Multiple studies have shown that successful antiviral therapy of chronic hepatitis C infection dramatically reduces both liver-related morbidity and mortality (including rates of end-stage liver disease and hepatocellular carcinoma), as well as all-cause mortality. Direct-acting antiviral treatment for hepatitis C has proven much safer, better tolerated, and more effective than treatments used in the interferon era, rendering the decision of when to initiate therapy much easier in some respects. 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 persons infected with HCV. Decisions regarding initiating therapy will naturally be influenced by the patient's willingness to undertake treatment and the ability to have the medication regimen paid for.
Generally Accepted Indicators for Treatment
The AASLD/IDSA guidance has previously provided a priority ranking for treatment based on both clinical and public health factors, with the highest priority for treatment conferred to those at increased risk of liver-related complications and severe extrahepatic HCV-related complications, high priority status to those with moderate fibrosis or other concomitant complications, and a priority status given to those persons with elevated risk of HCV transmission to others. In 2016, the AASLD/IDSA removed priority tables from the guidance—the AASLD/IDSA guidance emphasizes that all patients with chronic hepatitis C should, except for those individuals with short life expectancies, be considered for treatment given the preponderance of data demonstrating benefit on clinical outcomes as well as patient-reported improvements in quality of life and other factors.[1,2] The AASLD/IDSA guidance does, however, highlight specific subgroups of patients who should not be singled out for treatment as much as appreciated for their particular characteristics that make treatment all the more compelling, either because of the significant benefit conferred by treatment to their natural history (e.g. patients with cirrhosis or HIV or hepatitis B coinfection) or to the public health (e.g. healthcare workers, persons who inject drugs) (Figure 1). For further discussion regarding liver disease staging, please refer to Module 2 (Evaluation, Staging, and Monitoring of Chronic Hepatitis C), Lessons 4 (Evaluation and Staging of Liver Fibrosis) and 5 (Evaluation and Prognosis of Patients with Cirrhosis).