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Friday, July 25, 2014

The coming hepatitis C "tsunami"

Posted By on Fri, Jul 25, 2014 at 1:00 PM

There's a deadly virus infecting an estimated 38,000 Arkansans (only one in four of whom realize they have the disease) that is spread largely through IV drug use and sexual contact, but also medical procedures such as blood transfusions. It's not HIV, though — it's hepatitis C

Dr. Nathaniel Smith, ADH
  • Dr. Nathaniel Smith, ADH
Buried in the routine rule-reviewing of Friday morning's Public Health meeting at the Capitol was a presentation by Dr. Nathaniel Smith, director of the state Health Department, that told of the rising number of cases of liver cancer and cirrhosis caused by hepatitis C in Arkansas, and the increasing mortality rate. "In Arkansas today, more people die from hepatitis C than HIV," said Smith. The good news is that a new generation of breakthrough drugs has been developed that can evidently cure the disease in a majority of patients. Previous treatments, said Smith, were analogous to chemo — lengthy injection regimens with a low cure rate and a sometimes devastating toll of side effects. In contrast, one new cocktail based on the drug Sovaldi consists of taking one pill for 12 weeks; side effects are minimal and the cure rate is 90 percent.

The bad news is that the cost of a 12-week Sovaldi regimen currently costs about $84,000. Multiply that by 38,000 and consider that a good number of those patients are on Medicaid, and you see the potential problem. In Oregon, reports the Washington Post, Medicaid officials estimate that the cost of providing treatment to each of its beneficiaries with hep C would be roughly the same as that state's entire existing prescription drug program, about $360 million.

This has special resonance in Arkansas because of a recent lawsuit filed by cystic fibrosis patients who've been denied access to an expensive new treatment for their disease by the state's Medicaid program. And, because of the private option, which has added over 170,000 Arkansans to the Medicaid system in the past year; given the infection rate, there can be no doubt a number of those new enrollees are hep C patients, even if many of them are still undiagnosed. Drugs like Sovaldi — or the cystic fibrosis cure — are extreme examples of the rising cost of healthcare in general, and present dilemmas to Arkansas legislators and health officials that are bound to come due in the next year or two as the drugs become more available. Will the state choose who receives treatment and who doesn't? With costs this high, it's inevitable. But that could spark further lawsuits.

Of course, those sky-high drug costs are themselves decided in part by their creators. 

"It's an issue of what's a fair price to pay for these medications," said Smith after the meeting. He was quick to praise Gilead, the manufacturer of Sovaldi, for allowing a generic version to be distributed overseas at a 99% discounted price in Egypt, where hep C has become endemic due to a certain tragically faulty medical practice. Sovaldi itself is costly to manufacture — around $200 per pill — although that's nowhere near the $1000 per pill the company is charging in the US market. While Gilead's breakthrough is to be praised, it is certainly raking in the cash on its innovation as well.

Smith's own experience with hepatitis C is highly personal: his father died of liver cancer in the early 2000s because of exposure to hep C acquired through a blood transfusion in the late 80s. That's because infection can take decades to materialize into symptoms, and a great deal of today's hep C patients acquired the virus from blood transfusions performed before the early 90s, when new blood bank screening standards sharply reduced the incidence of transmission of blood-borne illnesses. Baby boomers are thus especially at risk for the virus, and comprise three-fourths of all hep C infections. The Center for Disease Control now recommends that all people in the US born between 1945 and 1965 receive at least one screening for hep C in their lifetime. (Even without the new generation of drugs, diagnosing the disease early can vastly help mitigate its effects in patients.)

"There is a tsunami of people headed towards irreversible liver disease and death," without proper diagnosis and treatment, Smith said. In the coming months, the Health Department will be rolling out new hep C screenings at local health units around the state.

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