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Hepatitis C Virus: From Trials and Tribulation to Triumph
Tracy Swan *Treatment Action Group New York NY United States
Background: Chronic hepatitis C virus (HCV) infection is a major global public health threat; at least 185 million people have been infected, and 2 to 3 million are newly infected each year. Untreated HCV can progress to cirrhosis, hepatocellular carcinoma and hepatic decompensation; these complications cause over 350,000 deaths annually. In the United States and Spain, mortality from HCV now exceeds AIDS-related mortality. People with chronic hepatitis C are at risk for premature death from respiratory failure, cardiovascular disease, and other non-liver related causes. Globally, an estimated 5 million people are HIV/HCV coinfected. HIV accelerates the risk for, and rate of HCV progression. Where antiretroviral access is widespread, HCV complications are a leading cause of death among HIV/HCV coinfected people. Conclusions: HCV is curable, an outcome known as sustained virologic response (SVR). Once cured, the risk for liver-related morbidity and mortality_and all-cause mortality--decreases significantly, as does risk of AIDS-related death in HIV/HCV coinfection. HCV treatment has rapidly evolved from peginterferon and ribavirin_a poorly tolerated, complex regimen with limited efficacy_to oral, direct-acting antiviral (DAA) combinations. In 2013, the first oral DAA regimen was approved in the U.S. and the E.U. Many promising DAAs are in the pipeline. In clinical trials, SVR rates after 12-week regimens have exceeded 90 percent, regardless of HIV status and HCV treatment history. Another wave of DAA approvals is anticipated during 2014. HCV is highly prevalent among marginalized groups facing significant barriers to health care: people who inject drugs, incarcerated, homeless and poor people, African-Americans, and people living with HIV/AIDS. HCV is most prevalent in low- and middle-income countries, yet limited access to diagnostics, care and treatment are commonplace in high-income countries such as the United States, where at least 75% of people with chronic HCV are undiagnosed. DAAs offer the opportunity to eradicate HCV, if political will and adequate resources are mustered. DAA regimens will facilitate scale up by simplifying treatment and streamlining requirements for on- and post- treatment monitoring, but prices for drugs and diagnostics remain prohibitive in most of the world. Both infrastructure and capacity to deliver treatment must be developed. Activists, clinicians, researchers, implementers, and our allies are working to increase worldwide access to evidence-based HCV prevention, as well as screening, care and treatment through clinical trials, demonstration projects, development of treatment guidelines; with donor, non-governmental and inter-governmental organizations, and by pushing governments to address hepatitis C.