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Treatment of hepatitis C infection

Editor—We were disappointed that McCarthy and Wilkinson’s review of recent advances in hepatology underplayed important public health issues and treatment options surrounding hepatitis C virus.1 In Western Europe about 5 million people are chronic carriers of hepatitis C virus, and in industrialised countries the virus accounts for 40% of cases of end stage cirrhosis and 30% of liver transplants.2 Hepatitis C is thus an important health problem. 
 
Recent data confirm that combination antiviral treatment with ribavirin and interferon is better than interferon alone, with a 38-43% sustained response rate (polymerase chain reaction negative) with 12 months of combination treatment compared with 13-19% with interferon alone.3,4 Although ribavirin has been supplied for use only in trials in the United Kingdom, it is imminently to be licensed for patients who relapse after interferon alone and is already licensed for this indication in the United States and other European countries. 
 
Moreover, a recent international consensus conference on hepatitis C recommended that interferon and ribavirin be first line treatment for previously untreated (naive) patients without contraindication to ribavirin. Duration of treatment should be tailored to viral load and viral genotype. It was suggested that patients with viral genotype 1 should have a six month course of combination treatment before viral response to treatment is assessed compared with three months for those infected with other viral genotypes. These recommendations (drawn from a panel of experts) have important public health and economic implications. 
 
Lastly, we are not aware of any large trials using ribavirin alone in patients with recurrent hepatitis C infection after transplantation as it has little in vitro activity against the virus. Preliminary data on 122 patients with chronic recurrent infection after transplantation from Italy suggest that sustained response rates of up to 50% (similar to that in chronic non-immunocompromised hepatitis C infection) can be obtained safely in selected groups without precipitating graft rejection.5 Patients with coexistent HIV infection should be considered for antiviral treatment of hepatitis C if HIV disease activity is stable. We must be aware of improvements in treatment options for hepatitis C and the public health issues surrounding these advances, particularly in an environment where health resources are finite.