Improving the Care Cascade: Early Intervention for Perinatal HCV, with Megan Rose Curtis, MD

Megan Rose Curtis, MD

Credit: Megan Rose Curtis on LinkedIn

New cases of hepatitis C virus are on the rise, especially among reproductive-aged adults – accordingly, rates of perinatal HCV are expected to increase, raising important questions as to the optimal timing of treatment initiation with direct-acting antiviral (DAA) therapy for children born with the infection.

Although spontaneous clearance typically occurs in 20%-40% of children with perinatally acquired HCV, testing and linkage to care are still important to prevent the potential development of clinical manifestations and complications from chronic HCV. The US Food and Drug Administration (FDA) has approved curative treatment for children ≥ 3 years of age, although the long-term impact and cost-effectiveness of intervening at an early represent large gaps in clinicians’ understanding of pediatric HCV.¹

“What we know from the natural history studies of pediatric hepatitis C is that for those who don't clear the infection spontaneously, about a third will develop cirrhosis by the third decade of life. So that really made me think that this is a population that needs to be thought about,” Megan Rose Curtis, MD, of the Medical Practice Evaluation Center at Massachusetts General Hospital and the division of infectious diseases at Brigham and Women's Hospital, said in an interview with HCPLive.

She and a team of investigators conducted a health economic study to examine disease progression and costs in a hypothetical cohort of 1000 US children with perinatal HCV over a lifetime horizon. Using a state-transition model, they determined treating at 3 years of age prevented 89 projected cases of cirrhosis, 27 cases of HCC, and 74 liver-related deaths compared with deferring treatment until 6 years of age. Additionally, projected life expectancy was longest (78.36 life years) and mean lifetime per-person health care costs were lowest ($148,162) when patients were treated at 3 years of age.¹

“Direct-acting antivirals are such a breath of fresh air in terms of having something that is so curative, especially coming from an infectious disease background,” Curtis explained, but pointed out children with HCV are “falling off the care cascade before they can even reach treatment, before they’re diagnosed.”

Citing poor linkage to screening and treatment in this patient population, she raised questions as to what clinicians can be doing to improve care and subsequent outcomes. Specifically, she alluded to what was done for the baby boomer generation and the need to replicate that approach in the current generation, but also noted uncertainties about the effects of treating HCV at a young age.

“A lot of times, we have to kind of weigh this trade-off between an intervention being really expensive, but for a specific health outcome that we want to achieve, but this study was actually very surprising to me in that it was what we call cost-saving,” Curtis explained. “Even though there was an upfront cost of the treatment for direct-acting antivirals, which is pretty expensive in the United States, over the course of someone's lifetime, untreated hepatitis C was actually more costly. As you might guess, it also improved health outcomes to cure hepatitis C early, so it kind of is like a win-win.”

Since the increase in HCV among reproductive-age women has only recently been observed, the increase in children with perinatal HCV is also relatively new. As a result, there are no long-term, real-world studies looking at this issue.

Whereas previous studies have looked at the short-term effects of treating perinatal HCV earlier, Curtis’ study was able to examine the impact over the course of a lifetime and show its positive health and economic benefits: “Mathematical modeling, or simulation modeling, is an evidence-based methodology that's used to evaluate and project long-term outcomes, and that's what I think is so exciting about the methodology is that you can take something that might happen years and years down the line, and you can take a holistic view of in health care intervention that you might do or a clinical decision that you might make.”

Curtis noted she hopes the study results will “plant a seed” and “start a conversation” about treating children with HCV at a younger age rather than deferring treatment. Looking ahead, she hopes to take her research one step further to examine the cost-effectiveness of treating HCV during pregnancy once safety and efficacy data become available.

Reference:

^{Brooks, A. Early Treatment of Perinatally Acquired HCV More Cost-Effective Than DAA Deferral. HCPLive. March 13, 2024. Accessed March 14, 2024. https://www.hcplive.com/view/early-treatment-perinatally-acquired-hcv-cost-effective-daa-deferral}