The Benefits of Hepatitis C Virus Cure: Every Rose Has Thorns

D. Salmon; M. U. Mondelli; M. Maticic; J. E. Arends

Disclosures

J Viral Hepat. 2018;25(4):320-328. 

In This Article

Collective Benefits of HCV Therapy

Curing HCV infection does not only benefit the infected individual but also reduces the burden of HCV infection at the population level.[60] Regardless of the stage of liver disease, complications and HIV coinfection, there is a significant survival benefit of achieving SVR.[3] SVR is associated with a significantly reduced risk of 10–year all–cause mortality, as well as liver–related mortality and liver transplantation in HCV–infected patients with advanced liver disease.[61]

Hepatitis C virus cure can also be anticipated to have a long–term impact on the collective economic burden of the disease.[62] Liver cirrhosis, HCC, liver transplantation and other manifestations of HCV infection are associated with high direct medical costs and massive utilization of healthcare resources.[63] It has been shown on a collective level that HCV cure yields substantial direct cost savings by avoiding complications, as well as lower indirect costs due to lost productivity through absenteeism.[62]

From a public health perspective, a major collective benefit of HCV cure would be a reduced HCV–prevalent population and therefore lower transmission and incidence rates ("treatment as prevention").[60] New DAA treatment regimens with SVR rates of more than 95% have the potential to transform the HCV landscape, provided treatment uptake is high.[64] Unfortunately, global estimations for 2015 suggest that only 20% of HCV–infected individuals have so far been diagnosed and that only 7% of those diagnosed have started treatment, with wide variations in availability and access to treatment among countries.[65] One of the most important barriers to HCV treatment is the high cost of DAAs.[66] A recent real–world report from Germany, where, officially, no restrictions on HCV treatment exist, the number of patients treated in 2014 and 2015 was far lower than expected from the projected number of patients who needed therapy. Thus, without additional measures, universal access to DAAs alone is insufficient to lower the HCV prevalence.[67] In various countries, modelling studies suggest that major reductions in HCV prevalence and incidence are possible with scaling up of HCV treatment for those at a high risk of transmission.[68] Recent real–world reports from the Netherlands showed around a 50% reduction in HCV incidence among HIV–infected men who have sex with men, during a 2–year period after roll–out of DAA therapy.[69]

There are several barriers to scaling up of HCV treatment in high–risk populations, particularly among people who inject drugs (PWID), who are the major drivers of the HCV epidemic in Europe.[70] In recent years, European and other international recommendations have called for HCV treatment of PWID, prioritizing treatment without delay for individuals at risk of transmitting HCV, such as active injection drug users.[64] However, a high proportion of these individuals remain undiagnosed, and many of those who are diagnosed remain untreated despite their willingness to receive HCV therapy.[71] There is a persistent misunderstanding among healthcare providers about potentially poor treatment outcomes and high rates of reinfection among PWID, despite evidence that DAA treatment outcomes among PWID are comparable to those in the general population, with a low rate of reinfection after interferon–based therapy.[72–74] To reduce the HCV incidence among PWID, universal introduction of DAAs must be combined with increased diagnosis and enhanced preventive measures such as opioid replacement therapy and needle and syringe programs provided in multidisciplinary settings.[75,76] Interestingly, economic models that incorporate both the individual and collective preventive benefit of HCV treatment of PWID suggest that treatment of PWID early in the disease is more cost–effective than treating other patient groups, because of the additional benefit of preventing further HCV transmissions.[77] Excluding ethical dilemmas and taking into account only strictly economic decision rules, based on "net monetary benefit" or the greatest gain in quality–adjusted life years, PWID with mild or moderate disease be prioritized for early treatment. However, this collective benefit is only based on indirect evidence from dynamic mathematical models suggesting that HCV treatment of PWID is likely to lead to reductions in HCV incidence and transmission.[78] No real–life direct observational data have been available.[79] For other populations at risk of HCV transmission, beside universal HCV treatment and scaling up of diagnosis, an increase in preventive measures such as safe medical procedures, safe sexual practices and prevention of mother–to–child transmission needs to be encouraged.[60]

In the era of highly effective DAAs that promise both an individual and a collective benefit, the World Health Organization (WHO) has launched the first global health strategy on the elimination of viral hepatitis as a public health threat by 2030.[80] Targets for 2030 are to achieve a 90% reduction in new viral hepatitis infections, a 65% reduction in liver–related deaths and a 90% diagnostic rate. An increased capacity for treatment and screening will be critical in several countries.[81] To achieve collective targets, a radical change in the response to hepatitis C is needed at the global and national levels: hepatitis C needs to achieve a higher priority in both the clinical and public health settings.[82]

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