State-of-the-art guidance for the treatment of hepatitis C virus (HCV) infection was updated this week to help healthcare providers to determine when and in whom to start antiviral treatment to cure patients of their HCV infection.
Launched earlier this year by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), in collaboration with the International Antiviral Society-USA (IAS-USA), the online guidance at HCVguidelines.org provides recommendations for testing, managing, and treating HCV, based on the latest evidence and on the consensus of a panel of 27 liver disease and infectious diseases specialists and a patient advocate. The three organizations have committed to regularly updating the guidance to keep pace with improved diagnostic tools and new drugs as they become available. This week’s addition was the first such update.
With the availability of recommendations from the CDC [PDF 879KB] and U.S. Preventive Services Task Force for one-time HCV screening among those born between 1945 and 1965 (i.e., “baby boomers”), coupled with new direct-acting antiviral treatments with high cure rates, shorter treatment durations, and fewer side effects, we have the opportunity to identify and care for the estimated 3 million Americans who are chronically infected with HCV—at least half of whom are unaware that they are infected. Those persons who receive HCV treatment and are cured of their infection will experience numerous health benefits including improvements in liver fibrosis (“scaring”) and substantial reductions in the risk of liver cancer.
The new guidance states that “the goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences” and that “treatment is recommended for patients with chronic HCV infection.” However, the authors of the guidance also note that “limitations of workforce and societal resources may limit the feasibility of treating all patients within a short period of time” and, as such, the updated guidance offers clinicians information on those populations who will derive the most immediate benefit from HCV treatment, including those populations that will have the greatest impact on further HCV transmission. According to the guidance, when resource limitations exist, the highest priority for treatment should be given to patients who:
- Have advanced liver fibrosis or compensated cirrhosis,
- Are liver transplant recipients, or
- Have severe extrahepatic disease such as cryoglobulinemia, proteinuria, and nephrotic syndrome.
High priority for treatment (owing to a high risk for complications) should be given to patients with:
- High risk for liver disease progression (based on stage of liver fibrosis),
- HIV coinfection,
- HBV coinfection,
- Other coexistent liver disease (e.g., nonalcoholic steatohepatitis- a.k.a. fatty liver disease)
- Debilitating fatigue,
- Type 2 diabetes mellitus, and
- Porphyria cutanea tarda.
While the guidance notes that further study is needed to define the “best candidates for (HCV) treatment to stop transmission,” it also states that “successful treatment of HCV-infected persons at greatest risk for transmission represents a formidable tool to help stop HCV transmission.” The following populations are identified as those in whom HCV treatment may yield transmission reduction benefits: men who have sex with men (MSM) with high-risk sexual practices; active injection drug users; incarcerated persons; and persons on long-term hemodialysis.
This updated guidance is an important contribution to ongoing efforts to strengthen the capacity of the health care workforce to successfully respond to viral hepatitis as called for in the Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis, updated and released earlier this year. Specifically, the updated guidance will aid hepatologists (liver specialists) as well as the diverse range of non-specialist providers who will become involved in delivering HCV care as treatments become easier to administer and more individuals become aware of their chronic HCV infections and seek care and treatment.