma’s Medicaid program did not cover hepatitis C treatment for people with little or no liver fibrosis until 2018. Prior authorization for treatment was required, and in some cases, months might have elapsed between initial evaluation and availability of antiviral medications. What’s more, some payers required evaluation by a specialist rather than a primary-care provider. “These delays might have led to some persons falling out of care,” they suggested.

“To achieve HCV elimination, the reasons for the gaps at each stage of the cascade of care need to be addressed, especially the delay in the acquisition of hepatitis C medications,” the authors wrote. “For CNHS, emphasis on treatment initiation should be a priority. Future research should explore barriers to linkage to care, initiating treatment after HCV evaluation, completing treatment and returning for the SVR12 visit among [American Indian and Alaska Native] persons as well as interventions to address these barriers.”

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