Let's start with the good news. AASLD and IDSA recognize the benefits of hepatitis C treatment, particularly early treatment. They state, "Because of the myriad benefits associated with successful HCV treatment, clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving an SVR, preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications...Patients who are cured of their HCV infection experience numerous health benefits...and a reduction in the rate of progression of liver fibrosis."
However, AASLD and IDSA go on to say, "Limitations of workforce and societal resources may limit the feasibility of treating all patients within a short period of time. Therefore, when such limitations exist, initiation of therapy should be prioritized first to those specific populations that will derive the most benefit or have the greatest impact on further HCV transmission. Others should be treated as resources allow."
This means that if there aren't a lot of doctors who can treat hepatitis C in your community, or if your healthcare plan budgets its resources, then certain patients may be given priority. Your state Medicaid program, insurance plan, or healthcare organization could limit access to hepatitis C treatment based on these priorities.
The good news is that the people who made the cut are those who need help the most--hepatitis C patients with advanced disease (stage 3 fibrosis or compensated cirrhosis ). I am NOT quibbling over their right to treatment. I wish nothing stood between them and immediate help. My issue is that we prioritize hepatitis C patients at all.
Here is the list, starting with the highest:
- Hepatitis C stage 3 fibrosis or stage 4 compensated cirrhosis
- Organ transplant patients
- Type 2 or 3 essential mixed cryoglobulinemia (Cryoglobulinemia is a type of vasculitis - a group of diseases that cause damage and inflammation of the blood vessels throughout the body)
- Proteinuria, nephrotic syndrome, or membranoproliferative glomerulonephritis (Kidney disease)
- Stage 2 fibrosis
- HIV-1 coinfection
- HBV coinfection
- Other coexistent liver disease (eg, fatty liver)
- Debilitating fatigue
- Type 2 Diabetes mellitus (insulin resistant)
- Porphyria cutanea tarda (a skin condition)
Persons Whose Risk of HCV Transmission is High and in Whom HCV Treatment May Yield Transmission Reduction Benefits
- Men who have sex with men (MSM) with high-risk sexual practices
- Active injection drug users
- Incarcerated persons
- Persons on long-term hemodialysis
Who Is Not a Priority for Hepatitis C Treatment?
The AASLD and IDSA guidelines say that those who are expected to die within a year from a cause unrelated to hepatitis C are not good candidates for treatment. The guidelines don't specifically recommend against treating hepatitis C patients with stage 1 fibrosis, but it is implied by the fact that they aren't prioritized. In my mind that is like saying that if you have stage 1 cancer, you should wait until you have stage 2 before getting treatment. I understand "limitations of workforce and societal resources" but rather than triage patients, shouldn't we fix the system?
I get that the sickest should be treated first. Triaging works well in ERs, wars and natural disasters. It works because trained medical people make the decisions. The problem with triaging hepatitis C patients is that the healthcare and insurance industry are also doing the triaging. When Gilead set the price of Sovaldi at $1000 a pill, the insurance/healthcare industry had to look for cost-cutting measures. I am nervous that these guidelines will give them the justification that they need in order to avoid treating those with stage 1 fibrosis. This means that those with limited access to healthcare, i.e. the poor, may be at the bottom of the list.
In my next blog, I will discuss some positive points in the guidelines, including recommendations for hepatitis C patients who are not waiting for treatment.