A Hepatitis C Lesson Inspired by Ice Cube

I have a serious obsession with infectious diseases and constantly search for references everywhere. My latest find: the movie Ride Along. This comedy is about a police officer (played by Ice Cube, who I once saw in concert) and an aspiring police officer (played by Kevin Hart). The infectious disease reference occurs in a scene in which the police officer questions the neophyte's resolve asking him how he would react if he were stuck with a hepatitis C needle. 

Hepatitis C is and injection drug use are indelibly linked: 90% of new infections are due to this risk factor. Needle exchange programs are the cornerstone of hepatitis C prevention and it is unfortunate, that despite the unequivocal evidence that supports them, political opposition exists. In Pittsburgh, we are luck to have an organization called Prevention Point Pittsburgh, whose board I serve on, that provides needle exchange and disposal services. Pennsylvania also allows needles to be sold without a prescription, another key component to hepatitis C prevention. 

Clean needles lead to a lowering of hepatitis C incidence and prevalence. This translates into a lower chance that a discarded needle will be contaminated with hepatitis C. 

Until a vaccine is developed for hepatitis C clean materials with which to inject drugs, coupled with extensive testing, are the primary means of prevention. 

In the Year 2036...Hepatitis C Will be Rare

I've written before about how the advent of new therapies for hepatitis C, with their promise of increased cure rates and compliance, could change the face of hepatitis C. Now, some of my colleagues at the University of Pittsburgh Graduate School of Public Health (led by Mina Kabiri) have shown just that with mathematical modeling in an important paper published in the Annals of Internal Medicine

As this viral infection, which exists in the over 3 million individuals,  progresses and  viral damage accrues, cirrhosis and need for transplantation will ensue. Hepatitis C is currently the leading cause of liver transplantation, liver cancer, and end stage liver disease. Anything that can diminish the disease burden of hepatitis C would be a huge boon. 

Kabiri and coauthors constructed a mathematical model that simulated the US hepatitis C population from the years of 2001 through 2050. Varied treatments were placed into the model based on what the standard of care treatment was in a given year, culminating with our modern regimens. 

The major finding of this study is that, using current treatment regimens coupled to universal screening, hepatitis C could become rare by 2036!

This study really provides a substantial quantitative basis to justify the excitement over newer hepatitis C regimens--regimens I believe are truly priceless, pathbreaking, and have the ability to alter the landscape of disease.

Breast Milk vs. Hepatitis C: Breast Milk Wins

An interesting paper published in the Journal of Infectious Diseases details the discovery that human breast milk has antiviral activity against the hepatitis C virus (HCV). 

Approximately 5-10% of deliveries by HCV positive women result in perinatal transmission of HCV to the child. Transmission is related to HCV viremia, HIV co-infection, prolonged membrane rupture, and intrapartum exposure to maternal blood. Breast milk, though it contains the virus, is not thought to be a major risk.

This paper adds further weight to the safety of HCV positive mothers breastfeeding their children. In this study, researchers incubated HCV--at concentrations 1000x higher than that found in breast milk--with breast milk from HCV uninfected women. Infectivity after incubation with breast milk was reduced 2-3 fold for all genotypes of the virus. Further experimentation confirmed that the mechanism underlying the antiviral effect was due to free fatty acids that disrupt the viral envelope (see graphic).

In an accompanying editorial, Ravi Jhaveri of UNC writes: "After reading this article, when we clinicians next encounter an HCV-infected patient that just delivered a healthy infant and wants to breastfeed, we have yet another reason to say 'Breast is Best'."

Interferon Free Therapy for Hepatitis C!

In the last few weeks the FDA approved two new antiviral agents for hepatitis C--a scourge that infects over 3 million Americans and is the leading cause for the need for liver transplantation. 

For years the standard treatment for hepatitis C virus had been a combination of two drugs, interferon via injection and ribavirin, taken for up 24- 48 weeks (depending on which genotype of hepatitis C virus is present). These medications had serious side effects including depression, anemia, and flu-like symptoms causing many individuals to stop treatment early. 

A few years ago, the landscape of hepatitis C changed with the approval of two new drugs to be used in combination with interferon and ribavirin in the treatment of the most common type (genotype 1) of hepatitis C. These protease inhibitors, boceprevir and telaprivir, have improved treatment response rates and can, in some instances, decrease the duration of treatment. Last month, the FDA approved simeprevir a once-daily protease inhibitor that can also be used in combination with interferon and ribavirin.

The 2nd drug the FDA  approved is sofosbuvir, a potential pathbreaking nucleotide analog.  The excitement over this drug stems from the fact that it can be administered in an interferon-free regimen, sparing patients months of dreadful side effects. Interferon-free regimens are restricted to genotype 2 and 3 infections. For genotype 1 infections, triple therapy with an interferon backbone remains the preferred treatment  because clinical trial data does not support the use of interferon-free regimens.