In August 2014, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) prioritized who should be treated for hepatitis C virus (HCV) infection. In Recommendations for Testing, Managing, and Treating Hepatitis C, the AASLD and IDSA give top treatment priority to HCV patients who are at the highest risk for severe complications, such as those with fibrosis at stage 3 or stage 4 compensated cirrhosis, and organ transplant patients. The next tier is labeled “high priority,” and it is separated into two categories: a) those who are at high risk for complications, and b) those who have a high HCV transmission risk. Examples of those who are at high risk for complications are HCV patients with stage 2 fibrosis, or coinfected with HIV or hepatitis B. The list of persons who have a high HCV transmission risk includes active injection drug users, the incarcerated, and HIV-positive men who have sex with men (MSM) with high-risk sexual practices.
In this column, I examine the facts and discuss why it makes sense to treat those who are at high risk of transmitting HCV.
People with High HCV Transmission Risk
Data from the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2010 estimated that 1.3% of the U.S. population has chronic hepatitis C. The NHANES only surveys people living in homes. Data was not collected from certain high-risk populations, including the incarcerated, homeless, hospitalized, the military, and immigrants. Some researchers estimate higher HCV prevalence at 2.0% of the U.S. population. Let’s call it 1% to 2% and compare this to high risk groups.
People Who Inject Drugs (PWIDs):
Research published by Amy Lansky and colleagues (Estimating the Number of Persons Who Inject Drugs in the United States by Meta-Analysis to Calculate National Rates of HIV and Hepatitis C Virus Infections; PlosOne May 2014) estimates that 6,612,488 adults and adolescent in the U.S. have injected drugs sometime in their life. This is 2.6% of the population. Researchers estimate a huge range of HCV prevalence among PWIDs, anywhere from 30% to 90%. Regardless of the actual prevalence, HCV risk is high among people with an injection drug use history.
People Who Are Incarcerated:
HCV prevalence in jails and prisons is also high. The Centers for Disease Control and Prevention (CDC) estimates that of the 2.2 million people in U.S. jails and prisons, 30% have hepatitis C. Other estimates are between 17% and 60%. We don’t know the actual prevalence since HCV screening is relatively uncommon in state prisons.
HIV-Positive MSM with High-Risk Sexual Practices:
HCV sexual transmission risk, which is normally low in most situations, is increased among HIV-positive MSM. A study conducted in Amsterdam reported that among HIV-positive MSM, the HCV prevalence may be as high as 21%. Although injection drug use may account for some of the HCV prevalence in HIV-positive MSM, there was a correlation between fisting and HCV-positivity. (Fisting is the practice of inserting the hand into the rectum or vagina.) Note: Two recent studies reported that HCV appears to be transmitted sexually in HIV-negative MSM.
Why It Makes Sense to Treat Those at High Risk for HCV Transmission
Prevention is the best medicine. There is no HCV vaccine, but the disease is curable. The AASLD and IDSA Recommendations state, “Persons who have successfully achieved an SVR (virologic cure) no longer transmit the virus to others?successful treatment benefits public health.”It’s easier than ever to cure HCV, and we are doing so with as little as 12 weeks of treatment. Virologic cure rates for people with genotype 1 are 90% to 100%; other genotypes have high response rates too. We are even curing those who are coinfected with HIV and HCV. Drug development is progressing rapidly, with shorter treatment durations on the horizon. Since prevention is the best medicine, then curing hepatitis C early is second best. In short, stop it before it spreads. The CDC estimated nearly 22,000 new HCV infections in the U.S. in 2012, which is an increase of 75% since 2010. The vast majority of these incidents are among PWIDs. This creates a transmission risk for those who have blood-to-blood contact with PWIDs, including other PWIDs, family, friends, and health care workers. Cure these early infections before the virus has a chance to sink its ugly viral teeth into the livers of our precious friends, family, and community.
The Reality Check
The reality is that despite the AASLD and IDSA’s urging to treat those with high risk of infectivity, it is unlikely that these Recommendations will be implemented. PWIDs, the incarcerated, and HIV-positive MSM are not exactly attracting public health care dollars. In fact, viral hepatitis receives less than 3% of the funding HIV receives from the CDC. According to Emily McCloskey of the National Alliance of State and Territorial AIDS Directors, “State health departments receive less than $1 dollar in federal funding for every person living with viral hepatitis for the Viral Hepatitis Prevention Coordinator (VHPC) program.” The U.S. Congress can’t get it together to fund the Viral Hepatitis Testing Act of 2014, which will help screen baby boomers and other at-risk individuals.
However, just because public funding isn’t pouring in to treat those at high risk of HCV transmission, it should. We share this world with those at high risk for transmitting HCV, and if we want to knock HCV off the planet, we need to cure everyone. Where best to start? Start where HCV is at its highest, and reach out to PWIDs, the incarcerated, and HIV-infected MSM. It’s not just good health policy, it’s the right policy.
We don’t stop there. Everyone should have access to HCV treatment, regardless of fibrosis stage or risk to infect others. The words of Diane Sylvestre, the director of the Oasis clinic in Oakland, CA ring truer now than ever, “If one of us has hepatitis C, all of us have it.”
Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate, author of Free from Hepatitis C and Hepatitis C Treatment One Step at a Time, and a Hep contributing editor.
This excerpt is reprinted from the HCV Advocate, October 2014. Copyright 2014 with permission from the HCV Advocate and Lucinda Porter.