Marcia Frellick

May 01, 2015

COPENHAGEN, Denmark — Even with new drug combinations that have cure rates nearing 100%, the fight against the hepatitis C virus is not over, according to one global expert.

"I believe that an infection present in 130 million to 170 million individuals cannot be eradicated with antiviral therapies. It's just not possible," said Jean-Michel Pawlotsky, MD, from Henri Mondor University Hospital in Créteil, France.

The disease is responsible for about 350,000 deaths each year around the world. But more than 80% of people with hepatitis C are unaware of their infection, especially in low-income countries.

There has been progress, Dr Pawlotsky said here at the 25th European Congress of Clinical Microbiology and Infectious Diseases. "When I started my career, approximately 10% of patients" achieved a sustained virologic response. With the interferon-free regimens now available, rates are "93% to 100%."

But rapid progress will not lead to eradication, he said. The exorbitant price for the new drugs is a well-documented issue that will work against widespread cure. There is no prophylactic hepatitis C vaccine available and virtually no research on preventive vaccines. "We don't know how to generate protective immunity against hepatitis C," he explained.

The goal, said Dr Pawlotsky, is to control the disease, at least in the countries that can afford to.

 
An infection present in 130 million to 170 million individuals cannot be eradicated with antiviral therapies.
 

Meanwhile, there are other issues to be dealt with, such as the problem posed by treating hepatitis C in people on a liver transplant list. If you cure the infection, the patient is taken off the list or moved down; however, the patient still has the cirrhotic liver and might develop decompensation.

"You think you did something good by curing the hepatitis C infection, but you prevented that person from being transplanted, and that patient could die because of a sick liver. The other option is to go for liver transplantation, but that is not a low-risk procedure. It's an open debate," Dr Pawlotsky said.

Another quandary involves the ethics of retreating people who reinfect themselves.

Ethical Questions Surrounding Retreatment

Michael Ohl, MD, from the University of Iowa in Iowa City, said he is beginning to see reinfections in high-risk patients, such as intravenous drug users and men who have sex with men.

"How many times should a patient be treated?" Dr Ohl asked.

"For society, it's a problem," Dr Pawlotsky acknowledged. "We recommend monitoring these patients every year."

Before treating these patients, it is important that they understand the reason they are being treated and the need to change their behavior, he added.

That's good in theory, but difficult in reality. "If we do cost-effectiveness analysis, these drugs are cost-effective on a societal basis if we treat once," Dr Ohl told Medscape Medical News.

"But how many times do we treat a particular individual?" he asked. "Or do we say the resources are better used to treat more people the first time. It's an ethical question as well as a resource question."

Dr Pawlotsky reports receiving grant and research support from Gilead; being on the advisory boards of AbbVie, Achillion, Bristol-Myers Squibb, Gilead, Janssen, and Merck; and speaking and teaching for AbbVie, Bristol-Myers Squibb, Gilead, Janssen, Merck, and Roche.

25th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID): Poster K05. Presented April 27, 2015.

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