The End to Hepatitis C

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New Hep C Treatments cure 90% of people with HIV Co-infectionshutterstock_324636710

In Australia it is estimated there are 230,000 people living with Hepatitis C virus (HCV), and there are over 27,000 people living with HIV (PLHIV) – for which approximately 10-15% of PLHIV also have Hepatitis C (HCV) coinfection. Hepatitis C causes liver disease.  To treat HCV, in the past, Interferon-based (injectable) treatment was required for 6 to 12 months which carried significant side effects, and Hepatitis C cure rates were harder to achieve among HIV-positive people co-infected with HCV using the older therapies.

From 01 March 2016, Australia has changed that history. New pill-based, more tolerable (few side effects), short duration treatments (8-12 weeks) have been listed on the Pharmaceutical Benefits Scheme (PBS), which work equally effective among HIV/HCV co-infected people towards a cure for most types of Hepatitis C. Four new hepatitis C treatments are now available – these are Harvoni® (sofosbuvir + ledipasvir), Sovaldi® (sofosbuvir), and Daklinza® (daclatasvir); and Ibavyr® (ribavirin).  These new HCV treatments are highly effective with cure rates expected above 90% over a short period of 12 weeks of treatment, without the difficult side effects of old treatments.

A cure is defined as a sustained virological response (SVR) 12 weeks after treatment has finished. Relapse after this point is rare.  Although achieving an SVR cure is like having a continuing ‘undetectable’ HCV viral load, this is unlike having a HIV undetectable viral load because HIV is integrated into the host (human) cell and hides in body reservoirs, whereas HCV does not.  Hepatitis C virus (HCV) can therefore be cured.

What are the issues for PLHIV?

Firstly, there is a greater than 90% chance of curing Hepatitis C among people with HIV-coinfection, at the same level as those without HIV. Side effects from these new HCV treatments are minimal (and the treatment is for a short 3 month period too, usually 1 or 2 of the pills daily).

Although about 15% of people with HIV who have acute (early) HCV infection will spontaneously clear the virus without treatment, if you have a recent new HCV infection ask your doctor or specialist whether HCV treatment should be commenced or to wait. However, the sooner it’s treated the better your liver health will be by clearing the virus, as some people get cirrhosis (liver hardening) as a result of having HCV long term  for many years (called ‘chronic hepatitis C’).  People with cirrhosis may need longer duration of treatment for 24 weeks (and possibly one extra pill), but a cure is still highly likely throughout all stages of HCV disease.  Also, if you have HIV then early treatment of HCV will lessen the burden that it puts on your liver, as HCV progresses faster in HIV-positive people and increases the risk of liver health problems such as cirrhosis (by about 3 times more than people without HIV).

If you are already taking HIV treatment, there are some HIV drug interactions to watch out for with the new HCV treatments but your doctor can work around theses with guidance from a specialist, or your liver specialist or HIV doctor will aptly work them out for you (so that your HIV treatment will continue to work well). If you haven’t yet started HIV treatment your doctor might suggest to treat HCV first to avoid any drug interactions (if your CD4 counts are high enough not to take HIV treatment straight away).  Your doctor or specialist will discuss these matters with you, and also do some scans to check the state of your liver.

People living with HIV (on treatment) will be no strangers to the need to take their HIV pills daily at 95% of the time, but with these new HCV treatments 100% adherence will give you the best chance of curing Hepatitis C. Also, it is best to avoid alcohol and other drugs during the period on HCV treatment if possible.  If you are prescribed HCV treatment it is important to have a discussion with your doctor about how to take it correctly.

How will my HCV treatments be selected?

The particular treatment that your doctor might choose for you will be a selection from the range new HCV treatments – usually only one or 2 pills a day taken for 8-12 weeks – depending upon your specific type of HCV virus (called ‘genotype’), stage of HCV disease and condition of your liver, and any HIV medications you may currently be on.

Only in rare cases will the old interferon (injectable) treatments be used, such as for chronic HCV infection with types 4, 5 and 6 HCV, but for only 12 weeks also with one of the new pills (sofosbuvir and ribavirin). However, in this case your doctor might suggest you wait for treatment, as some of these new pill-based treatments are expected to be approved soon for use with types 4 and 6 as well.  It is also exciting to note that even newer (second generation) HCV pill-based treatments are also in development, close in the pipeline, that can effectively treat all HCV (geno)types.  Your doctor will discuss all the options with you, but generally for the majority of people seeking treatment now it will be simple once-daily pills for 8-12 weeks.  Also, if you have previously had the old interferon (injectable) treatment and ribavirin but it did not work for you then, you can certainly try again with these new more effective HCV treatments.

Any GP (doctor) will now be able to prescribe the new hepatitis C treatment for you, in consultation with a specialist and clinical guidelines. You can, however, stick with you liver or infectious diseases specialist (if you have one already) or discuss the new treatment with your existing HIV doctor (who can also prescribe these treatments, or refer you to a specialist if needed should you have advanced liver disease or other medical concerns).  At the 4th week of treatment your HCV viral load and liver function may be tested, to check how it’s going, particularly if you have some existing liver damage or disease.  12 weeks after treatment has finished this will be checked again to qualify the success of your treatment.

If you are thinking about hepatitis C treatment, we encourage all people living with HIV/HCV coinfection to first have a discussion with their HIV doctor (or Infectious Diseases Specialist).

What about Hepatitis C (HCV) re-infection?

Once you have taken a course of the new HCV treatments and have been successful in clearing the virus, you can be reinfected with Hepatitis C, since there is no vaccine available against getting HCV again. The new HCV treatments are not a vaccine, they are a cure-based treatment only.  If you are reinfected with HCV you can take another course of HCV treatment but you may need to take a different or additional treatments compared to your first lot of successful treatment.  However, prevention is better than cure…

The most common way of contracting hep C, or passing it on, is through unsafe injecting drug use (sharing of needles and injecting equipment), and in some cases through tattooing or piercing with unsterilised equipment. Sharing clippers, razors, toothbrushes, and tweezers where there may be small amounts of blood can be risky. Needle-stick or sharps injuries have transmitted hep C (in occupational settings).

New evidence suggests that sexual transmission of hep C, although uncommon, is increasing among some gay men and men who have sex with men (MSM) through non-condom anal sex where blood to blood contact can occur. Sharing unwashed sex toys is also a risk for Hepatitis C.

Want More Info?

You can call your local hepatitis organisation on 1800 437 222 (1800 HEP ABC) to find out more.

Hepatitis Queensland have produced a useful fact sheet about the new medications here. http://www.hepqld.asn.au/images/resources/factsheets/FINAL_New_treatments_for_hepatitis_C.pdf and a helpful video here: http://www.hepqld.asn.au/news-media-a-events/our-news/3-news-a-events/348-the-moment-we-ve-all-been-waiting-for-is-here

You are also welcome to call QPP for more info on 1800 636 241 or (07) 3013 5555 or email us at info@qpp.org.au

The following consensus treatment guidelines have been developed in Australia, and are intended for health professionals. You can direct your GP (Doctor) to these guidelines: http://www.ashm.org.au/resources/Pages/01032016.aspx