Too expensive and too many individuals infected: The high cure rates will not curb hepatitis C

“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 the expert, 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, however, Dr Pawlotsky said 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. The exorbitant price (at least in the US) for the new drugs is a well-documented issue that will work against widespread cure. In fact, at a price of approximatly 80’000 to 100’000 dollars (for the US) for one tratement cycle of 12 weeks for therapies with anti-HCV-drugs or regimens such as Sofosbuvir (Sovaldi), Ledispavir, Simepravir, and/or combinations thereof (i.e. Harvoni), with or without ribavirin combined, who could afford such therapy? Moreover, as you can judge fromt the illustration at the left, the US is not even a  country with a high prevalence of HCV infection rates.  As you can see from the chart at left, in many of the most affected countries worldwide, patients generally eligible for treatment (namely those whose HCV-infection has progressed to a state where a liver transplantation has become inevitable)  could simply not afford it. This in itself would have to be judged as a discriminatory scandal in itself.

But there are other problems. The new and very effective drugs are not prophylactic. In fact, 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,” Dr.  Pawlotsky explained. The goal, said Dr Pawlotsky, is to control the disease, at least in the countries that can afford to. Additionally,, 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,” the expert said.

Another  quandary involves the more ethical question  of retreating people who reinfect themselves. 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, this is going to be 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 stated. “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.” And, of course, the blog author may add, there is not only one mondial society with one standard to live on. Again, particularly looking at the chart above, anglo-american societal standards may not even apply to the majority of the patients affected by HCV-infection.  So, what are we going to do about these patients? Being poor, and perhaps having a need to be treated more than once? Should we let them go and die, simply because their way of life does not adhere to anglo-american standards?