Hepatitis C Virus (HCV) is a growing public health threat largely driven by injection drug use and the opioid crisis. HCV is both a preventable and curable disease state and thus, can and must be eliminated as a public health threat. The World Health Organization (WHO) has defined elimination as a 90% decrease in new chronic HCV infections and a 65% reduction in mortality utilizing 2015 population data as the baseline. Elimination of HCV as a public health threat requires strategic planning on the global, national, state/jurisdictional, and local level. Efforts must be targeted to educate the public, prevent transmission, improve screening and diagnosis efforts, increase access to curative therapies, and reduce disparities across the entire HCV care cascade. While large scale planning on a global and national level is essential, jurisdictional planning is needed to address specific opportunities and threats among diverse populations. Thus, the impetus for a plan specific to the people of North Dakota has been developed and is described in this document, from which local planning will be fueled. While this plan is focused on hepatitis C, as further described in the Plan Development and Process section, synergistic efforts to address hepatitis A and B will be incorporated as able moving forward.
Hepatitis C Advisory Council
The mission of the North Dakota Hepatitis C Advisory Council is to provide representative community feedback on hepatitis C - related programs, services, plans and events of the NDHHS. This counicl is intended to represent the vast communities impacted by hepatitis C in North Dakota, including but not limited to members who represent diverse ages, races/ethnicities, hepatitis status, and experience or expertise. The boards looks to:
- Advise the NDHHS on how the department can plan and implement services and interventions that address the hepatitis C epidemic in and for all communities.
- Provide a community voice in decisions NDHHS makes about current and future services.
- Offer feedback on how well NDHHS works with members of the community in consideration of the needs of the jurisdiction.
ND Viral Hepatitis Elimination Goals
The North Dakota Hepatitis C Elimination Plan was developed by the North Dakota Hepatitis Elimination Council. The council is a group formed and supported by North Dakota Health & Human Services (NDHHS) Sexually Transmitted and Bloodborne Diseases Unit. Elimination planning began in December of 2022 and the plan was finalized by the council in June 2023. The primary roadmap utilized for elimination planning was the “2021 Guidance for Jurisdictional Hepatitis C Elimination Strategic Planning” document from the Centers for Disease Control and Prevention (CDC). This guidance document encouraged alignment of plan structure with the Viral Hepatitis National Strategic Plan: A Roadmap to Elimination for the United States 2021-2025 emphasizing HCV elimination.
The National Strategic Plan outlines five main goals. The North Dakota HCV Elimination Plan was structured in alignment with these goals, then developed with more detailed direction specific to HCV in North Dakota. Three work groups were formed among council members with diverse expertise: data and surveillance, community-based interventions, and clinical services. Amber Slevin, PharmD, BCACP, a clinical pharmacist with expertise in Hepatitis C, serves as the council chair and co-facilitated all work groups and council meetings with Sarah Weninger, MPH, HIV.STI.Hepatitis Prevention Coordinator with NDHHS. The data & surveillance work group then developed key performance indicators (KPIs) for each strategy in partnership with focus area experts, ensuring quantifiable activities and/or metrics for progress measurement. The plan was then reviewed, edited as necessary, and approved by the council.
Injection drug use (IDU) has been a driving factor for the increase in HCV rates over the past decade. Innovative and accessible harm reduction, education, screening, and linkage to care among persons with injection drug use (PWID) is thus a major focus of goal 1. Awareness of risk, current hepatitis status, and treatment availability is essential among PWID to reduce the transmission of HCV. In addition to reducing transmission through IDU, a focus on reducing perinatal transmission is a priority. New screening guidelines foster increased hepatitis status awareness when adhered to, and when prenatal care is sought.
The rural nature of the state of North Dakota presents unique challenges and opportunities in meeting the objectives of goal 1, and strategies have been designed accordingly. Initiatives to increase the capacity of both public health and the health care work forces to prevent and manage HCV are essential to the success of such strategies.
Optimizing the HCV care cascade in North Dakota will lower HCV prevalence on a population level and reduce individuals’ progression of HCV to liver fibrosis, cirrhosis, and death. Reducing these outcomes is the aim of goal 2. The HCV care cascade for people living with hepatitis C consists of screening, diagnosis, linkage to care, treatment with direct acting antivirals (DAA) that lead to greater than 95% cure in most individuals, and confirmation of cure via undetectable HCV RNA 12 weeks after DAA completion. Each step of the care cascade must be addressed to optimize access and reduce loss of follow-up, beginning with guideline-based HCV screening of all adults once per lifetime and more frequently for those with risk factors. It is estimated that fewer than 50% of people living with hepatitis are aware of their status.
Similar to goal 1, North Dakota faces a few unique challenges. For example, at the time of writing this plan the council is aware of only one provider actively treating HCV on the western half of the state. In many parts of the state, individuals have to drive several hours to access an HCV treating provider. Additionally, few non-specialist providers are treating HCV despite the reality that specialist involvement is rarely needed with current DAA therapies. In unique clinical scenarios requiring specialist involvement, there is free, virtual support available for providers through Project ECHO. Equipping non-specialist providers, particularly those serving disproportionately affected populations and individuals living in rural areas, is paramount to effectively eliminate HCV as a public health threat in ND. People living with hepatitis C in North Dakota also face barriers that are less unique to North Dakota, such as stigma, high cost of DAAs, payer restrictions, and a lack of broad scale implementation of universal HCV screening guidelines which were published at the height of the COVID-19 pandemic. North Dakota also has unique opportunities, including correctional facility leadership aggressively pursuing HCV care cascade optimization as well as collaborative involvement of state Medicaid representatives on the council.
Nationwide, HCV disproportionately affects certain racial and ethnic minorities (most significantly, Black American and American Indian), PWID, people who experience homelessness/unstable housing, and people in correctional facilities. Available North Dakota data similarly illustrates such disparities as outlined in the introduction, and further surveillance efforts are addressed in goals 3 and 4.
Additionally, stigma related to HCV diagnosis affects people at risk of or living with hepatitis C which worsens existing disparities and marginalization. HCV related stigma may affect many sects of an individual’s life, including quality of health care and progression through the HCV care cascade.
Although these special populations are included throughout the plan, goal 3 is specifically dedicated to reducing disparities and elevating the voice of those disproportionately affected by HCV. North Dakota must ensure that HCV elimination initiatives, especially education materials and provider
HCV elimination efforts must be data-driven and evidence-based in design, as well as regularly evaluated for effectiveness. This requires both strong baseline data as well as monitoring of progress on elimination efforts. NDHHS is currently scaling up HCV surveillance efforts, and goal 4 provides a road map for continued expansion. Monitoring of population level care cascade progression and care engagement are key aims of goal 4.
Surveillance is also essential to the timely detection and intervention of hepatitis outbreaks. At this time, North Dakota does not have a detailed hepatitis outbreak plan, and this is an imminent focus.
This goal focuses on the integration of HCV elimination within programs and services addressing other aspects of the syndemic (i.e. SUD, HIV, HBV, and STIs) which furthers the reach and impact of HCV elimination efforts. As new programs and initiatives are established, a proactive approach to comprehensive syndemic service design will facilitate efficient, holistic care for the people of North Dakota. As syndemic service integration is established, it is important to communicate and disseminate best practices with providers in North Dakota.
North Dakota has a unique advantage in that such integration of efforts is already occurring frequently within the NDHHS Sexually Transmitted and Bloodborne Diseases Unit. Extension of this design to local public health programs and external partners as well as integration into future funding agreements will amplify HCV elimination efforts. Such external partners of initial focus are outlined in the below strategies.