—Lucinda K. Porter, RN
In August 2014, the American Association for the
Study of Liver Diseases (AASLD) and the Infectious Diseases Society of
America (IDSA) prioritized who should be treated for hepatitis C virus
(HCV) infection. In Recommendations for Testing, Managing, and Treating Hepatitis C,
the AASLD and IDSA acknowledged the benefits of HCV treatment,
particularly early treatment. From this, I surmise that they endorse
treating everyone with HCV. However, the AASLD and IDSA recognize the
tragic reality we are facing: the cost of new HCV drugs and a shortage
of medical providers may make it hard to treat everyone initially.
Given these limitations, who should be treated first?
Top priority is given to HCV
patients who are at the highest risk for severe complications, such as
those with stage 3 fibrosis or stage 4 compensated cirrhosis, and organ
transplant patients. The next tier is labeled “high priority,” and it
is separated into two categories: a) those who are at high risk for
complications, and b) those who have a high HCV transmission risk.
Examples of those who are at high risk for complications are HCV
patients with stage 2 fibrosis, or coinfected with HIV or hepatitis B.
The list of persons who have a high HCV transmission risk includes
active injection drug users, the incarcerated, and HIV-positive men who
have sex with men (MSM) with high-risk sexual practices.
If I still had hepatitis C, and
had stage one fibrosis, I’d be at the bottom of the treatment priority
list. I’d be outraged if insurance denied treatment to me because my
liver disease wasn’t advanced, a practice we are seeing played out in
state Medicaid programs. To me it’s akin to saying to a cancer patient,
“Come back when your cancer is worse.” Add to this that if I were an
active injection drug user or incarcerated, I’d be assigned a higher
priority, I might feel abandoned by the health care system. This left
me wondering about the rationale for giving treatment priority to those
at high risk for transmitting HCV over those with stage one fibrosis
and low transmission risk.
In this column I’ll examine the
facts and discuss why it makes sense to treat those who are at high
risk of transmitting HCV. I’ll end with a reality check, but hint: I
need not worry that those with high risk of HCV transmission were given
priority over those with low-fibrosis scores. There are bigger issues
to worry about.
People with High HCV Transmission Risk
Data from the National Health and Nutrition
Examination Survey (NHANES) from 2003 to 2010 estimated that 1.3% of
the U.S. population has chronic hepatitis C. The NHANES surveys only
sampled people living in homes. Data was not collected from certain
high-risk populations, including the incarcerated, homeless,
hospitalized, the military, and immigrants. Some researchers estimate
higher HCV prevalence at 2.0% of the U.S. population. Let’s call it 1%
to 2% and compare this to high risk groups.
People Who Inject Drugs (PWIDs): Research published by Amy Lansky and colleagues (Estimating
the Number of Persons Who Inject Drugs in the United States by
Meta-Analysis to Calculate National Rates of HIV and Hepatitis C Virus
Infections; PlosOne May 2014) estimates that 6,612,488 adults and
adolescent in the U.S. have injected drugs sometime in their life. This
is 2.6% of the population. Researchers estimate a huge range of HCV
prevalence among PWIDs, anywhere from 30% to 90%. Regardless of the
actual prevalence, HCV risk is high among PWIDs.
People Who Are Incarcerated: HCV
prevalence in jails and prisons is also high. The Centers for Disease
Control and Prevention (CDC) estimates that of the 2.2 million people
in U.S. jails and prisons, 30% have hepatitis C. Other estimates are
between 17% and 60%. We don’t know the actual prevalence since HCV
screening is relatively uncommon in state prisons.
HIV-Positive MSM with High-Risk Sexual Practices:
HCV sexual transmission risk, which is normally low in most situations,
is increased among HIV-positive MSM. A study conducted in Amsterdam
reported that among HIV-positive MSM, the HCV prevalence may be as high
as 21%. Although injection drug use may account for some of the HCV
prevalence in HIV-positive MSM, there was a correlation between fisting
and HCV-positivity. (Fisting is the practice of inserting the hand
into the rectum or vagina.) Note: Two recent studies reported that HCV appears to be transmitted sexually in HIV-negative MSM.
Why It Makes Sense to Treat Those at High Risk for HCV Transmission
Prevention is the best medicine; cure is the second
best. There is no HCV vaccine, but the disease is curable. The AASLD
and IDSA Recommendations state, “Persons who have successfully
achieved an SVR (virologic cure) no longer transmit the virus to
others…successful treatment benefits public health.”
It’s easier than ever to cure
HCV, and we are doing so with as little as 12 weeks of treatment.
Virologic cure rates for people with genotype 1 are 90% to 100%; other
genotypes have high response rates too. We are even curing those who are
coinfected with HIV and HCV. Drug development is progressing rapidly,
with shorter treatment durations on the horizon.
Since prevention is the best medicine, then curing hepatitis C early
is second best. In short, stop it before it spreads. The CDC estimated
nearly 22,000 new HCV infections in the U.S. in 2012, which is an
increase of 75% since 2010.1 The vast majority of these
incidents are among PWIDs. This creates a transmission risk for those
who have blood-to-blood contact with PWIDs, including other PWIDs,
family, friends, and health care workers. Cure these early infections
before the virus has a chance to sink its ugly viral teeth into the
livers of our precious friends, family, and community.
You could ask, “Do we really
want to spend our healthcare dollars on people who are at a high risk of
HCV reinfection?” The answer is yes. Stopping HCV in one person,
regardless of how many times he or she is infected is far cheaper than
treating everyone who acquires HCV as a result of the virus spreading
like an out-of-control wildfire.
The Reality Check
If I thought for a single moment that treating
those who are at a high risk for transmitting HCV was going to take
precedence over HCV patients with minimal fibrosis, I was delusional.
The reality is that despite the AASLD and IDSA Recommendations and
the fact that it is the right thing to do, PWIDs, the incarcerated,
and HIV-positive MSM are not exactly attracting public health care
dollars. In fact, viral hepatitis receives less than 3% of the funding
HIV receives from the CDC. According to Emily McCloskey of the
National Alliance of State and Territorial AIDS Directors, “State health
departments receive less than $1 dollar in federal funding for every
person living with viral hepatitis for the Viral Hepatitis Prevention
Coordinator (VHPC) program.” The U.S. Congress can’t get it together to
fund the Viral Hepatitis Testing Act of 2014, which will help screen
baby boomers and other at-risk individuals.
However, just because public
funding isn’t pouring in to treat those at high risk of HCV
transmission, it should. We share this world with those at high risk for
transmitting HCV, and if we want to knock HCV off the planet, we need
to cure everyone. Where best to start? Start where HCV is at its
highest, and reach out to PWIDs, the incarcerated, and HIV-infected
MSM. It’s not just good health policy, it’s the right policy.
However, we don’t stop there.
Everyone should have access to HCV treatment, regardless of fibrosis
stage. The words of Diane Sylvestre, the director of the Oasis clinic
in Oakland, CA ring truer now than ever, “If one of us has hepatitis C,
all of us have it.”
Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time. Her blog is www.LucindaPorterRN.com
Share This Page