In 1989, when hepatitis C virus (HCV) was confirmed as a distinct genus of disease-causing virus, it was already known that thousands of American veterans had been infected with the disease. The discovery marked the onset of the VA’s hepatitis C program, perhaps the nation’s most comprehensive integrated system of HCV care and research.
A communicable disease passed almost entirely through blood-to-blood contact, hepatitis C is fought off successfully in the “acute” phase – the first six months after infection – by about 15 to 40 percent of those infected. The remainder of those with HCV enter the “chronic” phase of the disease, a persistent state in which the virus occupies the liver, inflaming and scarring it over a period of years. Twenty-five percent of chronic hepatitis patients will develop the advanced liver disease known as cirrhosis, which in turn can develop into life-threatening conditions such as liver failure and liver cancer.
“At this point, the VA has tested about two-thirds of people in that baby boomer cohort,” said Dr. David Ross, director of the VA’s HIV, Hepatitis, and Public Health Programs. “That’s compared to probably less than 50 percent for the country as a whole.”
Because these conditions often take years, even decades to manifest – and because most of those with chronic hepatitis C develop liver disease slowly enough that it never becomes a major issue – many Americans with HCV are unaware they’re infected. The U.S. Centers for Disease Control and Prevention (CDC) estimates that there are 20,000 new HCV infections every year.
According to Dr. Jack Stapleton, a physician with Iowa City VA Health Care System and professor of internal medicine at the University of Iowa College of Medicine, “The proportion of nonveterans who don’t know they’re infected is significantly higher than in the VA system. Many people are just not tested. The VA has really been a leader in testing for hepatitis C – it’s been our testing program, for example, that has shown us that Vietnam-era veterans have a much higher rate of HCV infection compared to non-Vietnam-era veterans.”
Guidelines developed by the CDC and the independent U.S. Preventive Services Task Force indicate HCV testing for anyone with a risk factor for the disease (i.e., intravenous drug use or a history of blood transfusion prior to 1992); anyone who specifically asks to be tested; and “baby boomers” born between 1945 and 1965.
“At this point, the VA has tested about two-thirds of people in that baby boomer cohort,” said Dr. David Ross, director of the VA’s HIV, Hepatitis, and Public Health Programs. “That’s compared to probably less than 50 percent for the country as a whole. So we’ve identified and diagnosed a substantial proportion of the patients in the VA who have hepatitis C. But we want to try and test everybody, or at least offer testing to everybody, who is in that baby boomer cohort.”
“Hepatitis C is much more a treatment problem now than a prevention problem for the VA.”
Ross estimates that there may be 30,000 to 40,000 more patients in the VA system who have hepatitis C but don’t know it yet – and identifying these patients will help the VA achieve better “secondary” prevention: keeping infected veterans from developing complications, or from transmitting the disease to others.
Improving Treatment Outcomes
With no HCV vaccine, nor any promising candidate undergoing trials, Ross said the primary prevention efforts of the VA and other public health agencies have focused on educating patients about the most common means of exposure to infected blood, such as injection drug use. These exposure routes are now widely known, he said: “Hepatitis C is much more a treatment problem now than a prevention problem for the VA.” In 2012, the most recent year from which data is available, 173,000 VA patients tested positive for chronic hepatitis C; about a quarter of them, Ross said, have developed cirrhosis. Overall, the VA provides care and treatment for the greatest number of HCV-infected people in the nation.
For years, the standard therapy for hepatitis C has been a cocktail of antiviral medications, typically anchored by pegylated interferon and the drug ribavirin.
The standard “peg/riba” therapy, said Ross, is a grueling ordeal for many: “Patients will feel awful,” he said. “They feel like they’ve got a bad flu. And given that the treatment lasts for up to a year, a lot of patients can’t tolerate it. There are also other side effects. People get depressed and sometimes suicidal. I have a number of patients who just refuse treatment because they’ve said, ‘It’s not worth it to me.’”