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By Alan Franciscus
Executive Director, Hepatitis C Support Project
Editor-in-Chief, HCV Advocate
The following article originally appeared in the September/October 2002 issue of Hepatitis. You can visit their Web site at www.hepatitismag.com
Is the freedom to make decisions about hepatitis C management and treatment being taken out of the hands of patients in collaboration with their doctors and handed over to the government?
For many patients, it certainly may have seemed that way since 1997, when the first National Institutes of Health (NIH) consensus statement on Management of Hepatitis C was written. Unfortunately, the impact of the 1997 consensus statement has been far-reaching, even after its contents became antiquated.
One area where this impact has been very apparent is the NIH guidelines concerning who should be treated. The 1997 statement included recommendations against treating people with normal ALT (liver enzyme) levels, children, elderly patients, people with psychiatric illness, and alcohol or drug users who had not been "clean and sober" for a minimum of six months. Even though the guidelines did not spell out specific recommendations regarding recovering injection drug users (IDUs) receiving methadone maintenance therapy, most healthcare providers and insurance companies have lumped this population in with the active alcohol and drug users who were not recommended for hepatitis C treatment. At the time the recommendations were written, there was not much room for debate in these areas because these patient groups had not been studied and the guidelines were written with little knowledge and few resources.
Now, five years later, a great deal has changed regarding our knowledge of the hepatitis C virus, the natural history of the disease, and how to treat hepatitis C in many different patient populations. In June the NIH consensus statement on Management of Hepatitis C was revisited. While the preliminary revised guidelines appear to have opened some doors to allow treatment for certain populations that have not had access in the past, will hepatitis C management and treatment really change as a result of the new consensus statement?
For example, I think few would argue that a person with normal ALT levels should be denied treatment now that we know that approximately 25% of patients with persistently normal ALT will go on to develop more advanced liver disease despite the absence of elevated liver enzymes. Who would say "no" to treatment for children now that it has been shown that not only do children achieve sustained virological response (SVR) rates similar to those of adults, but also that children suffer fewer side effects and tend to tolerate therapy better? Likewise, it has been shown that patients with psychiatric conditions can, with appropriate management and use of antidepressants, achieve favorable treatment outcomes.
So we can now add people with normal ALT, children, and people with psychiatric illness to the list of patients having endorsement for access to treatment. But a gray area remains. What about people who have not stopped drinking alcohol, patients that are still injecting drugs, and those on methadone maintenance therapy (MMT)?
Active injection drug users comprise the largest pool of new HCV infections, but have mostly been excluded from receiving treatment on the basis of the 1997 consensus guidelines. Is this likely to change with the new recommendations? Why has this population been excluded from treatment? Has the decision been based on moral considerations, or has it been based on scientific evidence?
In my opinion, active injection drug users are the segment of our society facing the most widespread discrimination. Views about injection drug users vary, but the predominant opinion I hear is that people who inject drugs deserve whatever happens to them as a result of their lifestyle. One could argue that injection drug use is an addiction that requires substance abuse treatment, but even patients on methadone maintenance have pretty much been excluded from hepatitis C therapy. One also could argue that hepatitis C is a public health issue and should be addressed as such, regardless of a patient's behavior. After all, isn't stopping the spread of an infectious disease the ultimate goal of public health? Shouldn't this be a question of science over emotions? Fortunately, some recent small studies have shed some light these difficult questions.
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