Intended for healthcare professionals

Practice Uncertainties

Do direct acting antivirals cure chronic hepatitis C?

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1382 (Published 10 May 2018) Cite this as: BMJ 2018;361:k1382

Re: Do direct acting antivirals cure chronic hepatitis C? Our question is: does Cochrane aim to inform health decision making, or actively interpret data to make those decisions?

Dear Editor,

We read the above article (1) and the authors’ responses to queries and comments with interest. Given the significant number of responses, we limit our comments to a couple of additional key issues that we feel have not been raised so far.

1. We had similar concerns to those raised by others regarding the apparent lack of consideration of the benefits of SVR in relation to transmissibility. It was therefore particularly interesting to note the authors’ response stating that “blood-borne transmission is still possible” when SVR has been achieved (1). However, the reference provided by the authors as evidence for HCV-RNA being found in peripheral blood mononuclear cells of those achieving SVR (2) to support the unequivocal statement made by the authors does not provide the required evidence to clearly and definitively substantiate these comments. Within that paper (2), the authors have provided a number of references that mention the findings of viral RNA in body tissues in some of those who achieve SVR. It is possible that we may have missed the secondary reference that clearly demonstrates viral RNA presence in peripheral blood mononuclear cells of those who achieved SVR, and a consequent risk of transmission. However, given the importance of this statement for clinical practice and public health, it is imperative that the supporting evidence for this statement is clearly presented.

2. We also question the value of members of a Cochrane group providing specific practice recommendations, as has been done here. The Cochrane Group state that “Our global independent network gathers and summarizes the best evidence from research to help you make informed choices about treatment and we have been doing this for 25 years” (3). The Cochrane Strategy to 2020 (4) extends to include a number of roles, within this overarching remit of informing health decision making, but it does not include actively interpreting data to make those decisions on behalf of the healthcare profession. In an open and inclusive decision making process, we expect the findings of such reviews to be interpreted in conjunction with a series of other considerations including patients’ views, health service access and funding, and to be fully appraised by a group or panel representing all important stakeholder groups in order to make a decision on practice implementation in a particular locality, region or country. In this case, members of the Cochrane group have been involved in interpreting the findings of the review in isolation to make and publish generalised recommendations for practice implementation. Particularly considering the wide-reaching impact of Cochrane reviews and the weight given by frontline health professionals to their findings, choosing to make such recommendations may have, in this instance, served to limit access to treatment for patients in some countries or situations leading to a missed opportunity to reduce the overall burden and spread of hepatitis C infection.

Dr Sam Ghebrehewet
Head of Health Protection & Consultant in Communicable Disease Control
PHE North West – Cheshire & Merseyside

Dr Katie Smith
Specialty Registrar in Public Health (ST4)
PHE North West – Cheshire & Merseyside

References
1. Jakobsen JC, Nielsen EE, Koretz RL, Gluud C. Do direct acting antivirals cure chronic hepatitis C? BMJ 2018; 361: k1382.
2. Koretz RL, Lin KW, Ioannidis JP, Lenzer J. Is widespread screening for hepatitis C justified? BMJ. 2015; 13:350:g7809. doi: 10.1136/bmj.g7809.
3. Cochrane (Trusted Evidence. Informed Decisions. Better Health): About Us https://www.cochrane.org/about-us (Accessed 29th July 2018).
4. Cochrane (Trusted Evidence. Informed Decisions. Better Health): Strategy to 2020 aims to put Cochrane evidence at the heart of health decision-making all over the world. https://www.cochrane.org/about-us/strategy-to-2020 (Accessed 29th July 2018).

Competing interests: No competing interests

09 August 2018
Sam Ghebrehewet
Head of Health Protection & Consultant in Communicable Disease Control
Katie Smith
PHE North West – Cheshire & Merseyside
Cunard Building, Water Street, Liverpool, L3 1DS