Treatment for hepatitis C remains low, despite success

Antiviral treatment reduces complications of hepatitis C infection, but only two out of every three patients diagnosed with the virus receive the treatment, according to two recent studies led by Mindie Nguyen, MD, professor of gastroenterology and hepatology.

“I’m hoping the data will bring home the magnitude of the problems,” said Nguyen, the senior author of both papers. “The benefits are clearly shown in our study. We are looking at a population with probably better coverage than anyone — patients in the United States with private insurance — yet less than 65% of people diagnosed with hepatitis C received treatment. That is quite sobering.”

Hepatitis C is a viral infection, spread through blood, that can develop into cirrhosis, scarring of the liver and liver cancer. From 2013 to 2016, about 2.4 million people in the U.S. had hepatitis C. Direct-acting antivirals, medication that targets the proteins of the virus, have been shown to eliminate the viral infection in about 97% of patients.

For both studies, Nguyen’s team used a database that included 60 million people with private insurance, including more than 100,000 adults with chronic hepatitis C.

In one of the studies, published in JAMA Internal Medicine Dec. 12, researchers found that the risk of liver-related outcomes, such as decompensation — progression of hepatitis C that deteriorates liver function — and liver cancer, were much lower in treated patients compared with untreated patients: 64% and 27%, respectively. The team also found a 26% lower risk of diabetes, as well as about a 10% lower risk of cardiovascular disease and non-liver cancer in those who received treatment. Overall, mortality for treated patients was about half (43%) that of the untreated.

Eiichi Ogawa, MD, PhD, of Kyushu University Hospital in Japan and a former visiting scholar, and Nicholas Chien, MD, a research associate, are co-lead authors of the JAMA Internal Medicine paper.

The other study, published in JAMA Network Open Dec. 7, found that between April 2018 and March 2019, the treatment rate of privately insured Americans was 65%. Vy Nguyen, a research coordinator at the Nguyen Lab and at Harvard Medical School, is the lead author of the paper.

“Treatment clearly decreases the risk of liver cancer and improves survival in people,” Mindie Nguyen said.

Barriers to care

There are several possible explanations for the low treatment rate, according to Nguyen. Many insurance companies require additional testing like pap smears because, she said, they may not want to cover treatment for someone who has cervical cancer and only a few years left to live, for example. The extra time and cost may prevent some people from receiving treatment.

Reimbursement is another barrier. Even if health insurance covers some of the cost, many people still have to pay thousands of dollars for the treatment. The annual household income of the patients with hepatitis C was less than $40,000 in 46% of the patients in this study, while the median out-of-pocket expense was $2,214.

In addition, Nguyen said, some doctors are hesitant to treat hepatitis C in patients with late-stage complications because the previous treatment, interferon, worsened those patients’ symptoms. Nguyen said that may be why her study found that people with decompensated cirrhosis and hepatocellular carcinoma — the most common type of liver cancer — were 31% less likely to receive treatment.

“Those who stand to benefit the most are least treated, likely because of the preconceptions of the previous treatment available,” she said.

A dire outlook

Nguyen believes that the treatment rate in the overall population is likely lower than that found in the JAMA Network Open study. The study looked only at privately insured patients, and those without insurance or with minimal insurance coverage are less likely to receive a hepatitis C diagnosis. Also, the study considered someone treated if they received at least one month of the three months of medication needed for full antiviral treatment. Those people who did not continue treatment will not have the full benefit.

“It’s sad that a treatment proven to be so effective is used by only a fraction of the diagnosed people,” Nguyen said.

In 2016, the World Health Organization called for hepatitis C elimination by 2030. Nguyen said we are a far cry from that. She hopes that her studies will be a call to action and help inform people of the benefit of treatment.

“There needs to be a better public campaign that reaches out to the people who may be more resource limited: those in rural areas and immigrant communities,” Nguyen said. “Insurance reimbursement should remove the barriers. It’s as easy as writing a prescription for antibiotics.”

Nguyen is a member of Stanford Bio-X, the Stanford Cancer Institute and the Stanford Maternal and Child Health Research Institute.

Researchers from the Cedars-Sinai Medical Center in Los Angeles, the National University Hospital in Singapore and the Veterans Affairs Palo Alto Health Care System contributed to the first study.

Researchers from the Kyushu University Hospital in Japan, the Cedars-Sinai Medical Center, the Xi’an Jiaotong University in China, the National University of Singapore and the National University Health System in Singapore contributed to the second study.

Both studies were supported by the National Institutes of Health (UL1TR003142).