Chronic hepatitis C

Abstract

Antiviral therapy is approved by NICE but too few patients receive it

Hepatitis C infection is a treatable disease.¹ Generally, people with chronic hepatitis C are relatively asymptomatic but risk progression over time to cirrhosis and its complications. Combination antiviral therapy with pegylated interferon and ribavirin achieves sustained virological response rates of 42-80% depending on genotype.² In August 2006 the National Institute for Health and Clinical Excellence (NICE) published updated guidelines for the management of patients with this infection.³ The guidance allows antiviral therapy for patients with hepatitis C viral RNA without the need for liver biopsy. This is a major change to the traditional practice of restricting treatment to patients with moderate or severe disease on liver biopsy.

Specialists in the field, who are keen to increase the uptake of treatment in eligible patients, will welcome the new guidance. However, they together with people infected with the virus and those who seek to deliver appropriate medical care will remain frustrated. Although the new guidelines will increase the number of people eligible for antiviral therapy, the broader public health and service provision issues associated with viral hepatitis have still not been recognised and tackled adequately.

Between 200 000 to 400 000 people are infected with hepatitis C virus in England and Wales.^{4 5} Lack of education in primary care physicians has meant that fewer than half of patients with antibodies to the virus are referred for specialist care.⁶ Even if patients are referred, specialist clinics are overburdened and antiviral therapy is often unavailable. In 2005 the Department of Health estimated that just 47 000 people had been diagnosed and only 7000 had been treated successfully.

What has been done so far to remedy this situation? In recognition of the importance of this virus as a public health issue the Department of Health released a hepatitis C strategy document for England in 2002.⁷ It recommended strategies to prevent and minimise harm, along with the implementation of clinical managed networks and specialist treatment centres. In 2004 an “action plan for hepatitis C” set out required actions for primary care trusts and National Health Service hospital trusts.⁴

In 2006 concern about the slow implementation of this action plan prompted the All Party Parliamentary Hepatology Group to audit hepatitis C healthcare provision in England.⁸ It found that only 8% of primary care trusts were approaching full implementation of the recommendations: only 33% had tried to estimate the number of cases in their area, 34% had a protocol for testing and screening, and 26% had protocols for monitoring treatment. In secondary care, 46% of clinics and hospitals reported considerable delays in starting antiviral therapy; the time to starting treatment varied from one week to one year. Reasons for delay included staff shortages, budget or contractual problems, and delays in accessing liver biopsy.

In a healthcare environment where financial pressures and short term targets are paramount, antiviral therapy (pegylated interferon and ribavirin) for hepatitis C virus might seem relatively expensive. The cost of treating one patient varies from £6000 to £8000 (€9-12 000; $12-16 000) per course in the United Kingdom. However, cases of compensated cirrhosis, decompensated cirrhosis, and hepatocellular cancer related to the virus more than doubled between 1995 and 2005 and are predicted to more than double again by 2015.⁵ Deaths from hepatitis C almost tripled from 1997/8 to 2004/5⁵ and hepatitis C is one of the most common indications for liver transplantation (UK Transplant, personal communication, 2006). Hepatitis C thus already places an important and increasing clinical and financial burden on the NHS.

At present service provision for viral hepatitis is piecemeal, disjointed, and poorly resourced.⁹ Knowledge within healthcare professionals remains suboptimal: 42% of primary care providers in East London were unaware that treatment for hepatitis C has good treatment outcomes.¹⁰ To change this will require a coordinated approach by primary care commissioners, primary care providers, and hepatology specialist services and must be based on an accurate assessment of local disease burden. In practice, this means improved knowledge at the primary care level and improved case ascertainment across a range of settings, including prisons.

Integrated primary and secondary care networks that provide counselling, appropriate testing, and seamless care pathways to specialist assessment and treatment should be established. Furthermore, innovative strategies and environments for service provision need to be examined for a population that does not always interface well with traditional models of health care. Incentives may need to be considered, given the considerable public health problems and disease burden surrounding viral hepatitis.

Hepatitis C is currently underdiagnosed and undertreated. Antiviral treatment is cost effective—it decreases the risk of progression and liver related complications.¹¹ Provision of adequate resources to fund NICE approved therapy, as well as the infrastructure to deliver it, merits a higher priority.