ID Specialist Involvement Key to Successfully Treating Hepatitis C

Rapid changes in the hepatitis C virus (HCV) treatment landscape over the past few years have led to debate about which care providers should be responsible for treatment. Contemporary antiviral therapy for HCV is safe, highly effective, and produces cures with finite treatment courses in most patients. Such therapy should be successful when administered by most healthcare providers. However, because HCV antiviral agents are new and have no uses outside of HCV treatment, they are often unfamiliar to non-experts. Also, because they are extraordinarily expensive, most pharmacy insurance plans have limited prescription of these medications to non-experts.

There are several reasons why infectious disease (ID) specialists should be assuming a major role in the implementation of these revolutionary new treatments.

1. HCV is an infectious disease. The field of ID is already a highly specialized niche.  While some ID clinicians may subspecialize in certain areas within the niche, a qualification of the specialty is still the ability to render expert care in all aspects of infectious diseases, including HCV.

2. Referral to gastroenterology/hepatology is no longer required. Interferon-based therapy was expensive and toxic, and was associated with a low success rate. The risk/benefit ratio was most favorable for those with biopsy evidence of advanced fibrosis. Contemporary, interferon-free treatment is safe and highly effective, making treatment reasonable for all infected individuals, as is clearly stated in the current guidelines from the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of American (IDSA).¹ Unfortunately, because of high cost, assessment of fibrosis is often required and then used by pharmacy insurance plans to deny treatment. This barrier to universal treatment is gradually eroding as competition among the many effective regimens now available reduces cost, and the consensus of expert opinion articulates the need for treatment. However, the identification of cases with cirrhosis is still needed to determine the optimal drug combination, treatment duration, and the need for monitoring for hepatocellular carcinoma during long-term follow-up. Fortunately, noninvasive methods such as transient elastography have been shown to be as good as or better than liver biopsy to assess fibrosis, thereby avoiding the need for consultation. Diagnostic algorithms based on combinations of blood tests also separate cirrhosis from noncirrhotic cases reasonably well and can be useful.

3. Expertise in HIV gives a huge headstart on HCV expertise. There are many similarities between HIV and HCV in pathophysiology, immunology, patient demographics, complications, and treatment. Both are chronic viral infections that usually are not controlled by natural immunity. Both generally damage their target organ system slowly, and both cause chronic immune activation, leading to an increased risk of cancer and other chronic noninfectious diseases. Definitive treatment of these viruses employs combinations of antiviral agents that target different steps in the viral lifecycle, and the evolution of resistance to antiviral drugs shares many similarities for these two highly mutable viruses.  Finally, the patient populations are overlapping, including drug users and men having sex with men. It takes a special set of skills as well as access to specialized ancillary services to deal with the medical and psychosocial issues that complicate the chronic viral infection that is the primary reason we treat these individuals. HIV clinicians are generally well suited to and experienced in this type of care. That experience makes ID specialists well positioned to treat not only HIV/HCV co-infection but HCV mono-infection, as well.

If you are one of the ID specialists who has avoided getting involved with HIV care, you will not have this advantage. The good news is that it’s not too late. Also, think about reason 1 above and avoid making the same mistake twice.

4. Elimination of HCV will require a large increase in treaters. The availability of safe and effective curative treatment makes elimination of the HCV epidemic a viable long-term public health goal. Greatly expanded testing and treatment capacity will be required. While the case for involvement of ID specialist in HCV care is strong, HCV should not be an exclusive turf. Obviously, gastroenterologists and hepatologists should treat HCV infection. Their expertise is essential in cases of decompensated cirrhosis, which should be managed only when there is access to liver transplantation. Primary care providers also can treat HCV, if they have the skills and inclination to manage this challenging patient population. The treatment regimens themselves are safer, less complicated, and more effective than those used to treat other chronic diseases, such as diabetes, COPD, and heart disease, all of which are frequently managed by primary care providers. To expand HCV treatment to all infected individuals and achieve the goal of HCV elimination, a large number of clinicians who can render expert care for HCV will be needed. ID specialists must be a large part of the effort.

Reference

1. AASLD/IDSA. Recommendations for testing, managing, and treating hepatitis C. http://hcvguidelines.org/sites/default/files/HCV-Guidance_October_2016_a.pdf. Updated September 27, 2016. Accessed October 24, 2016.