Background: Multiple studies have shown that successful antiviral therapy of chronic hepatitis C infection dramatically reduces both liver-related morbidity (including rates of end-stage liver disease and hepatocellular carcinoma) and mortality, as well as all-cause mortality. The new state-of-the-art treatment for hepatitis C in 2015 is much safer, better tolerated, and more effective than treatments used in the interferon era. Accordingly, from a medical standpoint, the decision of when to initiate therapy has become much easier. The cooperative guidance issued from the American Association for the Study of Liver Disease (AASLD) and Infectious Diseases Society of America (IDSA) notes that evidence clearly supports treatment of nearly all HCV-infected persons. The hepatitis C guidance provides priority criteria for treatment, outlining when therapy is most likely to provide the most immediate and impactful benefit. Decisions regarding initiating therapy must also take into account the patient willingness to undertake treatment and the ability to have the medication regimen paid for.
Generally Accepted Indicators for Treatment: The AASLD/IDSA guidance provides a hepatitis C priority ranking for treatment based on both clinical and public health factors: highest priority for treatment based on increased risk of liver-related complications and severe extrahepatic HCV-related complications (Figure 1), high priority for treatment based on moderate fibrosis or other concomitant complications (Figure 2), and a priority category based on elevated risk of HCV transmission to others (Figure 3). Measures used to identify patients with F3 or F4 fibrosis include liver biopsy, an Aspartate aminotransferase-to-Platelet Ratio Index (APRI) score above 2, or a fibrosis-4 index (FIB-4) above 3.25. The APRI threshold of 2 and the FIB-4 threshold of 3.25 have good specificity for correlating with advanced fibrosis, but scores below these values do not have adequate sensitivity to rule out advanced fibrosis.