New direct-acting antivirals have the potential to transform the hepatitis C (HCV) treatment landscape, with rates of sustained viral response in excess of 90%. As these new agents are expensive, an important question is whether to focus on minimizing the consequences of severe liver disease, or reducing transmission via ‘treatment as prevention’. A back-calculation model was used to estimate the impact of treatment of mild, moderate and compensated cirrhosis on incident cases of HCV-related end-stage liver disease/hepatocellular carcinoma (ESLD/HCC). In addition, a dynamic model was used to determine the impact on incidence and prevalence of chronic infection in people who inject drugs (PWID), the main risk group in England. Treating 3500 cirrhotics per year was predicted to reduce ESLD/HCC incidence from 1100 (95% CrI 970–1240) cases per year in 2015 to 630 (95% CrI 530–770) in 2020, around half that currently expected, although treating moderate-stage disease will also be needed to sustain this reduction. Treating mild-stage PWID was required to make a substantial impact on transmission: with 2500 treated per year, chronic prevalence/annual incidence in PWID was reduced from 34%/4.8% in 2015 to 11%/1.4% in 2030. There was little overlap between the two goals: treating mild stage had virtually no impact on ESLD/HCC within 15 years, but the long timescale of liver disease means relatively few PWID reach cirrhosis before cessation of injecting. Strategies focussing on treating advanced disease have the potential for dramatic reductions in severe morbidity, but virtually no preventative impact.
Bibliographical noteFunding Information:
NKM acknowledges research funding from the National Institute for Drug Abuse R01 DA037773-01A1 and the University of California San Diego Center for AIDS Research (CFAR), an NIH-funded programme (P30 AI036214), which is supported by the following NIH Institutes and Centers: NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA, NIGMS and NIDDK. DDA was supported by Public Health England and the UK Medical Research Council [Unit Programme number U105260566]. The study was partly supported by the NIHR Health Protection Research Unit in Evaluation of Interventions. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England. NKM has received research grants from Gilead unrelated to this work and has received honoraria from AbbVie, Gilead and Jannsen.
© 2016 The Authors. Journal of Viral Hepatitis Published by John Wiley & Sons Ltd.
- direct-acting antivirals
- hepatitis C virus
- liver disease
- people who inject drugs