Hepatitis C Cure: Symptoms, Treatments, Costs

There's no vaccine for hepatitis C.

Hepatitis C (HCV, hep C) is one of several viruses that cause hepatitis (inflammation of the liver). It Is hard for the human immune system to eliminate the virus from the body, and 85% of infections with hep C become chronic. Over decades, chronic infection damages the liver and can cause end-stage liver disease in the form of cirrhosis.

Hepatitis C usually does not cause symptoms or signs even though the damage to organ health is occurring. A person infected with the hepatitis C virus may have normal or slightly elevated liver enzymes in the blood (liver enzymes measure liver inflammation). In the U.S., infection with the hepatitis C virus is the most common cause of chronic hepatitis and the most common reason for liver transplantation. Chronic infection also is associated with liver cancer.

Hepatitis refers to any cause of liver inflammation, with or without scarring of the liver (cirrhosis). It is contagious and is spread from person to person by blood-to-blood contact. Other viral causes of hepatitis include hepatitis A, B, C, and E.

Other types of noninfectious causes of hepatitis include:

• Excessive alcohol intake
• Medications such as some prescription medications or even acetaminophen, for example, Tylenol liver damage and drug-induced liver disease.
• Bacteria and viruses other than the hepatitis viruses

How are hepatitis A, B, and E spread?

• Transmission of hepatitis A and E: These forms of the virus are acquired from improper hygiene during food or drink preparation by someone infected.
• Transmission of hepatitis B: This form is spread by blood-to-blood or sexual contact.

Hepatitis C spreads most commonly through inadvertent blood-to-blood exposure from sharing needles during intravenous drug abuse.

• Recreational drugs and HIV-infected men: There is an especially high incidence of HCV in those who inject recreational drugs and share injection equipment or needles, as well as HIV-infected men who have sex with men, thus these individuals should be screened for the disease at least once a year.
• Sharing razors, toothbrushes, nail clippers, etc: People with HCV should not share razors or toothbrushes with anyone else, because of the risk of blood-to-blood contact.

Lower risks of becoming infected

• Sexual contact risks: The risk is very low of acquiring hepatitis C through sexual contact (even in long-term relationships). However, risky behaviors such as unprotected sex with multiple partners without condoms have a higher likelihood of sexual transmission from breaks in the skin. Using drugs and/or alcohol during sex adds risks for any blood-borne infection, including HCV and HIV.
• During pregnancy and breastfeeding: The risk is very low of your baby becoming infected inutero or while being breastfed.
• Casual household items: Casual household contact, like sharing utensils or sharing drinks with someone, does not transmit HCV.
• Tattooing: The risk of acquiring hepatitis C from tattooing is very low when performed by a licensed professional practitioner who uses proper infection prevention precautions in a facility that passes regular public health inspections.
• Healthcare workers have a low risk of getting the disease from accidental needle sticks. The occupational risk for hepatitis C transmission has dropped from 3% to 1.8%. While the virus can be transmitted by blood transfusion, the blood supply has been carefully undergoing screening since 1992, and this risk is very rare.

At room temperature, the hepatitis C virus can survive on surfaces and other objects for up to 3 weeks, but you cannot become infected on surfaces because there is no blood-to-blood contact.

• Nausea
• Vomiting
• Fatigue
• Jaundice (yellowing of the eyes and skin)
• Pain (arthritis-like pain in joints and muscle pain)

Hepatitis C infection may cause disease outside of the liver (extrahepatic). Extrahepatic inflammatory conditions may include:

• Skin (porphyria cutanea tarda)
• Blood (mixed cryoglobulinemia)
• Kidney (glomerulonephritis, hemodialysis)

More importantly, chronic inflammation caused by chronic hepatitis C can lead to:

• Poor health
• Early or more severe atherosclerosis (heart disease, peripheral artery disease, stroke)
• Diabetes (high blood sugar). Patients with the virus are three times as likely to develop diabetes.

People infected with both the hepatitis C virus and HIV (coinfection) develop hardening of the arteries and diabetes much faster and often die earlier from these conditions than from HIV or hepatitis.

Most hepatitis C is currently treated with all-oral ("interferon-free") medical regimens of "direct-acting antivirals" or DAAs. DAAs is a term used to distinguish these hepatitis C drugs from an older generation of injected medicines (interferon, pegylated interferon) that act indirectly on the immune response to the hepatitis C virus. DAAs act directly on the virus to block different steps in its life cycle. Several DAAs are used in combinations that have been scientifically proven to cure hepatitis C. They are not interchangeable, and some are only available combined in one pill or dose pack as a specific combination. DAAs are not used as single-drug therapy because of the high risk of the virus developing resistance and because they work best in combinations. The choice of which regimen to use depends upon the genotype of the virus, the level of liver fibrosis (liver scarring), and any drug resistance that may be present (for example, someone who has received treatment before but was not cured).

Examples of combination DAAs with cure rates between 91%-100% include:

• Harvoni (edipasvir and sofosbuvir)
• Viekira Pak (ombitasvir, paritaprevir, and ritonavir co-packaged with dasabuvir tablets)
• Zepatier (elbasvir and grazoprevir)
• Mavyret (glecaprevir and pibrentasvir)

Genotypes 1a and 1b are the most common genotypes in the United States. Of all the genotypes, genotype 3 has been the most difficult to treat with DAAs alone and requires the use of ribavirin, which has significant side effects. All genotypes can now be treated with oral DAAs without ribavirin. Some genotypes may still require the use of injected pegylated interferon and/or ribavirin if there is no response to DAAs.

The goals of treatment include the prevention of cirrhosis and liver cancer, stopping diseases that affect other organs, and preventing transmission to others. Thus people who should have higher priority for treatment include those with advanced liver fibrosis or who may need a liver transplant, those with extrahepatic diseases, and those with risk factors for transmitting HCV, such as women planning pregnancy, IV drug users, and men who have sex with men.

A complete list of all approved hepatitis C used to treat the infection is available on the FDA website.

Considerable progress has been made through past clinical trials in the medical treatment of hepatitis C. The rate of cure has increased (about 95%-98%) with the development of direct-acting, all-oral antiviral regimens, and the length of therapy is much shorter.

Treatment recommendations continue to change as new medicines become available. Treatment helps to reduce the progression of liver damage to cirrhosis, may prevent liver cancer, and may prevent the spread of the infection to other people.

About 15% of people who are infected with hepatitis C can eliminate it in the first several weeks of infection. At present, there is no clinical sign or test that helps predict which patient will clear the virus and which will develop chronic infection.

Depending on the drug combination, the specific genotype of hepatitis C that is to be treated, any prior treatment, and whether the person has cirrhosis, the duration of medical therapy may be as few as 8 weeks or up to 24 weeks. Most regimens are for 12 consecutive weeks. This is much shorter than the interferon-based treatments years ago that lasted up to 48 weeks. Generally, a person is not considered "cured" until the "RNA viral load" is undetectable (there is no hepatitis C detected in the blood) for 24 weeks after therapy is stopped. This is called "sustained virologic response" or SVR.

The presence of cirrhosis or liver fibrosis (liver scarring) is determined by liver biopsy, noninvasive fibrosis scans, or formulas that estimate liver fibrosis based on blood tests, such as AST-to-platelet Ratio Index (APRI) or Fibrosis-4 (FIB-4) Index.³

A very important aspect of treatment is the elimination of all alcohol consumption. Alcohol adds fuel to the fire when it comes to chronic hepatitis. Drinking alcohol greatly worsens liver fibrosis and speeds the progression to cirrhosis, and there is no "safe" amount to drink for someone with chronic hepatitis. Drinking alcohol also makes it harder for the medications to be effective and may interfere with proper dosing.

The DAA is overall very well tolerated. This is a major advantage over interferon-based treatments, which may cause many physical and mental side effects, some of which may be life-threatening. An older medicine, ribavirin, is used in certain combinations for retreatment of hepatitis C virus not responding to DAAs. Ribavirin may cause anemia that may require additional treatment for it.

In the era of highly effective DAAs, a new and unanticipated adverse effect of hepatitis C therapy is a flare-up of liver inflammation in those who have had hepatitis B.¹ This may occur even if hepatitis B infection is resolved years earlier. After early infection, hepatitis B may become "latent" or live in the liver cells without causing chronic hepatitis.

Treating or eliminating the HCV somehow allows or triggers hepatitis B to reactivate. This has caused hepatitis B to flare up severely and even cause liver failure in some cases. Some of these cases occurred even after the end of HCV therapy. Therefore people are now screened for hepatitis B antibodies before HCV treatment.

If there is evidence of current or past hepatitis B infection medication to suppress hepatitis B is given along with the treatment for hepatitis C. A complete list of approved drugs used to treat hepatitis B is available on the FDA website.

The combination of any cause of hepatitis, such as alcohol on top of HCV, adds to and accelerates liver damage. Both hepatitis B and C can cause chronic hepatitis and progression to cirrhosis and liver cancer, although the disease is much more likely to become chronic in the U.S. Therefore, people with chronic HCV should not drink alcohol and should talk to a doctor about vaccines for other hepatitis viruses.

It is impossible to say what the exact cost is for the various regimens, but it is in the tens of thousands of dollars. In general, the out-of-pocket cost would be very high for the average person, and most people are treated through a health insurer, federal health benefits, or veteran's benefits. The cost of hepatitis C and the care of its complications, however, is much higher over a person's lifetime, and the roughly estimated savings are believed to make treatment a good health and financial investment. Liver transplantation alone may cost several hundred thousand dollars for the procedure alone, followed by several hundred thousand for the medications needed in the first 6 months afterward.² This does not include the many complications of liver transplantation.

Because negotiations are confidential business contracts, little is known about how much is paid for medical treatments by these drugs. One example is the medication sofosbuvir. The estimated cost for a standard 12-week treatment with sosobuvir was $84,000 in the US. Actual costs to individuals depend upon price contracts between pharmaceutical companies and health insurers, as well as government and private organizations. Thus, an individual with healthcare coverage may only pay a monthly co-pay.⁴