Hello, my name is Dr. Stacey Truskin, and I'm the Chief Medical Officer of Philadelphia FITE Community Health Centers, and a faculty member at the University of Pennsylvania Perlman School of Medicine. I'm joined today by my co-moderator, Dr. Michael Freed, who's a professor of medicine at UNC School of Medicine. Today's symposium, The Global Elimination of Hepatitis C from Ideas to Action, really sprang from ASLD's collaboration with fellow global liver associations and the Clinton Health Access Initiative. We're going to explore worldwide progress in the goal to simplify diagnostic and treatment algorithms to achieve a test and cure protocol for HCV. Today we're lucky to have global experts with us who will share landmark achievements and remaining challenges for HCV's elimination and help us brainstorm potential solutions. So without further ado, I would like to introduce today's speakers. Dr. Lessie will share with us viral hepatitis elimination strategies from Africa, followed by Dr. Wei, who will share with us strategies in Asia and the Pacific regions. Dr. Silva will speak with us about hepatitis elimination in Central and South America, and Dr. Beauty will share with us elimination strategies from Europe. Last but not least, Dr. Aronson will speak with us about elimination in North America. I would like to thank all of our speakers for their time and their expertise, and I'd like to thank all of you for spending this time with us. At the conclusion of these lectures, please join us in a breakout session to continue the conversation and to ask questions of these experts. Thank you. Hello. My name is Olufumilayo Lessie. I'm a viral hepatitis regional advisor for WHO Regional Office for Africa based in Congo-Brazzaville. And before I start, I would like to thank ASLD for inviting me to this digital experience to share viral hepatitis elimination in Africa. My outline is to highlight four important points on introduction of the global strategy, success so far in Africa, and some lessons learned to promote success. This is a graph we know very well, and the point I want to make here is that 33 of 47 countries in Africa have a prevalence of hepatitis B exceeding 5% in the general population. Therefore, the epidemic is generalized, and it is the same for hepatitis C. Half the countries have a prevalence of hepatitis C that exceeds 1% in the general population. And the importance of highlighting the generalized nature of the epidemic is that it is important in the planning of screening and treatment services. And of course, we know that globally, people who inject drugs are an important source of infection. But in Africa, generalized infection from unsafe injections, from unsafe blood transfusion over the past two decades have really been the pool of infection. However, there is a rapidly growing epidemic of people who inject drugs also. The mortality rate is 1.34 million deaths in 2016, and it's a death toll we can no longer neglect. The panel on the right shows an African patient with advanced liver cancer attributed to chronic HPV infection. The point here is that presentation is late in Africa, and clinical services are not available really for managing liver cancer. And of course, again, we know surveillance is very weak, and liver cancer, liver cirrhosis are poorly documented and usually underestimated in the region. In view of the large burden of infection, the rising death rate, the World Health Assembly endorsed the Global Strategy for Elimination of Viral Hepatitis as a public health threat by 2030, with two main impact targets related to incidence reduction by 90% by 2030 and mortality reduction of 65% by 2030. Now, modeling studies show that five core interventions with significant coverage can lead to elimination. These interventions include four preventive interventions and a major one on hepatitis B and C testing and treatment. Highlighted in yellow are the baseline targets, and highlighted in yellow are 2020 targets that are shown beside it. So what I'm trying to do is compare the progress we have made from 2015 to 2030. But before I do that, I just want to go quickly through these snapshots that have demonstrated some of the successes that the region has accomplished in the past five years of viral hepatitis. And the first is the development of the hepatitis framework to support countries in implementing the global strategy. To date, 30 countries have developed national strategic plans for viral hepatitis, even though 15 have officially launched it. In terms of data, the WHO Global Reporting System launched in 2018. We have like 12 countries who have started reporting viral hepatitis data. Right in the center of the presentation is an iconic picture taken in Rwanda that marked the beginning of their significant hepatitis response. And in terms of partnership, I want to highlight the Africa Union Cairo Declaration of Viral Hepatitis and also the Kampala Declaration by Civil Society that was done at the Africa Hepatitis Summit in 2019. So to report progress, we use a traffic light system where red reports no progress to date and green shows interventions that are on track with requiring limited action or yellow where they are completely incomplete. So if we look at hepatitis prevention interventions, we see that hepatitis B vaccinations are majorly on track, but breast dose is incomplete and harm reduction shows little progress. The global achievement of the hepatitis B targets on the prevalence of hepatitis B surface antigen in children under 5 was accomplished in 2019-2020. However, gaps still remain in the Africa hepatitis B prevalence in children less than 5 years old, which remains at 2.5%. So there is a lot more action to be done with hepatitis B in Africa. In terms of people who inject drugs, although they represent 10% of the global people who inject drug population, they are important in the hepatitis C elimination response and very little progress has been made to this issue. We look at the cascade of care for hepatitis B infections. On the right panel is the response in the WHO regions of the world and globally, we see that action is incomplete and only minor actions have been taken. What I'm trying to illustrate with this slide is data from the WHO reporting system from seven African countries show that 7.2% are on treatment and shows inadequate data and surveillance. In Africa, the hepatitis B testing and treatment gaps exceed 90% and is so much deeper than the global gaps. And the same is true for hepatitis C infection, where the hepatitis C testing and treatment action is incomplete, minor actions have been taken globally. But in the Africa region, from the data we have, the testing and treatment gaps still exceed 90%. It's interesting that major testing and treatment gaps that are influenced by hepatitis diagnostics, availability of drugs, and even the drug prices. A recent publication in the Lancet Global Health 2019, which was UHC projections for 67 low-income and middle-income countries, showed that diagnostic tests account for nearly 70% of hepatitis B cost of care. And medicines account for over 58% of HIV cost of care. And in this case, it's 31% for HCV. So the diagnostic testing and the drug treatment are an important piece of cascade of care that needs to be overcome before elimination. And the Clinton Health Access Report, hepatitis C market report, showed that there are significant differences in prices paid for, for diagnostics, and highlighting Algeria, Nigeria, Rwanda. This price variation in diagnostic tests, and even in the cost of DAA, is very important. Showing that there needs to be a lot of work done in the market to bring down prices or to standardize prices using different strategies. So the major barriers to accelerating the hepatitis response in Africa are funding, including the high cost of the tests and the drugs, DAAs. And many of these may be from fragmented procurements because of lack of public health programs. The data gaps are enormous. There's information gaps on disease and economic burden. There's little monitoring and evaluation and surveillance. In terms of engagement, there's need or there is a lack of government engagement, community engagement. And there's limited partnerships as well, both regional and international implementing partners. Even academia and professionals in the African hepatitis progress. Planning and actions are lacking in the African hepatitis. So in terms of scaling up to reach elimination, there are some lessons that we can learn globally and there are lessons we can learn from countries in Africa. So the next slide highlights three important lessons that we can learn from programs. And the first is the HIV response scale up. Simplification of guidelines, simplification of service delivery with decentralization of care is really critical to the hepatitis HIV response scale up. To date, we have two champion countries in Africa. Rwanda in sub-Saharan Africa and Egypt in Eastern Mediterranean. And strong government leadership and an integrated service delivery model were important in their success. They streamlined regional and global procurements and achieved a measure of pricing transparency for their national programs. And these are lessons we must learn in other parts of Africa to scale up. The COVID-19 response is also another lesson because now we're seeing integration of diagnostic platforms, which we must promote within the hepatitis program and the HIV and TB. In the COVID response, we're seeing focused testing, which in the hepatitis response in some countries, they have taken this on as a micro elimination where you have a pocket of hepatitis C infection. Regional and global partnerships, digital technologies have been defining features of the COVID-19 scale up. So intense efforts for vaccine development and novel therapies has been done for the COVID-19 responses needed in the hepatitis response. So the key takeaways from the presentation is that implementing a public health approach will accelerate regional response. Three messages, funding data and engagement must urgently target testing and treatment. Two, we must leverage opportunities for integration, research and innovation to accelerate the regional response. And of course, government leadership and partnerships are critical success factors. I want to thank ASLT again and some colleagues who have made this presentation easy to prepare. Thank you. Good morning, everybody. It's really an honor to be here, to be part of this global symposium. And my talk is entitled Viral Hepatitis Elimination in Central America. My name is Marcelo Silva. I'm the head of Hepatology and Liver Transplant Unit at Austral University Hospital in Buenos Aires, Argentina. I'm the current president. These are my disclosures. To start with this conference, we need to start with the targets that WHO has established for viral hepatitis elimination in 2030. And these targets are very tough targets because they request us to get a 90% reduction in new cases of chronic hepatitis B and C infection and a 65% reduction in death from chronic hepatitis B and C at the end of 2020. WHO vision on viral hepatitis elimination. And the question is why elimination and not eradication? The vision is a world where viral hepatitis transmission is stopped, that everyone has access to safe, affordable and effective treatment and care, and elimination as a public health issue of concern, removing viral hepatitis as a leading cause of mortality worldwide. And is elimination and not eradication? Because a long wave of prevalence will remain for decades. Technically, elimination is feasible by scaling up six interventions to a high coverage level. These key interventions for scale-up are hepatitis B vaccination, including birth dosing, safe injection practices and safe blood, harm reduction for injecting drug users, safer sex, hepatitis B treatment and hepatitis C cure. The regional hepatitis agenda is a bit behind when compared with the global agenda, at least the global agenda in the European countries and in North America. Hepatitis is just getting on the agenda in this region. Advances in treatment results in a greater awareness of all the access issues that we still have here. There are some champion countries that are showing us the way out, and yet there is a continued limited regional and country funding limitations. Major opportunities to move forward with key interventions to modify disease burdens are still needed. And action will always be cheaper than inaction, and preventing and treating will be cheaper. Instead of entitling this conference viral hepatitis elimination in Central and South America, we changed it a little bit to Latin America and the Caribbean. And we did that because if not, Mexico should stay out of the conference and is a very important country for the region. Latin America and the Caribbean is a region with more than 25 countries and more than 629 million inhabitants, who have different ethnicities, languages, prevalence of hepatitis B and C, routes of transmission, resources and access to care, and different models of public health systems. Although we are a very diverse region with different ethnicities, population, access to care and health systems, we do share some structural challenges to achieve WHO viral hepatitis elimination goals. Some of them are related to the type of disease, you know that viral hepatitis induces an enormous burden of disease, and the entire population could be at risk, and they produce a huge economic impact for these countries, and there are countries with poor access to care and cure, and also insufficient policy responses, with high need of high-cost patients and medicines. And the underlying reason for this usually is that we have a segmented and fragmented healthcare system, and this segmentation is related to the financial model, this mixed model that we have in LATAM, except from Brazil, in which you have at least three or four different segments, which are the ones that are the payers, and they decide their own policies, and there is a bad coordination of what is need to be done. And also we have a design of the providers that is different, it's not adequate for the type of disease that we're dealing with. We're talking about chronic asymptomatic diseases and they usually they are not close to the big hospitals and we have healthcare providers models that are hospital centric and hospital consumes a high proportion of the health budget and that creates difficulties to develop primary care networks to take care of these ambulatory patients. Therefore the consequence we have usually a poor outreach for this pathologies and or diseases. This PAHO survey regarding viral hepatitis in the region, they estimated that at least in the total of the Americas from Canada to Argentina, we have more than 7.2 million individuals that are viremic with hepatitis C, but if we look into the detail into the Latin American and Caribbean region, more than 60% of them, what it is a round number of 4 million individuals are viremic for hepatitis C and from this 4 million, the estimation is that we have 1 million cirrhotics in LATAM and the Caribbean due to this infection. So we do have a problem that is. Same survey for hepatitis B, surface antigen shows that in the blood units, the prevalence of surface antigen in the region is really low, it's always less than 1% except in Haiti. But if we look into the prevalence in the general population, we're going to see something that is really interesting, there are niches. The average is low, is less than 1, is 0.8% of the population, but we have areas in which the prevalence is extremely high. For example, in Suriname, in South America, in Peru, 2.2%, in Jamaica is 3.7%, in Haiti is 13%, Dominican Republic is 4% and one of the most interesting areas is the Amazonian basin, Brazil, Bolivia, Colombia, Peru, Venezuela, all the basin has a high prevalence of hepatitis B, surface antigen that ranges from 4% to 8%. And what is amazing on that region is that we have not only surface antigen positive but also a lot of delta superinfection. One of the most important information that I got out from this PAHO survey is the one that is related to the number of viral hepatitis national programs and their policies. Less than 60% of the countries do have national programs as per that survey. And this is incredible, with that kind of a structure it's going to be hard to have a systemic approach to the disease and to accomplish the goals of WHO. And even further, when you look into those that they answer that they do have a program, programs are weak, the efficiency of the programs are not strong enough. For example, only 45% of those that answer that they did have a program, they did have direct antivirals as the first line treatment for chronic hepatitis C. Hepatitis B was a bit better with 86% of them responding that tenofovir and entecavir were the first line therapy. And talking about the national guidelines on hep C and hep B, 60 and 73% respectively of the countries did have a guideline. But this is not enough, you can have a guideline but the guideline is not good or you have two or three or four different guidelines in a country and then you have a mess. So this kind of survey is giving us a bit of information that is critical, that is important, but those that we leave there understand that they are incomplete and imperfect. When this survey got into the laboratory capabilities of the countries in the region for diagnosing and monitoring hepatitis B and hepatitis C, we were also amazed because we did have only 63% of the countries able to genotype for hepatitis C and viral load only 72% for B and 62% for C. So it looks like countries do not have all of the tools that are needed to diagnose, to do a massive screening diagnosis and follow the patient's appropriate population. And what about the perinatal transmission, the prevention of the perinatal transmission of hepatitis B? These policies, as you can see here, again, less than 80% have HIV for exposed infants, less than 80% do test women that are pregnant for hepatitis B and only 43% of them have described the goal of eliminating maternal to child transmission of hepatitis B. Therefore, not even in the papers we look at it. Regarding hepatitis C continuous of care, the cascade, the continuous of care, it is well known that less than 25% of the hepatitis C patients have been diagnosed in the region and that less than 16% of them are being treated. So we are far behind here also. There are some countries like Brazil and Dominican Republic that establish a population treatment type of strategy, but in most of the other countries this is per demand. We diagnose, we treat and we treat only if we have social security that allow us to treat. It's not obligatory to treat them for the social security, therefore we continue to have a problem. Most of the LATAM countries are far behind the target goals for 2030, but we're positive. Why? Because we know where do we stand and we know where to go, where we need to go, and we need to change the system. If we do not change the healthcare system, we're going to be in trouble. A people-centered health system approach for viral hepatitis elimination is critical. We need a national strategic plan which includes stakeholders, patients and also clinicians. The task force should be able to achieve elimination with an adequate budget for testing and treatment and a capacity to monitor progression and strategies to retain patients within the system and adequate vigilance and surveillance in an observatory that is going to allow us to understand the right thing. Latin American countries need a bespoke strategy to be able to eliminate viral hepatitis. We have mentioned that we have so many different regions, sub-regions and insurance companies and sub-insurance type of models that we cannot deploy just one strategy. We need to accommodate this strategy to the country, to the province, to the state, to the region, to the population that we have there. But it's important to be smart. It's important to go initially for those patients that are F3, F4 to prevent mortality and morbidity and second to go for the public health threat, this is to treat the high incidence population, prevent infection in those that usually have a high prevalence and incidence like drug users, hemophiliacs, end-stage liver disease patients or veterans and at the end go for the rest of the population. Have a general base population strategy in order to be able to achieve elimination. But remember that it's not just one approach. One approach does not fit all. We need to have in mind and in context not only the context of the country, the social security, the insurance of the country, but the population. So how can elimination be affordable in Latin America? Three important things. We need a radical reduction of the treatment cost. We need to share costs with other strategies. We need innovations and efficiencies. And last but not the least, what we take from Latin American countries, energy, stakeholders, commitments and resources, a public health approach with simplification, integration, affordability and equitable access, partnership integration with governments, civil society, private sector, scientific associations and concrete and tailored actions in countries guided by national law. Thank you very much for your attentions and my apologies for my accent. Thanks again. Thank you very much for inviting me to talk about the elimination of hepatitis C in Europe. My name is Maria Buti. I am professor of medicine at Hospital Vallebron, one of the experts of the Spanish National Plan Against Hepatitis C and ESEL Policy and Public Health Chair. These are my disclosures. I would like to start by introducing WHO Europe region, which comprises 53 countries and have 741 million of inhabitants. And it is bigger than the European Union on European Economical Area, made up for 27 countries on 30 countries respectively and a population of 515 million of people. Demographic, social, political and economical situation vary across different countries, as well as the healthcare system, making the response to hepatitis C elimination in Europe complex and limited. In the WHO region, approximately 40 million people are chronically infected with HCV, leading to more than 100 deaths per year from related complications. The prevalence of anti-HCV antibodies ranging from low in countries of Western and Central Europe to intermediate and high in many countries of Eastern Europe and Central Asia. In European Union countries, deaths from viral hepatitis exceeded those from HIV and tuberculosis in 2015, making hepatitis C an important health problem. The estimated number of people living with hepatitis C in the European Union is 3.9 million and between 20 to 90% of them are undiagnosed. And the key population are people who inject drugs who have the highest HCV prevalence. In 2016, WHO set up the first global health sector strategy on viral hepatitis, aligned with the Sustainable Development Goals for the Elimination of Viral Hepatitis as a public health threat by 2030. The goals of WHO elimination strategy are a 90% reduction in the number of people infected are a 90% reduction in incidence of chronic infection and a cut in mortality of 65% by 2030. The plan identifies priority actions needed to be taken by these countries, such as blood and injection safety, harm reduction program, 90% of cases diagnosed and 80% of those eligible for therapy treated. Europe also has intermediate goals for this year shown here. The European CDC is monitoring these priorities in the European Union. The number of countries reporting care for each stage of the continuum of care decreases decreases for estimated number of patients to 25 and for SVR rates only 11 countries report this data. The proportion of people with HCV who have been diagnosed is variable across the countries and many countries don't reach the 2020 target that is 50% of people diagnosed. And also the same happens with the proportion of people diagnosed who are on treatment still low in many European countries. Hamid Razavi presented at the last ILC an update analysis of the timing of HCV elimination in 45 high income countries. Only 11 of these 45 high income countries are on track to eliminate HCV by 2030. And among them, eight are from the European Union. Iceland, Spain, Sweden, France, Switzerland, Italy, Canada, and the United Kingdom. All of these countries on track to eliminate HCV have in common a free and universal healthcare system, access to therapy for all patients, micro eliminations program, a strong political commitment, and many of them also have a national plan against hepatitis C. Let's see a specific data for the two countries that will reach first hepatitis C elimination. Iceland, a small country with a prevalence of hepatitis C 0.3%, an estimated number of total dynamic individuals between 800 and 1,000, the majority, this nation have an elimination program focused on active people who inject drugs and a strong commitment in case finding and no restrictions to treatment. Everybody can receive treatment. These are the latest data on the continuum of care reported this year, suggesting that the majority of cases has been diagnosed, treated, and cured, and probably this country might already reach the W targets. In addition, the harm reduction target has also been achieved. The second country that I would like to comment is my country, Spain. With a population of 46 million people, HCV dynamic prevalence is low, 0.22, and estimated number of dynamic individuals, approximately 76,000. A national plan against hepatitis C started in 2016. There is no restrictions to treatment that is given at hospital level. A screening of high-risk groups is recommended, and there is a commitment in case finding. These are the results, the data, on the cascade of care, and in general population, the majority of these items will be achieved by 2030, probably even before, but in few weeks, the data are still incomplete, and we need to generate more data. Finally, the last country I would like to comment is Russia. Russia has a population of 144 million of inhabitants, and anti-HCV prevalence of 4%, and the total number of people with antibodies is around 5 million. The key population, again, are fluids, but due to restrictions in the reimbursement of viremia, it is now the number of individuals that currently have active hepatitis C. DBAs are reimbursed by some regional programs. There are no genetics. Therapy is restricted to patients with advanced fibrosis. There is not a national plan, only a national or regional register, hepatitis C register, that record the patients on their treatment. Data reported for each stage of the continuum of care are scarce due to the lack of reimbursement of HCV RNA tested, and also the restrictions to treatment and high price of the drugs that has led to development of a black market. It's registered that last year, approximately 50,000 patients started therapy, but there is overall a lack of data in the different steps of HCV cascade. In addition, harm reduction programs don't exist in Russia. The situation is similar in some WHO European low-middle-income countries. As you can see in this slide, relatively high prevalence of HCV infection, but restrictions to treatment in the majority. Finally, one of the steps important for hepatitis C elimination is harm reduction programs. This is probably one of the main weakness in Europe. The coverage of these programs is very low, particularly in Eastern European countries. In many countries, it's not possible to calculate. In summary, there are challenges for HCV elimination in Europe, such as a lack of robust and updated estimates of prevalence, incidence, and population size. Gaps in data availability on continuing of care, particularly for key populations such as people who inject drugs, affordable diagnostic tests and drugs are needed in many countries to scale up the cascade of care. There are suboptimal harm reduction programs, and finally, the negative impact of COVID-19 pandemic in hepatitis C elimination programs. To sum up, hepatitis C elimination in Europe by 2030, it's still a dream in many of the WHO European countries. Only a limited number of countries are on track to meet the WHO goals. Most European countries lack a comprehensive overview of their local situation to inform an effective response. Improvement in the cascade of care are mandatory, including wide HCV screening, affordable drugs to remove treatment restrictions, and the development of preventive policies to enable HCV elimination. I would like to acknowledge Erika Dufel and Vasily Isakov. Both have provided me data for this presentation. Many thanks again for the invitation. Hi, my name is Andrew Aronson, and today I'm going to be talking about viral hepatitis elimination in North America. I'm a transplant hepatologist at the University of Chicago, and I'm a member of the ASLD IDSA Hepatitis C Guidance. I've also worked as a committee member for the National Academy of Medicine Strategy for the elimination of hepatitis B and C. I also work on capacity building in my city through HCV Echo Chicago. I don't have any relevant financial disclosures. First, I'll give an overview of my talk. As you can see, I'm going to be focusing on Canada, the United States, and Mexico. Of course, there are other North American countries that are putting in significant efforts towards hepatitis C elimination, but due to limitations in time, I'm only going to be discussing these three largest countries. With Canada, I'll be focusing on priority populations, prevention of hepatitis C, and highlighting a micro-elimination project. In the United States, we'll talk about access to treatment as well as capacity building and I'll provide some data about current hepatitis C status in Mexico. First, I'd like to focus on the big picture. As you can see from this map provided by the CDA Foundation, this looks at the elimination targets for the WHO elimination, for hepatitis C elimination by 2030. You can see here red means not on track to the WHO guidelines, yellow means working towards these guidelines, and green is on track. Unfortunately, you can see most countries are red, meaning that they are not on target to the WHO recommendations for hepatitis C elimination by 2030. Canada is doing a little bit better, which I'll show you, and is working towards these goals. First, looking at hepatitis C in Canada, as you can see, the prevalence does vary based on the province. Recently, a blueprint was published that is aimed to inform hepatitis C eliminations within the country. Some of the key features of this blueprint are addressing stigma, going into some detail about priority populations and how to reach these folks and to get them treated, federal recommendations, monitoring progress of these efforts, prevention of hepatitis C, diagnosis and testing of hepatitis C, and care and treatment for patients who are infected. Priority populations is something that the Canadian blueprint really spends a lot of time going into detail about how to address these populations, get them into care, and get them treated. In Canada, about 66 percent of people who inject drugs have a past or current hepatitis C infection. About a quarter of people with experience in the prison system have been exposed or have a past or current hepatitis C infection. Up to 75 percent of all infections in Canada are among people born between 1945 and 1975. Finally, it focuses on endemic immigrant populations, that up to 35 percent of all hepatitis C infections in Canada are among immigrants and newcomers, especially if they come from endemic areas. The Canadian blueprint really discusses in detail these priority populations and some of their unique needs. Another thing that the Canadian blueprint talks a lot about and make some very strong recommendations is the importance of prevention. What I want to highlight here is needle syringe programs and opioid agonist therapy in Canada. The WHO recommends about 300 needle or syringe sets needed per person who injects drugs per year for safe injecting practices, and 40 opioid agonist therapy treatments per 100 people who inject drugs every year as well. You can see that Canada is doing quite well in these two areas. When looking at opioid agonist therapy, their average is about 66 per 100, which is well over the WHO recommendation of 40. You can see there is some variation depending on what province you're looking at. Also for needle and syringe exchange, they're at 291 based on this data published last year. Also with some variability based on province, but you can see in many provinces, they're doing quite well and have lots of access and good penetrance of needle and syringe exchange. Although there's a lot more to go on about the Canadian blueprint, I do want to highlight the importance of micro-elimination and Prince Edward Island is a great example of this. They are on track to eliminate hepatitis C by 2025, and this was recently published, some of these efforts. Of course, Prince Edward Island being relatively small and somewhat isolated is helpful in achieving some of these efforts. But I think this is a really good model, and I know there's models all around the world that are doing this even on a larger scale, but I think I would highlight this. What they have leveraged is centralized triage and intake, really making sure there's enough hepatitis C treatment specialist. Of course, no fibrosis restrictions for DAA therapy, making sure patients are educated, individualizing follow-up, and of course, creating a robust treatment registry, which has helped monitor progress and show needs to reach target goals. This is also data from the CDA Foundation looking at hepatitis C elimination in Canada. You can see there's about 212,000 estimated infections within the country. About 75 percent are diagnosed. You can see on the lower graph, they are close to being on target for the 2030 goals with cumulative diagnosis, certainly with blood safety and injection safety, as well as syringe exchange, but are still need to make some progress with hepatitis C treatment, but are on their way. Moving to the United States, in 2016 and 2017, the National Academies of Medicine had published two phases of a report, two reports looking at hepatitis C and B elimination in the United States. This was sponsored by the CDC, HHS, National Viral Hepatitis Roundtable, the IDSA, and the ASLD. The first question for the first report was whether it is feasible to eliminate hepatitis B and C in the United States by 2030. The answer from the first report is yes, but not likely without attention to some very serious barriers. Then in the second report, it goes into the strategy to eliminate viral hepatitis from the United States, looking at targets for diagnosis and treatment, essential interventions, service delivery, financing, and as well as research. Starting with targets, it is a fairly ambitious goal to get to where we need for hepatitis C elimination by 2030. This would entail treatment without any restrictions on severity of disease, and to consistently diagnose new cases even as a prevalence decreases, and you can see this in the arrow above. The goals will need to be about 110,000 diagnoses per year by year 2020 or this year, 89,000 diagnoses per year by 2025, and 70,000 diagnoses per year by 2030. This is ambitious, but will be needed in order to reach elimination goals. Next is essential interventions, and I really want to focus here on treatment access. This is data below from stateofhepc.org, and what this essentially does is give a report card to every state, how well their Medicaid programs are doing in order to achieve access for the patients in that state to receive DAA therapy. The report card is based on three major topics. The first is fibrosis restriction, so whether all patients can get DAAs or whether this is just reserved for patients with advanced fibrosis. The next is sobriety restrictions, so whether DAAs are available no matter if there's a history of substance use. Finally, provider restrictions, whether DAAs can be provided by anybody or requirements for subspecialists like transplant hepatologists or infectious disease doctors or gastroenterologists. The darker the shade of red, the worse the grade. You can see F is dark red and A is a very light red. You can see comparing 2017 to 2018, the needle has moved quite a bit. Many states were teetering on the F category, whereas in 2020, they're much better. Now, though we're not perfect yet in many states, there has been quite a bit of improvement in this relatively short period of time. The National Academy of Medicine supports these efforts by stating that public and private health plans should remove these restrictions, and this is something that's. The last thing I want to highlight within the United States is capacity building. There are models that estimate about 260,000 people will need to be treated every year. This is something that is unlikely to happen just with specialist treating, so task shifting is going to be needed. It is recommended that the ASLD and the IDSA partner with primary care providers to allow for treatment more in the community. Project ECHO, which many of you are familiar with, is a great example of this. This is something that I'm involved in in Chicago, and you can see from the start of our project, this is a map of Chicago. We've trained quite a few primary care providers, and this has really improved access in our city. Although we still have a lot of work to do with elimination within our city, we've made the first steps by building capacity. Some data for elimination as our progress report, about three million people in the United States infected with 63 percent diagnosed. We still have some ways to go with diagnosis, doing well with blood safety and injection safety, but still have quite a ways to go with cumulative treatment as well as syringe exchange penetrance throughout our country. I'd like to conclude by giving a few words about Mexican hepatitis C treatment and elimination efforts and direct your attention to the consensus of treatment for hepatitis C in Mexico, which was recently published, which does go into some of the important factors for elimination in widespread treatment within that country. You can see here about half a million people in Mexico with hepatitis C and still have some way to go as far as diagnosis with only 49 percent. Blood safety and injection safety are doing quite well, but cumulative treatment as well as needle syringe exchange programs will need to be increased. The take-home point, many North American countries are well behind the WHO targets for hepatitis C elimination. Some of the key aspects are priority populations, reducing transmission, surveillance, access, and capacity building, and highlighting the importance of micro-elimination as a model of hepatitis C elimination moving forward. Thank you so much for your time.

hepatitis C

global elimination

symposium

diagnostic algorithms

treatment protocols

viral hepatitis

priority populations

stigma

micro-elimination projects