June 13, 2002 -- Five years ago, the best available treatment for hepatitis C worked in only about one in 10 people -- but today that figure is closer to one in two, thanks to dramatic treatment advances. The nation's top hepatitis C experts met this week to update doctors and the public on these new treatments, and to clarify what is and is not known about the hepatitis C virus (HCV) -- the leading cause of liver disease and liver transplants in the U.S.
To the surprise of few, the 12-member, independent panel concluded that the best available treatment for HCV is an approach that became available in the U.S. last fall. The treatment combines pegylated interferon -- a long-acting form of the longtime HCV drug -- and ribavirin. Studies show that up to 55% of patients can be cured with this combination.
The experts noted that such treatment should be considered for everyone with chronic hepatitis C. This is a significant shift from five years ago, when those with only mild disease, or no signs of worsening disease, were rarely treated. Contrary to previous thinking, new research shows that these people also respond well to treatment, hepatitis specialist Bruce Bacon, MD, tells WebMD. Bacon is director of the division of hepatology at Saint Louis University School of Medicine.
"It is true that many patients with normal [liver enzymes] or mild disease may never progress to the point where the infection adversely affects their lives," Bacon says. "But given that some patients with mild disease will progress to more serious disease, all patients need to at least discuss treatment with their doctors.'"
The panel also weighed in on the treatment of certain groups of patients including:
- Intravenous drug users -- Treating IV drug users is important because they "make up the largest group of hepatitis C patients in the U.S., and successful treatment may reduce transmission."
- The experts recommend HCV testing for everyone infected with HIV. Those infected with both HIV and HCV often progress to liver disease very rapidly. Treatment is also recommended, but better data are needed evaluating the new treatments in this group of patients.
- Alcoholics -- Alcohol plays a major role in the progression of HCV to cirrhosis and liver cancer. Although a history of alcohol abuse is not a reason to avoid treating someone, those who continue to abuse alcohol do not respond well to treatment.
The frequency of HCV infection declined sharply in the late 1980s when transmission from blood transfusions and other blood products was virtually eliminated through testing. It is estimated that 35,000 new hepatitis C infections now occur in the U.S. each year, but an epidemic of HCV-related illness is expected within the next decade, as people infected decades ago begin getting sick.
Those who engaged in recreational drug use in their youth make up the largest group of people who may be infected with HCV and not know it. Specialist Mitchell L. Shiffman, MD, says anyone who ever abused intravenous drugs is at risk and should be tested.
"You don't have to have a long history of drug use," he tells WebMD. "Just one IV drug experience is enough." Shiffman is medical director of the liver transplant program at the Medical College of Virginia.
It is estimated that 1.8% of the U.S. population is infected with HCV, making it one of the most common chronic infections. These days, two-thirds of new infections occur through intravenous drug use. Up to 90% of IV drug users are believed to be infected. The experts note that needle and syringe exchange and educational programs shown to be effective in preventing HIV are also useful for decreasing HCV transmission.
The majority of other cases can be attributed to occupational exposure to blood and to sexual transmission, but it is much more difficult to spread HCV this way.
The chance of contracting the virus in a monogamous relationship is quite low and condoms are not absolutely recommended, say the experts. However, "couples should be advised that the use of condoms may decrease the risk of HCV transmission." Among monogamous couples in which one person is infected with HCV, about 1% will transmit the virus to their healthy partner annually.
The panel outlined the risk for other potential modes of transmission, including:
- Sharing household items -- The sharing of common household items such as razors and toothbrushes may spread the virus. But there is no evidence that kissing; hugging; sneezing; coughing; casual contact; or sharing food, water, eating utensils, or drinking glasses can lead to infection.
- Tattooing and body piercing -- The transmission risk may be significant when contaminated equipment or supplies are used. However, the transmission rate appears to be less than 1% overall.
- Mother to child -- The risk of transmission from an infected mother to her child during pregnancy or childbirth is approximately 2% overall, but is higher in mothers who are at high risk. It may reach 20% among women who are also infected with HIV.
- Breastfeeding -- Breastfeeding does not appear to transmit HCV.
The most important areas for future research include developing less toxic treatments and finding better ways to identify those who are infected.
The panel also called for new studies, including evaluations of the newest combination treatment in patients who haven't responded to other treatments, or who had to stop those treatments due to side effects.