Screening and treatment for hepatitis C: a balanced perspectiveBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h644 (Published 24 February 2015) Cite this as: BMJ 2015;350:h644
- Philippa C Matthews, National Institute for Health Research academic clinical lecturer in infectious diseases1,
- Katie Jeffery, consultant virologist2,
- Paul Klenerman, professor of immunology3,
- Eleanor Barnes, Medical Research Council senior clinical fellow and consultant in hepatology4,
- Graham Cooke, senior clinical lecturer in infectious diseases5
- 1Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK
- 2Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
- 3NIHR Biomedical Research Unit, John Radcliffe Hospital, Oxford, UK
- 4STOP-HCV Consortium, University of Oxford, Oxford, UK
- 5Wright-Fleming Institute, Imperial College, London, UK
Koretz and colleagues proposed a randomised trial of hepatitis C (HCV) screening on the basis of a selective literature review.1 We offer a contrasting view based on four key points:
Studies of the natural course of HCV—Koretz and colleagues state that “natural course is best determined by following an entire cohort determined at the time of infection.” This is impractical—the point of acute HCV infection can rarely be established, especially in developing countries,2 and follow-up over decades would be needed. The evidence base on disease progression is already substantial,3 and the lack of a gold standard study should not delay access to diagnosis and treatment.
The value of cure; safety and effectiveness of new drugs—The authors downplay the compelling health benefits of successful HCV treatment. A recent meta-analysis identified substantial reductions in all cause mortality, liver transplantation, and hepatocellular carcinoma after treatment.4 Emerging robust data support the efficacy, safety, and tolerability of direct acting antivirals.5
Trial of HCV screening to determine success of direct acting antivirals—The authors propose a trial of HCV screening. However, as we enter an era of life changing treatment for HCV, it is unethical to randomise patients such that some are denied access to diagnosis and treatment. We nevertheless agree that long term follow-up of treatment outcomes is essential.
Cost implications of screening—The article did not discuss concerns about the cost of new drugs. Expanded screening increases the pool of patients for whom treatment should be offered; this is currently beyond the reach of most healthcare budgets.
Although many questions remain, we do not believe that a randomised trial of screening is ethically sound, feasible, or beneficial to the 150 million HCV infected people worldwide.
Cite this as: BMJ 2015;350:h644
Competing interests: PK has acted as a consultant on HCV immunology for Tibotec. GC has been an investigator on studies sponsored by Janssen, Gilead, and BMS. He has acted as a consultant in relation to hepatitis for Boeringher-Ingelheim, Merck, Gilead, Janssen, and WHO.
Full response at: www.bmj.com/content/350/bmj.g7809/rr-7.