- Guidelines also recommend offering treatment to all people with hepatitis C.
- Update lists a wide range of treatments, including latest drugs.
- Nonspecialists encouraged to get involved in hepatitis C care and treatment.
Hepatitis C virus (HCV) is a blood-borne infection that can cause serious disease. HCV infects the liver and, if left untreated, proceeds to slowly injure and degrade this vital organ. As liver injury accumulates, severe complications can occur, including liver failure, liver cancer and death.
As a result of the slow pace of liver injury, most people who have HCV are not aware that there is something wrong until serious symptoms appear. In Canada, researchers estimate that, overall, about 44% of people who have HCV are not aware that they are infected. Among a sub-group of people born between 1945 and 1975 (“baby boomers”), researchers further estimate that up to 70% of people who have the virus are unaware of their infection status.
In order to help uncover more cases of HCV infection and move people into care and treatment, the Canadian Association for the Study of the Liver (CASL) has issued updated guidelines for the management of HCV infection. The 2018 update emphasizes that healthcare providers should offer HCV testing to baby boomers and people at risk for infection with this virus. Also, given advances in HCV treatment over the past several years, the update encourages healthcare providers to offer treatment to all people with chronic HCV infection. The guidelines list all treatment options for HCV, including the latest therapies. They also have information on the medical monitoring of HCV infection.
Here are some key points from the updated guidelines:
Who should be screened?
As mentioned earlier in this bulletin, the guidelines recommend offering HCV testing to baby boomers and people with the following factors:
- “history of current or past (even once) injection drug use”
- “received health care or personal services where there is a lack of infection prevention and control practices”
- “received a blood transfusion, blood products or organ transplant before 1992 in Canada”
- “history of or current incarceration”
- “born or resided in a region where HCV [is relatively common] such as the following: Central, East and South Asia; Australasia and Oceania; Eastern Europe; Sub-Saharan Africa; North Africa or the Middle East”
- “born to a mother who is HCV-infected”
- “history of sexual contact or sharing of personal care items with someone who is HCV-infected”
- “HIV infection, particularly men who have sex with men (MSM)”
- “received chronic hemodialysis treatment”
- “have elevated alanine aminotransferase (ALT)”
The guidelines note that in certain populations at high risk for HCV, such as people who inject street drugs and MSM, screening for HCV should be offered “at least once per year.”
What to use for HCV testing?
The guidelines recommend that an HCV antibody test be used for the initial screening of people. If the antibody test is positive, the guidelines recommend a confirmatory test—the HCV RNA test, which checks for the presence of HCV’s genetic material; its presence reveals a current infection. In cases where there has been a history of HCV infection and that infection was either spontaneously resolved or cured, future testing should use the HCV RNA test. The rationale behind using the RNA test in such cases is that people who were initially infected with HCV will produce and carry the antibody to that virus even after they have been cured or the infection has resolved.
Who should be treated?
The updated guidelines state: “We suggest that all individuals who test positive for HCV RNA be evaluated by practitioners with experience in HCV management.” The guidelines encourage a range of healthcare providers to acquire the training and support so that they can care for people with HCV, including the following specialists:
- primary care doctors
- addiction clinicians
- nurse practitioners
The guidelines note that “expansion of nonspecialist HCV care will be required in Canada to ensure that all infected individuals receive appropriate care.”
The guidelines recommend that all people diagnosed with chronic HCV receive an offer of treatment. Furthermore, the guidelines indicate that treatment should be promptly initiated in people with advanced liver injury or when scarring has engulfed the liver, a stage called cirrhosis.
In people with minimal or moderate liver injury arising from HCV, the guidelines encourage initiation of treatment to help improve health-related quality of life and reduce the further spread of this virus.
The guidelines note that the Canadian Agency for Drugs and Technology in Health (CADTH) conducted a “careful review” of modern, all-oral HCV treatment and found that such treatment was “cost-effective” at all stages of liver injury. The guidelines also state the following:
“Recent negotiated price reductions should make treatment more cost-effective. Although some regions in Canada continue to limit access to treatment to those with hepatic fibrosis [serious liver injury], there is no medical or epidemiological evidence to support restrictions based on fibrosis stage. Price reductions have led to removal of restriction in many jurisdictions.”
About HCV treatment
Treatment for people with HCV infection has improved significantly over the past five years. Cure rates with the latest treatments are usually around 95%. Many treatments can be taken once daily and are available as pills. Also, in many cases treatment can be taken for as short a duration as eight weeks. Some treatments are even effective against all strains (or genotypes) of HCV. The update to the guidelines lists treatment options for patients depending on their degree of liver injury and genotype.
A good read for care providers
The latest update to the guidelines was written by a team of experienced and knowledgeable specialists in liver health and infectious diseases. The update is chock-full of helpful additional information for care providers and is well worth reading.
Hepatitis C – CATIE
—Sean R. Hosein
Shah H, Bilodeau M, Burak KW, et al. The management of chronic hepatitis C: 2018 guideline update from the Canadian Association for the Study of the Liver. CMAJ. Jun 2018;190(22): e677-d687.