Hepatitis C treatment: The future is now

Correctional institutions face a disproportionate amount of the hepatitis C (HCV) disease burden, with estimates of chronic infection between 12 and 35%ii, [i]. Correctional populations represent about 1/3 of total US HCV cases[ii]. Left untreated, HCV can lead to cirrhosis and liver cancer, and it is the leading cause of liver transplants in the US[iii].  HCV treatment is rapidly improving as emerging therapies have fewer side effects, higher efficacy, and shorter duration than previous regimens. Between 80-90% of current patients can now be cured, and future regimens will approach cure rates of 100%.

Prior to 2011, the standard of care for HCV was 6-12 months of pegylated interferon and ribavirin, a combination of injections and pills.   This regimen has numerous contraindications and side effects during treatment, including flu-like symptoms, depression, neutropenia, and anemia, that require frequent monitoring.  The high HCV prevalence rates in corrections combined with the yearlong treatment, multitude of side effects, and high monitoring needs led to a workload burden on correctional systems.   When combined with the limited efficacy of the regimen of 40-50%, treatment was largely reserved for eligible incarcerated patients with longer sentences

In 2011, the first direct acting antivirals (DAAs) to treat HCV, telaprevir and boceprevir were introduced.  They are used in combination with pegylated interferon and ribavirin.  While these drugs increased treatment efficacy to 65-75%, they came at a higher price tag, presented numerous implementation challenges in corrections, and added to the side effect profile. In late 2013, two additional DAAs were FDA-approved, simeprevir and sofosbuvir. Suddenly, cure rates over 85% were possible even for the most challenging to treat patients.  These newer DAAs can be dosed once daily, have fewer drug-drug interactions, no food requirements, and less side effects, but come with a very high price tag.

Despite many improvements in HCV treatment, new medications pose challenges alongside opportunities for health care providers in the correctional setting.   As HCV treatment rapidly changes so will its role in the treatment of individuals as well as its impact on public health.  Correctional systems will need to play a large role in this changing paradigm to have an impact on the HCV epidemic.  

This presentation discusses the changing nature of HCV treatment and practical challenges for correctional health care providers.

[i] http://www.cdc.gov/hepatitis/Settings/Corrections.htm

[ii] Varan et al.Hepatitis C Seroprevalence Among Prison Inmates Since 2001: Still High but Declining. Public Health Reports, 2014; 129: 187-195.

[iii] http://www.cdc.gov/Hepatitis/