Laird Harrison

November 17, 2015

SAN FRANCISCO — Despite powerful new medications, the lack of screening and treatment capacity will make it difficult to eliminate the hepatitis C virus in the United States, according to projections presented here at the Liver Meeting 2015.

Current trends show that even after 2020, more than 500,000 people will be unaware that they are infected with hepatitis C, said Jagpreet Chhatwal, PhD, from the Massachusetts General Hospital and Harvard Medical School in Boston.

"We need aggressive screening and treatment policies to further reduce the burden of hepatitis C," he said.

The landscape of hepatitis C has changed rapidly in the past 5 years.

Treatment outcomes have advanced with the advent of direct-acting antiviral, from a sustained virologic response rate of less than 50% before 2011 to better than 95% in 2015. At the same time, the Affordable Care Act has expanded the number of people with healthcare coverage.

To project the course of the disease, Dr Chhatwal and his colleagues assessed patient demographics, disease characteristics, therapeutics, screening policies, insurance coverage, and access to treatment in the United States using the Hepatitis C Disease Burden Simulation model they developed (Ann Intern Med. 2014;161:170-180).

Mortality and Morbidity

Medications, including the new direct-acting antivirals, will reduce the number of hepatitis C deaths by more than half from 2015 to 2050, Dr Chhatwal reported.

But if current trends continue, 317,000 people will still die from the virus during that period.

In addition, 154,000 patients with hepatitis C will develop hepatocellular carcinoma, 198,000 will develop decompensated cirrhosis, and 31,000 will undergo liver transplantation.

This year, there are 2 million noninstitutionalized patients chronically infected with hepatitis C and viremic, the researchers estimate. Of these, 1.1 million are aware of their infection status and have insurance, but it appears that most of them are still not being treated.

On the basis of drug sales, they estimated that only about 140,000 patients were treated in 2014, and this year, about 180,000 will be treated.

At this rate, it will take at least 10 years before the number of treatment candidates is below 50,000, Dr Chhatwal reported.

"We can treat more than 180,000," he told Medscape Medical News. "We want to send a message that if we can increase the number of people getting treated, then we can reduce the disease burden."

He added that the true burden of hepatitis C in the United States was probably underestimated in this study because it doesn't include the many people living in institutions.

After the presentation, Kenneth Sherman, MD, from the University of Cincinnati, said that his own research has shown that the increase in heroin use has led to many people being infected with hepatitis C.

The high rate of infection in immigrants could also affect trends, said session moderator Rajender Reddy, MD, from the Hospital of the University of Pennsylvania in Philadelphia.

Dr Chhatwal said he agrees that it would be worthwhile to include data on heroin users and immigrants in future projections. It is possible that heroin-related infections could increase the incidence of infection, he said.

Cost of Care

In a separate study, Dr Chhatwal and his colleagues estimated that the annual cost of care for patients with hepatitis C grew from $7 billion before the advent of direct-acting antivirals to $21 billion in 2015.

That cost will decrease as the prevalence of the disease declines, likely down to $2 billion by 2020, the researchers report. They estimate, however, that it will cost $106 billion over the next 25 years to make hepatitis C a rare disease.

Primary care providers can help reduce the disease burden by screening more patients, said Gyongyi Szabo, MD, PhD, president of the American Association of the Study of Liver Diseases (AASLD).

Currently, the Centers for Disease Control and Prevention recommends that everyone born from 1945 to 1965 get tested for hepatitis C.

The Institute of Medicine is contemplating a study, supported by the AASLD, to assess strategies for the eradication of the virus in the United States, Dr Szabo told Medscape Medical News.

During a global summit at the Liver Meeting, representatives from hepatology societies around the world and from the World Health Organization set their sights on drastically reducing the burden of the disease, she said.

"We agreed that it is a global potential goal for hepatologists to treat hepatitis C with the vision of not necessarily eradicating it," said Dr Szabo, "but getting to the point where it is a minimal entity."

Dr Chhatwal reports relationships with Merck, Gilead, and HEOR Solutions. Dr Szabo reports relationships with Conatus, GlaxoSmithKline, Bristol-Myers Squibb, Idenix, Ideral Integrated, Therapeutics, Intercept, Johnson & Johnson, Novartis, Novelos, Ocera, Roche, Schering-Plough, Vertex, and Wyeth.

The Liver Meeting 2015: American Association for the Study of Liver Diseases (AASLD). Abstract 104. Presented November 16, 2015.

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