March 6, 2015
With the advent of short, safe treatment that can cure hepatitis C, is there still a need to identify and treat hepatitis C early? To help answer this question, TheBodyPRO.com's correspondent Terri Wilder spoke with Arthur Kim, M.D., of Harvard Medical School in Boston and Massachusetts General Hospital. Kim gave a presentation on diagnosing and treating acute hepatitis C, at CROI 2015 in Seattle, Washington.
Why is it important to identify people with acute hepatitis C?
I think even if you cannot apply the treatments right away, knowledge about the infection for the individual is highly likely to inform their future decisions.
For instance, if one is hepatitis C positive, they may decrease the risky behaviors that got them there in the first place. There's good data to show that once one has a diagnosis, their relapse rates and their use of drugs and injection are lower.
Next, if they get a negative result -- because you're looking for acute hep C -- they can then not share with other people who might be hepatitis C positive. So, similar in HIV, where people are serosorting, so to speak, and HIV positives sometimes match up with HIV positives for risk-taking behaviors, and HIV negatives with negatives, hepatitis C does that to a certain extent as well.
Early diagnosis and provision to that patient of their true viremic and infectious status remain important.
Is acute hepatitis C hard to diagnose? Do we have the right technology? One of the doctors that I work with is always doing trainings on acute HIV. And we just keep saying, "If you look, you will find it."
Exactly. I think, "if you look, you will find it" for hepatitis C, as well. There are three main reasons I can think of that impede the early diagnosis of hepatitis C. One is, there's not a single test that really defines the acute stage. You have to use an amalgam of different tests. For instance, going from negative antibody to positive is very helpful, but that implies that you've done two tests. There's no single test.
Next, the care of these patients is extremely fragmented. They can show up in one place for detox. They can show up elsewhere to get their abscess treated for their injection behaviors. And so that also presents a major barrier.
Finally, just education to providers, of the awareness to look and treat. When we looked in the prisons, when you look in emergency rooms, when you look in other places, you will find acute hepatitis C in these areas. But one has to look to find.
It's easier with HIV because the test includes antigen and antibody, all in the same test. If we had that type of testing for hepatitis C, one-stage, dual testing, that would be extraordinarily helpful.
If you identify a patient with acute hepatitis C, what is the recommended treatment plan?
I think you saw by the audience response -- it's very interesting -- that many people were not enthused about treating a recent injection drug user, or someone who has recently injected drugs. I think that's very interesting because they are very high-risk for further transmission.
And yet they were more willing to treat, for instance, someone acutely infected after a needle-stick injury. We are also very likely to treat acutely infected individuals who are HIV positive, who acquired it sexually, who may again engage in sexual behavior someday that would place them at risk for reinfection.
I would argue that we need to explore whether or not these novel treatments could be applied in these younger populations, with the goal to reduce further transmission down the line. We've never controlled an infectious disease without reducing the pool of the number who are able to infect others. I believe that in order to address the thousands of cases we're seeing in our state, we do need to apply some level of treatment, in addition to opiate substitution, drug treatment and other resources.
Also, to successfully evaluate, and to successfully treat someone, is extremely rewarding -- to cure them of an infectious disease that otherwise could remain in their body for 20, 30, 40 years, and is associated with 20 years of lost life, on average. It's a slower infection than HIV, but nonetheless important to identify, control early, if we can.
Would there be anything unique in identifying acute hepatitis C in somebody with HIV, versus somebody who doesn't have HIV?
That's a great question. I think persons with HIV often are being followed regularly and getting labs every four to six months these days, so there are opportunities there to identify hepatitis C early -- because they're in, anyway, to be monitored for their HIV and antiretroviral therapy. That is a group that should be screened at least yearly for hepatitis C infection. And that is recommended by multiple societies for HIV care.
We found that the screening rates in our clinic for hepatitis C within the past year were about 20%. So there's still a long way to go, in terms of achieving the recommended guidelines. We screen for syphilis much better than we screen for hepatitis C.
This transcript has been edited for clarity.
Terri L. Wilder, M.S.W., is a director of HIV/AIDS education and training in New York City.
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