What is Killing People With Hepatitis C Virus Infection?

JasonGrebely, B.Sc., Ph.D.; Gregory J.Dore, M.B.B.S., Ph.D., F.R.A.C.P., M.P.H.

Disclosures

Semin Liver Dis. 2011;31(4):331-339. 

In This Article

How can we Currently Prevent People With Hcv Infection From Dying?

The availability of PEG-IFN/ribavirin-free regimens for the treatment of HCV infection are still 5 to 10 years away and other strategies will be required if we are to stem the projected rise in liver-disease burden.[9–14] Strategies that increase the proportion of individuals diagnosed, assessed, and treated for HCV infection with currently available treatment regimens are required.

Increasing the number diagnosed with HCV infection will be important as we move forward. In the United States, the true number of people infected with HCV is likely underestimated (5.2 million as compared with previous estimates of 3.3 million from household surveys), given that homeless people, prisoners, IDUs, and other marginalized populations at high-risk of HCV are often not included in national household surveys.[82] Strategies to enhance diagnosis of HCV may include the promotion of national HCV testing guidelines,[83] and enhanced education and training of general practitioners about HCV testing and diagnostic criteria to enhance diagnosis and referral. Further strategies include the provision of mentoring diagnosis programs among general practitioners with higher case loads of HCV-infected patients,[84] an improved awareness of programs offering comprehensive multidisciplinary HCV care (particularly for IDUs), and improved pathways for referral. Incorporation of HCV assessment and treatment services into drug and alcohol treatment settings is also required.

Enhancing the proportion assessed for HCV is crucial. Non-invasive tests of fibrosis (e.g., FibroScan and FibroTest) offer considerable opportunities for enhanced screening and assessment of liver disease. In a study at one hospital in France, a cohort of 1457 consecutive patients with chronic HCV were assessed for liver fibrosis by liver biopsy, FibroScan, FibroTest, aspartate aminotransferase to platelet ratio index (APRI), and FIB-4 score to evaluate all-cause and liver-related mortality during a 5-year follow-up period.[85] Survival was significantly decreased among patients diagnosed with severe fibrosis (regardless of the noninvasive method employed) and all noninvasive methods were able to predict shorter survival times, although FibroScan and FibroTest had higher predictive values. These tools will help physicians determine prognosis at earlier stages and therefore allow enhanced targeting of therapy to those with significant liver disease.

Strategies are needed to enhance HCV assessment and treatment in the community to reduce mortality among people with HCV. Barriers to expanding HCV treatment in the community are multifactorial and include issues of access to therapy and barriers at the level of the patient, practitioner, and system.[86] HCV-infected patients often have complex social, medical, and psychiatric comorbidities, complicating decisions around care. Currently, there is limited infrastructure for the provision of HCV assessment and treatment delivery beyond well-established, hospital-based liver clinics. However, successful strategies to improve engagement with HCV services and enhance HCV assessment have been explored.[21] One model to enhance access to HCV care for underserved populations focused on the integration of community-based health centers in New Mexico using state-of-the-art telehealth technology to provide training and support for primary care providers to deliver best-practice HCV care.[87] This model was effective, with similar responses to HCV treatment observed among community-based clinics as compared with a university-based hospital.[87] This approach represents a needed change from the conventional approaches in which specialized care and expertise are concentrated in academic medical centers in urban areas.

Lastly, given that 70 to 80% of current HCV infections occur among IDUs,[88] it is clear that strategies to reduce mortality among those living with HCV will require specific strategies for this marginalized group. There is now overwhelming evidence that the treatment of HCV infection in this population is safe and effective across multiple models of care.[89] As such, older IDUs in particular will be an important group to follow clinically (perhaps with noninvasive liver fibrosis screening) and perhaps offer intensified HCV assessment and treatment in an effort to reduce liver-related mortality.

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