Equitable access to direct-acting antivirals: Canada's path to a hepatitis C-free tomorrow

To the Editor,

The Blueprint to Inform Hepatitis C Elimination Efforts in Canada outlines the necessary steps for Canada to achieve the WHO targets (1), which complements the Public Health Agency of Canada action plan on sexually transmitted and bloodborne infections (STBBIs) (2). Fortunately, with the implementation of direct-acting antivirals (DAAs) into many diverse care settings, elimination may be within reach by 2030 in many provinces (3). At the time of the publication of the Blueprint, one of the six groups identified as a priority focus was newcomers and immigrants. Notably, this population accounts for a disproportionate number of HCV cases in Canada (4,5); and importantly, a recent single centre study found that, on average, 17 years passed from immigration to first assessment (6).

Many challenges remain related to HCV screening and linkage to care for this population. However, even once linked to care, access to treatment is not universal. In 2022, an estimated 2.8% of the Canadian population was ineligible for either public or private prescription drug coverage (reviewed by Snell et al. (7)). This point was a major consideration during the development of The Ontario Hepatitis C Elimination Roadmap that follows the Blueprint to guide HCV policy in Ontario. It was noted that ‘most’ but not ‘all’ have access to treatment (8). Specifically, for those who are accessing Interim Federal Health (IFH), DAAs are listed (9); and once connected to provincial health insurance, reimbursement is available through provincial coverage, and co-pay through patient support programs (10). However, a plan of action must also be developed for those who cannot access IFH or provincial insurance, but who are living in Canada, and are medically uninsured. Importantly, such persons may have recently moved to Canada, or may have been in Canada for years or even decades (e.g., current or expired student, work, or visitor's visa).

HCV is a chronic viral infection that can be treated in 1–2 visits. It is important that a shift begin among federal and provincial policy makers and government to allocate public funding to adopt a ‘treat-all’ approach to eliminate HCV in Canada. This same approach has already been adopted in public health settings to treat bacterial STBBIs such as chlamydia, gonorrhea, and syphilis, as well as tuberculosis; where treatment is straightforward and has major public health benefit. Funding HCV treatment for those who are medically uninsured is a crucial step towards equitable access and will prevent transmission as well as the long-term consequences of untreated HCV.

Contributions:

All authors contributed to the writing and editing of this letter.

Competing Interests:

MJ Biondi reports receiving research support and consulting fees from AbbVie, Gilead, Abbott, Specialty Rx Solutions, and McKesson Canada. JJ Feld reports receiving research support and consulting fees from AbbVie and Gilead. No other competing interests were declared.

Abbreviations:

DAAs, direct-acting antivirals; IFH, interim federal health; STBBIs, sexually transmitted and bloodborne infections.