HCV and Primary Care: A Special Report Recap

Ticking “Time Bomb.” Many of the roughly 3.5 million Americans who have HCV infection are unaware of their infection status. Many others have known for decades that there was a “time bomb” ticking inside of their livers and there was little or nothing they could do about it.

Deadly Disease. US deaths associated with HCV increased from 11,000 in 2003 to more than 19,000 in 2013, exceeding the number of deaths associated with 60 other “nationally notifiable infectious conditions combined.” The 6% annual increase in deaths is expected to continue.

Hepatitis ABCs. About 1% of the US population is infected with HCV, the third hepatitis virus discovered, after HAV and HBV. The existence of a “non-A, non-B” hepatitis virus associated with blood transfusions was known from the early 1970s, when assays could detect HAV and HBV but not HCV.

HCV’s Genetic Breakdown. Genotypes 1a and 1b predominate in the United States, followed by genotype 2, genotype 3, and genotypes 4-6. Genotype 1 has been considered the most difficult to treat, but multiple directly acting agents have “cure rates” of as high as 90%-95% after ≈ 12 weeks of treatment.

New Treatment Target. Injection drug use is now the predominant mode of HCV transmission in the United States. Targeting for treatment those at greatest risk for spreading HCV-injection drug users-has been suggested as the best way to reverse the ongoing epidemic.

Screening the “Baby Boomers.” Screening recommendations start with 1-time HCV testing for adults born 1945-1965 without prior ascertainment of risk. HCV rates are high in the “baby boomer” population, possibly because of a high rate of blood transfusions given in the 1950s and 1960s.

3 Good Reasons for Testing. When infected patients are identified, (1) clinicians can offer counseling and options for treatment, (2) patients can take the necessary measures to limit HCV-associated disease progression, and (3) transmission of HVC to an uninfected person can be minimized.

Turnaround in Insurance Coverage. With the high cost of direct acting antiviral agents, private insurance companies and state Medicaid programs have balked at providing the drugs to their insured customers. But insurance coverage is changing rapidly, and substantial progress has been made in the past year.

“Modern” Treatment Era Under Way. FDA approval of Harvoni (ledipasvir/sofosbuvir) for HCV monoinfected patients introduced the “modern” era of HCV treatment in 2014. That indication has been expanded to include the HCV/HIV co-infected population, and the FDA has approved 5 more DAAs or combinations of DAAs.

HIV Treatment Offers Resistance Lesson. Resistance-associated variants limit the activity of some drugs. A principle of treating HIV infection applies to HCV: Use drugs from at least 2 classes to increase the potency of the treatment regimen and to make resistance less likely to develop during therapy.