NEEMA Funded Projects - Viral Hepatitis

NEEMA 3.0 (2024-2029)

Estimating the annual number of perinatal hepatitis C virus exposures and infections in the United States

Reducing perinatal transmission of hepatitis C virus (HCV) is a priority for national viral hepatitis elimination goals, with an estimated 5-10% of perinatally exposed infants acquiring HCV infection. However, current national estimates of perinatal HCV exposures and infections are outdated, and no state- or jurisdiction-level estimates exist. Prior estimates using 2006-2014 data are now over a decade old and predate substantial increases in HCV infection among reproductive-aged individuals. A recent global model estimated 1,312 annual perinatally acquired HCV infections in the U.S., more than five times the number reported to national surveillance in 2023. This project will estimate the annual number of perinatal HCV exposures (pregnant women meeting HCV case definitions) and resulting perinatal HCV infections at both the national and state level, using established surveillance case definitions. By generating updated, jurisdiction-level estimates that reflect current HCV epidemiology, this project fills a critical gap in data needed for state and local prevention planning. Findings will support programmatic targets and resource allocation to reduce perinatal HCV transmission nationally and within individual states and jurisdictions.

Assessment of the effects of CDC guidelines for one-time universal hepatitis C screening among adults

In 2020, CDC updated its hepatitis C virus (HCV) testing recommendations to include universal screening at least once in a lifetime for all adults aged 18 and older, except in settings with very low hepatitis C prevalence. However, the effects of achieving higher hepatitis C screening levels nationally, specifically in terms of overall morbidity, mortality, and costs, require further characterization. This project will adapt an existing model of hepatitis C progression to analyze how increasing screening among the U.S. adult population could affect population health and economic outcomes. The model will compare 3 screening scenarios (no additional screening, current practice, and enhanced screening), assuming interventions are sustained for 10 years. Outcomes modeled over a lifetime analytic horizon include the number of people tested, diagnosed, and treated, along with associated healthcare costs. By quantifying the potential benefits of expanded HCV screening, this project fills a gap in evidence needed to guide screening implementation and resource allocation. The project is also developing a web-based tool that will allow state and local decision makers to enter data on hepatitis C prevalence and other local conditions to estimate the potential costs and impacts of expanding hepatitis C screening efforts.

Estimating effects of multi-infection prevention and diagnosis approaches for HIV and bacterial sexually transmitted infections among men who have sex with men

CDC recommends routine screening for syphilis, gonorrhea, and chlamydia alongside HIV testing for sexually active men who have sex with men (MSM), particularly those at higher risk or on HIV pre-exposure prophylaxis (PrEP). However, sexually transmitted infection (STI) screening is not automatically bundled with HIV testing, and screening rates remain below recommended levels, especially in non-hospital settings. This gap contributes to missed diagnoses amid rising syphilis incidence, continued evolution of drug-resistant gonorrhea, and a substantial proportion of MSM unaware of their HIV status. This project will use an agent-based microsimulation model to evaluate the potential impact of integrated HIV and bacterial STI screening among MSM under a syndemic approach. Primary objectives include estimating the epidemic impact of integrated screening and evaluating how coordinated diagnosis and treatment of HIV, syphilis, chlamydia, and gonorrhea affects infection incidence. The project will generate outputs such as infections averted per 1,000 tests to support cost-effectiveness analyses. By quantifying the benefits of integrated screening, this project fills a critical gap in evidence needed to improve testing practices and inform public health strategies to control HIV and STI transmission among MSM.

Cost and cost-effectiveness of implementing point-of-care Hepatitis C virus (HCV) testing in select high-impact settings

Over half of acute hepatitis C cases in the U.S. are linked to injection drug use. High-impact settings, including syringe services programs, offer a critical opportunity to reach people at high risk for hepatitis C with limited access to traditional healthcare. While most syringe service programs (SSPs) currently offer on-site HCV antibody testing, few provide RNA testing, and the higher cost of point-of-care (POC) RNA testing raises questions about its cost-effectiveness relative to standard testing algorithms. This project uses an established dynamic agent-based network model of HCV transmission, enhanced with detailed testing and treatment cascades, to compare the costs, outcomes, and cost-effectiveness of POC HCV RNA testing against two alternative algorithms: standard antibody testing with lab-based RNA confirmation, and antibody testing followed by POC RNA testing. The model incorporates treatment pathways, including telehealth and offsite referral with or without patient navigation, to assess impacts on diagnosis, treatment uptake, and HCV transmission. This project provides evidence to inform decisions on the value of implementing POC HCV RNA testing for early detection and treatment in high-impact settings. Findings will directly inform program planning for hepatitis C elimination efforts for populations with higher burden of hepatitis C.

Assessing the impact of expanded efforts for hepatitis C elimination in the United States

Despite highly effective treatments, hepatitis C diagnosis and treatment initiation remain suboptimal. Evidence shows point-of-care (POC) testing and care and treatment coordination in high-impact settings, such as syringe services programs and opioid treatment programs significantly increase treatment initiation, but the population-level impact and cost-effectiveness of scaling these interventions remain unclear. This project will extend an existing HCV compartmental transmission model to incorporate testing and treatment access through high-impact settings. Intervention scenarios, including POC testing and care coordination/navigation, will be evaluated to estimate impacts on hepatitis C diagnosis, treatment initiation, and the number of new hepatitis C infections and hepatitis C-related mortality through 2030 among persons who inject drugs compared with current practice. By quantifying the health and economic impact of scaling evidence-based interventions, this project fills a critical gap in understanding how to optimally implement and prioritize services for populations with a high hepatitis C burden. Findings will inform technical assistance and guidance to support efficient resource allocation and program prioritization to advance national hepatitis C elimination and reduce hepatitis C- related morbidity and mortality.

Cost-effectiveness of new treatment guidelines in reducing chronic hepatitis B mortality and morbidity in the United States

Chronic hepatitis B (CHB) affects an estimated 580,000 to 2.4 million people in the United States and is a leading cause of liver cancer and liver-related death. Highly effective, low-cost antiviral therapies exist but are underutilized by patients who could benefit. In 2025, the American Association for the Study of Liver Diseases (AASLD) expanded treatment eligibility to include patients in disease stages not recommended for treatment in earlier guidelines. This expansion was supported by trial evidence showing reduced fibrosis progression with treatment in previously ineligible patients. The earlier AASLD guidelines from 2018 had complex eligibility criteria that may have limited treatment to approximately 57% of eligible patients. This project will adapt existing hepatitis B simulation models to project hepatitis B-related mortality, liver cancer incidence, and economic outcomes over patients' lifetimes, as well as at interim points in 2030 and 2035, comparing projected patient outcomes under the 2025 AASLD guidelines to outcomes under the 2018 guidelines. The analysis will evaluate the cost-effectiveness of treating newly eligible patients and assess population impact under varying treatment uptake and adherence scenarios. By quantifying the health and economic impact of expanded treatment eligibility, this project fills a critical evidence gap needed to inform patient and clinician shared decision making. Findings will also inform potential progress toward the U.S. goal of reducing hepatitis B-related mortality by 65% from 2015 levels by 2030.

Impact of jail implementation of the CDC screening and treatment recommendations for correctional settings on national and state prevalence of hepatitis C and syphilis

People who are justice system-involved experience higher rates of hepatitis C and sexually transmitted infections than the general population, and correctional health services are often their first or only touchpoint for testing and treatment. CDC recommends comprehensive opt-out testing at intake, treatment during incarceration, and linkage to care upon release for incarcerated individuals, but staffing, budget constraints, rapid turnover of the incarcerated population, and limited collaboration with local health departments create significant barriers to full implementation. Since 95% of incarcerated individuals return to their communities, successful implementation could meaningfully reduce community disease prevalence and transmission. This project will estimate changes in national and state hepatitis C and syphilis incidence, along with associated health and economic outcomes, if all U.S. adult jails fully implemented the CDC Recommendations for Correctional Settings. Using a model incorporating national epidemiologic estimates, correctional statistics, and intervention effectiveness data, the project will evaluate scenarios reflecting varying levels of implementation and community background testing and treatment rates, along with associated costs and sensitivity analyses across the care continuum. By quantifying the potential population-level and economic benefits of full implementation, this project fills a critical gap in understanding how correctional health interventions could reduce disease transmission and disparities, informing investment and program decisions.

Cost-effectiveness and budget impact of HCV testing and treatment strategies in prisons

Hepatitis C elimination in correctional facilities is essential to achieving national hepatitis C elimination goals, yet efforts within departments of corrections have been limited by the high cost of direct-acting antivirals and the substantial work required to build effective elimination programs. The California Department of Corrections and Rehabilitation (CDCR) has led this effort, launching a hepatitis C elimination program in 2016 that includes HCV opt-out testing, treatment, and scaled-up medications for opioid use disorder. Understanding how these program components contribute to progress towards elimination within a correctional population with frequent turnover is critical to informing implementation elsewhere. This project will model CDCR's progress toward hepatitis C elimination and assess the comparative effectiveness and cost-effectiveness of its testing and treatment interventions, incorporating program cost and health spending data from California Correctional Health Care Services (CCHCS). The economic evaluation, including a cost-effectiveness analysis and budget impact analysis, will provide critical evidence to carceral health system decision-makers facing budget constraints. By evaluating CDCR's approach, this project fills a gap in evidence on effective, scalable hepatitis C elimination strategies for correctional settings, informing implementation in departments of corrections nationwide.

Impact of reducing infectious disease prevention service access and use on HIV and hepatitis C transmission in the US over time

High-impact settings such as syringe services programs serve as critical entry points to access sterile injection equipment, infectious disease testing and treatment, and navigation to substance use disorder treatment. There is a need to understand how reduced access to these services could affect health outcomes for populations at risk for HIV and hepatitis C. This project will develop a modeling framework to estimate the population health and economic impacts of hypothetical reductions in services, including sterile injection equipment, infectious disease testing and treatment, and treatment navigation. Using the model, we will evaluate how such reductions would affect HIV and HCV transmission, overdoses, healthcare expenses, and long-term health among people who inject drugs and their communities. We will also analyze differences in impact by considering local factors, such as the community's initial HIV and hepatitis C rates, current prevention and treatment efforts, and the extent and duration of service disruptions. By quantifying the potential population health and economic impacts of service reductions, this project fills a critical gap in understanding the community-level impact of infection prevention and control strategies in high-impact settings, including syringe service programs, and provides evidence to inform decision-making around community-level prevention and treatment services and efficient access points.

Estimating the population of persons who inject drugs in U.S. States and the District of Columbia (D.C.)

Injection is a common, high-risk route of administration for opioids and other drugs, increasing risk for bloodborne infections like hepatitis C and HIV. Due to the stigmatized and illicit nature of injection drug use, population-level prevalence is difficult to measure through standard survey methods. The current national population size estimate does not reflect injection trends, limiting the ability to accurately target and evaluate infectious disease prevention efforts, as well as efforts to reduce injection drug use. This project will validate the existing national estimates of the population of persons who inject drugs (PWID) and update national prevalence estimates if new data sources improve validity. Secondly, the project will generate state-level PWID population size estimates, including for D.C. By providing validated, updated, and more granular PWID population size estimates, this project fills a critical gap in the denominators needed to assess national and state infection rates to inform resource allocation and intervention planning to prevent HIV and viral hepatitis among PWID. These estimates will also enable CDC and states to accurately compute per-population infection rates, monitor whether HIV and viral hepatitis risk is increasing or declining among the PWID population, and take appropriate public health action based on these trends.

Evaluating ecologic models to identify geographic areas at risk for HIV and viral hepatitis from injection drug use

The U.S. opioid epidemic has driven increases in hepatitis C infections and stabilization of HIV infections linked to injection drug use. In 2016, CDC identified county-level indicators associated with vulnerability to HIV and HCV outbreaks among people who inject drugs, later supporting state-led vulnerability assessments. However, drug use patterns have since shifted substantially, with synthetic opioids like fentanyl now predominating, and the burden of injection drug use has nearly tripled between 2010 and 2018. Existing vulnerability assessments rely on data that are now 10 years old or older, and are largely cross-sectional, limiting their ability to capture lagged relationships between risk factors and outcomes. This project will reassess factors associated with injection drug use using more recent, longitudinal data to identify geographic areas most at risk for HIV, HCV, and other related health outcomes. It will also develop a decision-tree approach for evaluating the sensitivity and specificity of this and related vulnerability models. By updating and validating vulnerability assessment methods, this project fills a critical gap in timely, accurate data needed to prioritize prevention services and interventions. Findings will inform decision-making for federal and state agencies, public health leaders, and researchers working to prevent disease outbreaks.