July 28 is World Hepatitis Day. Hepatitis C can become chronic, life-long infections, which can lead to liver cancer. Millions of Americans are living with chronic viral hepatitis, and many do not know they are infected.
Hepatitis C was discovered only five years before I started my first job as a ‘liver doctor’ at the Veterans Affairs Medical Center in Washington D.C. in 1994. At that time, there were no good treatments. People with hepatitis C developed cirrhosis and liver cancer. Hepatitis C became the most common reason for needing a liver transplant.
In the early 2000s a combination antiviral therapy (pegylated interferon plus ribavirin) was developed to help prevent the virus that causes hepatitis C from reproducing in the body. It could eliminate the virus in about 50 percent of patients; however, most patients had unpleasant side effects. Other patients, including African-Americans, those with HIV infection, and those with kidney disease, had a very poor response (<20 percent). There was great concern that hepatitis C-related liver disease would become a significant public health problem by 2030, affecting as many people as cancer and heart disease.
Fortunately, researchers were able to understand the virus’ structure and how it replicated. This enabled the development of ‘direct acting agents’ (DAAs) to treat it. Pegylated interferon and ribavirin act by boosting the immune system of the patient in an attempt to help it recognize and eliminate the hepatitis C virus. By contrast, DAAs attack the hepatitis C virus itself, preventing it from entering cells, or making it difficult for it to replicate. As a result, the virus cannot establish chronic infection in the liver. The first DAAs were approved by the Food and Drug Administration in 2011. These medications were great. They could be given for short periods of time (six months rather than one year), sometimes without interferon, and had a response rate of 75 percent to 80 percent.
Then, a breakthrough happened just this past year: Hepatitis C is now a disease that can be cured!
Two new treatments – Harvoni and Viekira – are available to treat hepatitis C. Both provide a greater than 90 percent likelihood of cure. Both are all-oral medications (no interferon), both are given for short durations (12-24 weeks), and both have a very low risk of side effects. Treatment does require management by a hepatitis C specialist (to assess response and rule out resistance with periodic blood work). The treatments are available at The University of Vermont Medical Center.
It is important to know that ‘cure’ is not ‘immunity.’ It is possible to be re-infected with hepatitis C after cure if a patient becomes re-exposed to the virus (via IV drug use, cocaine snorting, unsafe tattoo practices, etc.). In addition, ‘cure’ of hepatitis C does not necessarily melt away cirrhosis; therefore, patients with cirrhosis (or advanced fibrosis/scar on a liver biopsy) will still need to be followed after cure of hepatitis C to make sure they do not develop liver cancer.
In just over 25 years, we have gone from merely being able to see the hepatitis C virus under the microscope, to a cure! This is exciting news for the community of people infected with hepatitis C, those who love them, and those of us who treat them. With any luck, hepatitis C will be a disease of the past, similar to leprosy and polio.
Doris Strader, MD, is a gastroenterologist at The University of Vermont Medical Center and a professor at the Larner College of Medicine at UVM.