Hepatitis C: Screening, Identification, and Care

Digestive Disease Week (DDW) 2015

Nancy S. Reau, MD; Lauri R. Graham


July 21, 2015

In This Article

Relapse and Re-infection

Medscape: With the high cost of the new hepatitis C drugs, there's concern about treating patients only to have them relapse. What do we know now about the relapse rates with these drugs?

Dr Reau: Datareleased from real-world observational studies, such as HCV-TARGET,[3] suggest that the sustained virologic response (SVR) rates parallel phase 2 and 3 clinical trials, meaning that relapse from these agents should be rare.

Given the potency of the new agents, pretty much all patients who do not respond to sofosbuvir-based therapy or to combination oral direct-acting antiviral therapy are going to relapse, as opposed to having inadequate viral suppression like with pegylated interferon-ribavirin. We don't understand the full impact of treatment failure, but luckily it should be uncommon.

We do need to be aware that we have to follow our patients for a certain interval to make sure that they are truly cured. Once you achieve the SVR rate at 12 or 24 weeks, we can use that with as much reliability as we did with the SVR rate for pegylated interferon-ribavirin. Even still, with these newer therapies, data from the TRIO network (Trio Health; La Jolla, California) and HCV-TARGET[3] are being used to help show whether we do as well in real life as the clinical trials suggest that we should.

Now, with that being said, the clinical trials have been much more generous in recruiting and enrolling patients who are more difficult to treat. They're not all easy-to-treat patients. A lot of these studies recruited treatment-experienced patients, cirrhotic patients, and even those with decompensated disease.

Yet, they are still patients who are appropriate for a clinical trial, meaning that some of those adherence issues common in the real world probably would not occur. If you have a patient who goes through the evaluation process to participate in a clinical trial, you know they're going to be adherent, versus the patient who comes into your office who may or may not be.

Every cure has to come with education.

Medscape: For patients who have been treated and "cured," how big of a risk is re-infection, and what preventive tactics might be implemented?

Dr Reau: Studies have shown that re-infection rates are real, but low.

In terms of prevention, again, I think it boils down to patient education. There is always a risk for return to prior behavior. However, I think that the patients who have gone through treatment do tend to be a little more motivated, and certainly the majority of patients do not return to high-risk behaviors. Every cure has to come with education.

Medscape: Hepatitis C has been linked to more deaths than HIV. Could a model of care like that used so effectively for HIV be implemented for hepatitis C?

Dr Reau: That is absolutely a testament to what infectious disease specialists and primary care providers have done in terms of HIV treatment. It is effective risk stratification, effective drugs, and effective follow-up. And it's not that hepatitis C is severe and HIV is mild-mannered—it is screening, identification, and care. But until we have something like the Ryan White CARE Act, which would allow funding to treat patients with hepatitis C, or even just to screen, identify, and link patients to care, it is going to be a challenge.


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