for Health Care Providers
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The prevalence of chronic hepatitis C virus (HCV) infection is approximately 1.3% in the general U.S. population and 5-10% in veterans who use Department of Veterans Affairs (VA) medical services (1, 2) . Although there is a higher prevalence of HCV in veterans, the following recommendations are intentionally broad enough to apply to the general hepatitis C population.
After initial exposure to hepatitis C, HCV RNA is detectable in blood within 1-3 wk. By 3 months, hepatitis C antibodies are present in 90% of patients. Up to 85% of patients with acute HCV eventually progress to chronic infection. HCV is composed of at least six major genotypes. In the United States, genotype 1 accounts for about 75% of HCV infections with the remainder usually being genotype 2 or 3.
The natural history of HCV is highly variable with some patients advancing to cirrhosis within 15 yr and others never progressing this far (3) . Approximately 15-20% of patients with chronic HCV infection will develop cirrhosis. HCV is clearly linked to advanced liver disease, hepatocellular carcinoma (HCC), and has become the leading indication for liver transplantation (4) . Treatment of chronic HCV is aimed at slowing disease progression, preventing complications of cirrhosis, reducing the risk of HCC, and treating extrahepatic complications of the virus. Antiviral therapy with interferon-based regimens is an important part of a comprehensive approach to HCV treatment, resulting in sustained elimination of viral replication for a portion of those treated. Sustained virologic response (SVR) is defined as having undetectable virus for at least 6 months after completion of therapy.
All patients with chronic HCV infection are potential candidates for antiviral therapy. Medical care providers should discuss the natural history of HCV infection, the risks and benefits of antiviral therapy and other steps to minimize liver damage with every HCV-infected patient. Currently, standard antiviral treatment for chronic HCV involves once weekly pegylated interferon (peginterferon alfa) injections and daily oral ribavirin. Patients most likely to benefit from antiviral treatment include those at risk for progressive liver disease and those with diminished quality of life secondary to their viral infection. It is crucial that individuals in whom treatment is deferred are reevaluated for treatment candidacy as their comorbid conditions are effectively managed.
The following recommendations summarize the growing literature and current best practices on chronic HCV treatment, including treatment in difficult-to-treat populations. These recommendations are based on an extensive review of published data, national consensus recommendations, and input from thought leaders involved in HCV care and treatment (5, 6) . Recommendations are graded according to criteria used by the American Association for the Study of Liver Diseases (AASLD) 2004 practice guidelines on the Diagnosis, Management, and Treatment of Hepatitis C (Table 1) (7) .
|I||Randomized, controlled trials|
|II-1||Controlled trials without randomization|
|II-2||Cohort or case-control analytic studies|
|II-3||Multiple time-series, dramatic uncontrolled experiments|
|III||Opinions of respected authorities, descriptive epidemiology|
These recommendations should aid health-care providers involved in the management of HCV-infected patients including general internists, medical specialists, mental health clinicians, pharmacists, nurses, and addiction specialists. Additional resources pertaining to the care of the HCV-infected patient have been developed by the VA Hepatitis C Resource Center (HCRC) program and are available on this Web site. They include the following educational resources:
- Management and Treatment of Hepatitis C Virus Infection in HIV-Infected Adults
- Management and Treatment of Patients with Cirrhosis and Portal Hypertension
- Initiating and Maintaining a Hepatitis C Support Group: A How to Program Guide
1. All patients with chronic HCV infection should be evaluated as potential candidates for HCV antiviral treatment(III).