Thomas Robertson, MD: Eradicating Hepatitis C in the Next Decade

Eradicating hepatitis C virus (HCV) might be a realistic goal globally by 2030.

The advent of direct-acting antivirals (DAAs) has put a major dent into the spread of the virus, enabling patients to be treated and clear the disease quite easily.

But there remains some concern, particularly in lower income countries, whether or not this is a realistic goal.

In an interview with HCPLive®, Thomas Robertson, MD, FACP, Internal Medicine, Associate Program Director, AHN Internal Medicine Residency Program, talked about the recent progress in treating HCV and how promising the future is.

HCPLive: How big is the gap between the societal costs and burden of hepatitis in developed countries and developing countries?

Robertson: It really depends on the type of viral hepatitis and the population being evaluated. For HBV, the gap is massive between low- and middle- income countries (LMICs) and high-income countries such as the US.

There are more than 1 million HBV related deaths each year worldwide, and very few deaths in US due mostly to more widespread vaccination. For HCV, the burden is still higher in low- and middle- income countries, but relatively higher in the US (compared to HBV).

This is largely driven by the opioid epidemic, with rates of HCV infection increasing more than 400% in younger individuals over a 10 year period. The burden is high if left untreated with progression of liver disease to cirrhosis and high risk of liver cancer.

HCPLive: From a US standpoint, what is 1 thing that needs to happen to improve hepatitis care?

Robertson: The one thing that needs to happen in the US is more primary care clinicians being empowered to treat HCV. This is not a subspecialist disease anymore- it can and should be managed within primary care and that can be done actually more quickly and with less downstream issues than by subspecialists, and the data support that.

Coupled with that is increased screening in the community particularly for marginalized populations, more outreach, and more support for substance use treatments. The other thing to highlight again and again is that active drug use or other risky behaviors are not reasons to not treat- that goes against all available data and guideline recommendations.

HCPLive: There is always a lot of talk that HCV can eventually be eradicated. Do you think that is possible and if so, what needs to happen for that to occur?

Robertson: That’s the goal of the WHO and AASLD for the HCV Elimination target of 2030: which has a goal of reducing new infections by 80% and HCV related mortality by 65% compared to 2015 levels.

I think it’s possible with increased screening, particularly through outreach to marginalized populations, increased uptake in treatment through primary care, promotion of safe drug use practices, increasing substance use disorder treatments, and believing in the concept of treatment as prevention- similar to the HIV campaign- where treating and curing someone’s HCV eliminates the possibility of that person spreading the virus.

In fact, models show a reduction in overall prevalence and transmission, suggesting the possibility of a 90% reduction in incidence by 2030 as more people who use injection drugs are treated.

HCPLive: Are there any drugs in the pipeline that could potentially help this patient population?

Robertson: The reality and beauty of viral hepatitis today is we have all that we need: universally effective medications for HCV, and vaccination for HAV and HBV. The modern HCV treatment options, called DAAs, are truly a miracle of science- one of the most revolutionary advances in modern medicine.

Treatment involves a short course of medication- typically 8-12 weeks- with some follow up blood work. This leads to a >95% cure rate. HCV wasn’t discovered until the mid-1990s, and the initial treatments were horribly tolerated and marginally effective. Since the advent of DAAs, cure rates and tolerability have skyrocketed.

The most recent advances are that all of the DAAs used now are pangenomic, meaning they will cure any and all HCV genotypes, which makes it much easier for a clinician to understand which medication to use and how to treat.

For chronic HBV, treatment is much less effective and much longer. The key is prevention- through vaccination and risk factor modification.

HCPLive: How has the COVID-19 pandemic impacted HCV screenings. Do you think we will be playing catch up in the future?

Robertson: The pandemic has definitely set back any progress regarding HCV screening and treatment, for a multitude of reasons; healthcare bandwidth, energy and attention on behalf of both clinicians and patients and worsening of the opioid epidemic.

So, here we are and we must restart our investment into efforts to screen all adults for HCV, bust outside of the traditional 4 walls of an office to meet people in the community, and empower primary care clinicians to treat this curable disease regardless of ongoing risky behavior on behalf of the patient.