Screening, Diagnosis, Treatment, and Management of Hepatitis C: A Novel, Comprehensive, Online Resource Center for Primary Care Providers and Specialists

Abstract

Current initiatives focusing on hepatitis C (HCV) screening and diagnosis, together with the advent of oral interferon (IFN)-free treatment regimens have prompted Elsevier Multimedia Publishing and the American Journal of Medicine (AJM) to develop a novel, comprehensive, online Resource Center dedicated to providing both primary care providers and specialists with the latest information on the screening, diagnosis, treatment, and management of HCV. To date, only 25% of infected patients have been diagnosed and only 5% cured. With the Centers for Disease Control and Prevention (CDC) and the US Prevention Services Task Force (USPSTF) recommendation of one-time screening for all individuals born between 1945 and 1965, and the availability of safe and effective therapy, it is anticipated that primary care providers and community practices will become increasingly responsible for the screening, diagnosis, and management of infected patients, as well as providing access to care by specialists when needed. The AJM Hepatitis C Resource Center site will have two major channels; one channel tailored to specifically address the needs of internal medicine physicians and other primary care providers, and one channel tailored to address the needs of specialists including hepatologists, gastroenterologists, and infectious disease specialists. Systematic surveys of these clinician audiences are being conducted by Elsevier to assess educational gaps, and ensure that the content of each channel of the Resource Center satisfies the needs of the intended audiences. In a recent Elsevier survey of primary care physicians (PCPs) who had screened and/or participated in the care of patients with HCV within 6 months of participating in the survey, 60% of PCPs stated that they were not very confident or only somewhat confident about screening patients for chronic HCV infection. A recent Elsevier survey of specialists revealed low levels of satisfaction with the treatment options available in 2013, with “no therapy” being selected for up to 38% of patients. This survey also showed that experience with newly-approved options for HCV including IFN-free regimens is currently limited, but the likelihood that a variety of patient types will be treated with these options is high. This provides an impetus for educational opportunities focusing on optimizing treatments for the different HCV genotypes and for patients with comorbidities. Further results of the PCP and specialist surveys will be published on the Resource Center. Each channel of the Resource Center will be comprised of a variety of specific communication elements, which are open to sponsorship, and include roundtable panel discussions, case studies, and direct links to relevant original research, review articles, and guidelines. All Resource Center components are peer-reviewed for publication on the Resource Center by the AJM Editorial Office and the Resource Center Guest Editor, Edward Lebovics, MD. The AJM Hepatitis C Resource Center will be accessible from the AJM online home page (http://www.amjmed.com) and will be launched immediately prior to the American Association for the Study of Liver Diseases (AASLD) Liver Meeting to be held from November 7 to 11, 2014 in Boston, Massachusetts.

Introduction

Of an estimated 4.1 million persons infected with hepatitis C (HCV) in the United States (US), approximately 3.2 million have a chronic infection.¹ Chronic infection is the hallmark of HCV, and is defined as a persistence of the virus for greater than 6 months after the initial infection.² While 25% to 30% of patients acutely infected with HCV may develop jaundice, abdominal pain, or more commonly, nonspecific flu-like symptoms such as fatigue, muscle aches, and nausea, the majority of acutely infected patients are asymptomatic.³ Up to 80% of people infected with HCV will develop chronic disease.² Chronic HCV infection is often asymptomatic for decades, and individuals harboring the virus may go unnoticed unless tested or discovered incidentally such as during an investigation of elevated aminotransferases.² To date, only 25% of infected patients have been diagnosed and only 5% cured.⁴ HCV RNA can be detected as early as 7 days after exposure, but the antibody to HCV (anti-HCV Ab) may not be present until 6 to 8 weeks after exposure.⁵ Chronic hepatitis C is diagnosed when HCV RNA is present 6 months after exposure.⁵ A patient with a chronic HCV infection may also present was nonspecific symptoms such as nausea, anorexia, and fatigue or signs of cirrhosis upon examination.² Cirrhosis, the end-stage outcome of fibrosis progression, may take an average of 30 years to develop in HCV-infected individuals.⁶

Progressive liver fibrosis is an important consequence of chronic HCV infection, with resultant cirrhosis that may lead to liver failure (decompensation) and hepatocellular carcinoma (HCC).² HCV is the leading cause of HCC, and the most common indication for liver transplantation in the US.7, 8 It is likely that more cases of HCC, decompensated cirrhosis, and liver transplants due to HCV, will be observed in the coming years.⁹ Unfortunately, HCV-associated mortality is on the rise in the US and currently exceeds that for HIV.¹⁰ It has been estimated that in 2012, the healthcare cost of HCV was $6.5 billion, and it has been predicted that the cost will peak at $9.1 billion in 2024.¹¹ While the high health burden of HCV largely relates to the development of advanced liver disease, additional disease burden and costs are generated by extrahepatic manifestations of HCV infection including cryoglobulinemic vasculitis, lymphoproliferative disorders, renal disease, and rheumatoid-like polyarthritis.¹²