Pharmacotherapy for Hepatitis C Virus Infection
Identified more than a decade ago, hepatitis С virus (HCV) is the leading cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC) and is the primary indication for liver transplantation in the U.S. This common chronic blood-borne infection affects approximately 3.8 million people in the U.S., with more than 50% of these cases occurring in adults between the ages of 30 and 49. However, the peak prevalence of chronic HCV is in the fourth and fifth decades of life (Figure 1). Although the infection resolves in 15% of patients, it becomes chronic in 85% of those infected. This article reviews the overall impact of HCV infection on society and health care.
Epidemiology and Distribution
The National Health and Nutrition Examination Survey (NHANES) study concluded that 1.5% of Caucasians, 3.2% of African-Americans, and 2.1% of the Hispanic population are infected with HCV. The peak prevalence of anti-HCV, the antibody to HCV, occurs in the fourth and fifth decades of African-Americans but peaks in the fourth decade in Cau-casians. In fact, anti-HCV is two to three times more common in African-Americans, with African-American men appearing to have a higher rate of chronicity (90%-95%) than Caucasians and a lower rate of viral clearance after acute infection.
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Figure 1 Prevalence of hepatitis C virus (HCV) infection by age and race/ethnicity in the U.S., 1988-1994.
The higher prevalence of HCV among African-Americans has been correlated with a lower socioeconomic status, genetic variables, specific genes, and immunological status. In any group, the overall true incidence of infection and the extent of morbidity become difficult to estimate because of the high number of asymptomatic, acute HCV cases and the prolonged natural history of disease.
Cost is an important variable in the treatment of patients with HCV infection. It becomes a critical variable in providing quality health care, especially in patients with coexisting human immunodeficiency virus (HIV). In 2001, the American Gastroenterological Association (AGA) estimated a total of 317,000 outpatient visits for HCV treatment in the U.S., with the cost of outpatient services projected at $23.9 million and the cost of antiviral therapy averaging $530 million.
Leigh et al. discovered total HCV costs, direct and indirect, to be approximately $5.46 billion (nine times that projected by the AGA), with chronic liver disease accounting for 92% and primary liver cancer contributing to 8% of the total costs (excluding pain and suffering). Because mortality rates for patients with HCV are still increasing, costs need to be assessed regularly to cover all patient variables, including therapy, socioeconomic status, lifestyle, employment earnings, fringe benefits, length of hospital stay, pain, suffering, and other disease states as well as the expenditures for homeless, incarcerated, and institutionalized persons.