Hepatitis C advances are gifts that will keep on giving
The number of Australians living with hepatitis C virus (HCV) who have advanced liver disease, and the number living with hepatitis C-related cirrhosis, have declined for the first time in 10 years. While the report card for HCV isn’t all good news, the benefits of second generation medications are starting to show, and will be gifts that keep on giving well into the future.
Before we look at the future of hepatitis C, let’s revisit its past.
“Hepatitis C was initially called non-A, non-B hepatitis. We knew there was something there that wasn't hepatitis A or B, but we couldn’t identify what it was. It was finally discovered and named hepatitis C around 1989 thanks to improved molecular techniques,” explained Professor Bill Rawlinson, Senior Medical Virologist at SAViD, NSW Health Pathology Randwick & UNSW.
Prof Rawlinson said a snowball effect kicked in once the virus was identified. Hepatitis C was initially associated with infected blood products until a test for the virus was introduced in 1990, with Australia the second country in the world to screen its entire blood supply.
The ability to reliably test for HCV halted transmission of non-A non-B hepatitis from blood. First generation medications were later developed to treat the infection, although Prof Rawlinson said they were of varying efficacy, as low as 50% in some populations. The regimens were difficult to administer and adhere to, and they came with some nasty side effects. Second generation medications, known as Direct Acting Antivirals (DAAs), were the game changers.
“There was a problem and some really clever people persisted until they solved it. The second generation medications for hepatitis C are easier to take than the first generation, have shorter courses, come with far fewer side effects and have better cure rates for a wider range of HCV genotypes.”
The cure rate for HCV for people who receive treatment is very high. About 227,306 people in Australia were living with chronic hepatitis C at the start of 2016. Of these, 14% (32,550) received HCV treatments, of whom 93% (30,434) were cured. Their treatment paths were determined by their HCV genotype or strain, although the effectiveness of DAAs has rendered this determination less critical.
“There is also more advanced technology available to investigate liver damage, bypassing the need for an invasive liver biopsy, as well as better tests for the virus itself,” explained Prof Rawlinson.
“Another flow on effect of being able to diagnose and cure patients with HCV will be an eventual decrease in the number of people who require a liver transplant. This is because liver failure resulting from HCV infection is currently the most frequent reason for liver transplants in many countries including Australia.”
Within one generation the HCV virus was identified, reliable pathology tests were developed to diagnose a HCV infection, the blood supply was safe guarded, treatments were developed that have high cure rates, and fewer liver transplants are on the horizon. All of these point to a brighter future for people living with HCV, and for the community as a whole.
A bit more about hepatitis C
- Hepatitis C is a contagious liver infection caused by the hepatitis C virus (HCV).
- There are six major genotypes (strains) and numerous subtypes labelled a, b, c etc.
- The virus exists in the infected person as a group of closely related species, or quasispecies, which has an influence on how the person’s immune system responds to the infection.
- Transmission is through blood-to-blood contact (parenteral transmission) and from mother to newborn (vertical transmission).
- HCV is now mostly transmitted through the sharing or re-using of injecting equipment such as needles and syringes. Needle syringe exchange programs and needle cleaning programs are attempts to reduce this transmission in some settings.
- Pathology tests to diagnose HCV infection include a blood test to look for antibodies to the virus. If this test is positive, further tests are requested to see if the virus is still present in the blood and to determine the specific genotype of virus. Other tests, such as liver function tests, may be requested to determine whether the virus is damaging the liver.
Prof Rawlinson is also Director of SAViD (Serology & Virology Division), the Director of a NSW State Reference Laboratory for HIV/AIDS, and founding Director of the NSW Organ and Tissue Transplant Donor Screening Laboratory. He was interviewed about hepatitis for the May 2016 edition of ePathWay.
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This article appeared in the December 2017 Edition of ePathWay which is an online magazine produced by the Royal College of Pathologists of Australasia (http://www.rcpa.edu.au/Library/Publications/ePathway).
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