Hope in Hepatitis C treatment

The advent of effective, interferon-free treatment for hepatitis C (HCV) represents a significant medical advance, but challenges remain in identifying those infected, effective implementation and paying for the new drugs.

HCV is dubbed the slow, silent killer because it can cause chronic liver disease that progresses insidiously, unnoticed for decades. However, just 25 years after its discovery, we now have effective cures.

HCV affects over 216,000 people in the UK and up to 150 million worldwide, but it could now be eradicated by new, game-changing drugs offering cure rates in excess of 90 per cent along with improved tolerability. These treatments have the potential to cure the disease in a single, short course.

However, the sheer numbers of people who require these expensive medicines are putting financial pressure on healthcare providers and leaving patients with an anxious wait to find out if they qualify for treatment.

With minimal side effects and vastly reduced treatment duration, the new drugs offer a dramatic contrast to previous medications and mark out HCV as the only chronic viral illness that can be halted and the fastest to have been identified and cured.

"Doctors have faced frustration and desperation to find the people infected, to implement treatment and wipe out this virus"

This is not a story that ends with scientists; it is also one of doctors. They have faced frustration and desperation to find the people infected, to implement treatment and wipe out this virus, all while fighting the politics and economics, ignorance and apathy that hold them back.

Awareness

Only in recent years have doctors realised that HCV can be sexually transmitted. As it is carried in the blood in low amounts, in semen and other bodily fluids emitted during sex, the risk of transmission during sex was presumed to be negligible. That was until patients who had never injected drugs started testing positive.

Rougher sex, anal sex and the sharing of sex toys, especially among the MSM (Men who have sex with men) community, who may also be infected with HIV, make sexual transmission possible. Individuals can also pick up HCV, which is ten times more infectious through blood-to-blood conduct than HIV, by sharing razor blades or even toothbrushes. The virus can exist on surfaces outside the body for a few days, and even for weeks within syringes. It is most common in those who have shared needles, or who received blood transfusions or tattoos before the virus was discovered.

Global problem

In low-income countries many transmissions result from unsterile medical treatments and babies can also inherit it from their mothers.

Prevalence of HCV around the globe varies from about 1 per cent in the US, and lower still in the UK, to 10 per cent of 15-to-59-year-olds in Egypt, which has the highest incidence in the world.

Personalised HCV treatment may improve adherence and completion rates

People receiving treatment for HCV value clinicians who give information and clinical feedback that is personalised to their individual needs and lifestyle, which is an important facilitator of good adherence. I feel clinicians should better understand and acknowledge their patients' motivations for persevering with what is often a difficult course of treatment.

The cost of HCV treatment may be a barrier for emerging markets

In England, the National Institute for Health and Care Excellence (NICE) has approved the use of Sovaldi for HCV. Even though England is getting the drug at a discounted price of £35,000 (about $53,000) for a 12-week course, rather than the $84,000 wholesale price, NICE is allowing NHS England to postpone implementation for 180 days rather than the standard 90, which means that the drug is unlikely to be available widely until the end of July 2015.

I do not blame the pharmaceutical industry for this price, as many patients are going to be cured within two or three months. Therefore this new treatment actually works out cheaper than previous drugs. The price for interferon and ribavirin was around $50,000 and it was less effective, with a cure rate of 50 per cent, working out at '$100,000 per cure'.

The drug Harvoni also cures virtually everybody and is cost effective. For patients on it who are cured in 12 weeks, the cost works out at about $94,500 (or just $63,000 if achieved in eight weeks).

The price is already falling as other drugs are soon to come on to the market – including Merck's combination.

But many governments still could not afford to treat all the people with HCV. It would cost trillions, globally, to wipe it out using the new medications.

Should governments be developing their own drugs?

It would be economical for governments around the world to develop a novel set of drugs themselves. The reduction in cost could be immense. In the UK alone it is estimated the cost for treating all patients with HCV would amount to £6 billion, which is more than 20 times greater than the annual budget for England's Cancer Drugs Fund.

There are no easy answers to the funding problem. Keeping the drugs for the most ill patients would not be the most effective way to eradicate the disease. The longer you wait, the greater the risk of patients developing liver cancer or end-stage liver disease. They also remain infectious to others.

Online poll

In our most recent poll we asked respondents: 'In which format would you prefer to receive information on HCV testing?'

Our findings showed us that smartphone and tablet devices were the most popular choice (18.8 per cent), followed by social networking (18.5 per cent), websites (15.5 per cent), face-to-face meetings (12 per cent), forums (9.5 per cent), blogs (8.6 per cent), newspapers and magazines (7.8 per cent), video (6.2 per cent), radio (2.6 per cent) and finally television (1.3 per cent).

Technology is allowing us to communicate quicker and smarter than ever before. Online social networking can be used as an innovative method of HCV education and prevention. As use of these technologies is increasing, standards must be established to grow these networks further.

Applications on smartphone and tablet devices improve access to online blogging and forums, but I feel it is important that patient groups also have access to more traditional resources which have been shown to be effective, including printed materials and, critically, face-to-face contact with people living with HCV or treatment experienced.

In response to the question, 'Where would you prefer to access Hepatitis C testing?' the findings put sexual health (GUM) clinic as the most preferred choice (43.8 per cent), followed by home testing/sampling kit (23.9 per cent), non-clinical/community settings (15.9 per cent), A&E (8 per cent), GP practice (7 per cent) and lastly private healthcare (1.5 per cent). Nobody marked the 'I am unsure' or 'I wouldn't want to access hepatitis C testing' options.

"We must identify the carriers first by increasing home testing/sampling kits and continuing community screening is essential"

The focus on increasing screening for HCV is vital. We must identify the carriers first by increasing home testing/sampling kits and continuing community screening is essential. Importantly, access to screening in A&E and at GP practices needs to be targeted to the higher-risk populations, with the aim of breaking down stigma and enabling appropriate signposting for individuals to access service providers.

If we suspect that more transmissions are occurring, and we know that screening can help prevent further transmissions and further liver damage, what is it going to take for governments to identify those who are infected and implement effective services? Even in the UK, which is a comparatively small infected population, eradication will probably take many decades.

Poll data

A total of 183 respondents provided 509 responses between 1 March and 15 April 2015, with data collected via online hosting at www.Design-Redefined.co.uk and social networking sites. Thank you to the community for their input.

The next poll examines the British HIV Association's (BHIVA) Standards of care for people living with HIV, specifically Standard 6: psychological care. View the poll and vote here.

About the author:

David Rowlands is the director of Design-Redefined.co.uk, delivering effective healthcare communications to professionals and patients.

His key objective is to design, develop and deliver community projects to enable people living with, or affected by, HIV and/or Hepatitis C (HCV) to become better engaged with their treatment and care.

Working over a number of media platforms, across the public, private and third sector, he is able to establish a link to these sometimes hard-to-reach communities.

Contact David: Email: david@design-redefined.co.uk Website: Design-Redefined.co.uk Twitter: @DR_tweetUK