Recent data show that Hepatitis C (Hep C) kills twice as many people in Arkansas as HIV-related illnesses making it the most deadly infectious disease in the state.
“It is estimated that 38,000 adult Arkansans have Hep C and do not know it,” said Arkansas Department of Health Medical Director for Infectious Disease Naveen Patil, MD. “Since we began testing in our health units in the late summer/fall of 2014, we’ve tested 2,658 people and 282 of those were confirmed reactive.”
The recommendation is that anyone born between 1945 and 1965 be tested for Hep C at least once. Anyone, regardless of age, who is at risk for infection should also be tested. That includes healthcare workers who might have come into contact with infected blood through a needle stick. Other major risk factors are illegal IV drug use, receiving a tattoo or body piercing from an unregulated entity, a history of incarceration, HIV infection, or receiving a blood transfusion before 1992.
“It’s difficult to estimate the number of IV drug users in the state, though some predict that number is increasing with the crackdown in prescription opioid drug abuse,” Patil said. “Individuals who are addicted can no longer acquire prescription opioids and may be turning to heroin, which can be used in a variety of ways, including injection. If national trends in IV drug use also represent Arkansas, it’s likely that we will see an increase in Hep C infections over time.”
Because Hep C often doesn’t show any symptoms until years or decades after infection, it’s likely that many of those who were exposed a long time ago are just now beginning to have physical symptoms from the bacterial and viral infections that cause inflammation of the liver.
Patil said Hep C can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Hep C can be either acute or chronic. Acute Hep C infection is a short-term illness that occurs within the first six months after someone is exposed.
“For most people, acute infection leads to chronic infection,” Patil said. “Chronic Hep C is a serious disease than can result in long-term health problems, or even death. There is no vaccine for Hep C. The best way to prevent Hep C is by avoiding behaviors that can spread the disease, especially injection drug use. About 80 percent of those exposed to the virus contract the disease.”
Andres Duarte-Rojo, MD, a University of Arkansas for Medical Sciences (UAMS) assistant professor who specializes in gastroenterology and hepatology, said the good news is that anti-viral medications that have come on the market in the past year or so are seeing cure rates of above 90 percent for the vast majority of infected people. That is a great improvement over earlier medications including peginterferon and ribavirin that have been in use for about the past 25 years that are effective in about 45-55 percent of patients, across the seven different genotypes) of Hep C.
“Those two medications are pretty good, but have way more side effects and about half the efficacy for the majority of patients as the newer drugs,” Duarte-Rojo said. “The efficacy and safety both are pretty good with the newer medications. Side effects are minimal. About five to 15 percent of patients will have fatigue, headaches, insomnia, diarrhea and nausea.”
The newer medications for chronic Hep C include Sofosbuvir, which used with other anti-viral medications (i.e. Ledipasvir and\or Ribavirin) can cure the majority of patients within 12 to 24 weeks. A second is the three-drug combo commercialized as Viekira approved in March 2015, approved only for use in genotype one. A third one is Daclatasvir, approved in combination with Sofosbuvir for the fewer patients with genotype three infection.
The medications are extremely expensive which has led to rationing of the drugs.
“That is the problem,” Duarte-Rojo said. “We have medication that is very useful that can be given to majority of patients, but we cannot pay for everyone to have antiviral regimens that can cost between $84,000 to $150,000. Use is being restricted to patients with the most urgency: cirrhosis or a state previous to cirrhosis. This means, if you are a nurse working ICU, and you get stuck with a needle from a Hep C patient and develop the chronic disease, you are not going to get treated because that medication is not covered for initial stages. That doesn’t make sense to me. It goes against the good practice of medicine, and we have some people here who work at university under that circumstance. But that is how the policies are right now.
“I expect the policy will change when the price decreases. It is easy to blame it on insurance or drug companies, but the problem is actually more complicated than that. It will create a great debt to the health system if we treat everyone at the early stages of infection. So we might have to be selective on whom to treat in early stages of disease for the next few years.”
While it is discouraging that the new drugs can’t be used to treat everyone, including some healthcare providers, Duarte-Rojo said we should all feel very positive about the newer medications. He expects to see the medications become more affordable and available in the near future, and is also hopeful that new anti-viral medications will be developed to treat about ten percent of the Hep C patients who don’t respond to any of the current antivirals.
“I believe a time will come when all patients will be able to get treatment and have Hep C eradicated,” Duarte-Rojo said. “Anyone in dire need now can get therapy. They should not feel they are being abandoned. People who really need it are getting therapy right now.”
Illegal IV drug users are the largest risk group. It is important to have a statewide strategy combining substance abuse rehabilitation and antiviral therapy so patients can remain drug-free in order to prevent re-infection. Duarte-Rojo said from the public health perspective, it does not make sense to invest a large amount of money on antiviral therapy on people with a high likelihood of getting re-infected, particularly when no support is offered for their substance abuse problem.
“That is why we delay treatment of people who use IV drugs until after rehabilitation,” he said. “Otherwise, they are likely to use another dirty needle, and will get re-infected.”
Duarte-Rojo recommends more people in the state be screened for Hep C. There is recent evidence from emergency departments showing people with no identifiable or disclosed risk factors having a high frequency of Hep C infection.
Photo notes: Mugshot of Naveen Patil, Andres Duarte-Rojo
