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    The $180,000 Backpack on Muni

    naomiWould you carry $180,000 worth of products on public transportation? I know of at least one patient who must do just that. Here’s how the scenario begins: You start by picking up your 90-day supply of medications, just like you do every 3 months. Your doctor has just prescribed a new regimen to treat your chronic Hepatitis C (HCV). Since 25 percent of HIV-positive people also have HCV (co-infection) your doctor tested you early on for HCV and has been monitoring your liver function tests. You’ve had no obvious symptoms but gradually, over the years, your liver function tests show liver damage that has recently worsened.

    You’ve waited for months for the new drugs to become available, because the clinical trials have amazing cure rates (over 90 percent), and you’ve heard scary things about the standard of care treatments with interferon. You stop to take a look at the resulting price tag, the one you’ve ignored because your blessed insurance covers everything but a small copay.

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    A recent patient of mine did take a look, and realized he was carrying $180,000 worth of medication in his backpack while innocently riding Muni home! That’s enough money to cover a reasonable down payment for a house in SF.

    Despite the “what if’s” that had him sweating all the way home, both he and the backpack arrived safely. One month later he feels great, and his HCV viral load is non-detectable.

    HCV is one of the most common viral infections worldwide, with over 3 million in the USA alone and 130-150 million worldwide. It is the leading cause of liver cancer and liver transplants. It is more common than HIV/AIDS as a cause of death. Over 15,000 people die annually from hepatitis C related illnesses in the United States.

    The initial exposure to Hep C may cause an “acute” infection, a short-term illness approximately 6-7 weeks after exposure. The symptoms may include fever, fatigue, loss of appetite, dark urine, jaundice and others, but most people have no symptoms. The majority (75-85%) infected with Hep C will then develop a “chronic” infection, which means the virus will always be there and may lead to serious problems such as liver cirrhosis or cancer, but there may be no symptoms until the damage is extensive. There is no vaccine for hepatitis C as there is for Hepatitis A and B. (Please go get vaccinated for those if you haven’t already done so!)

    Hep C is caused by direct contact with the blood of an infected person who has either an “acute” or “chronic” infection. For this reason, about half of IV drug users are Hep C positive. But clearly it can be spread in other ways and there is a lot of recent concern among health care providers about an ‘epidemic’ of HCV in the HIV-positive community, indicating that sexual transmission is more common than previously thought. Co-infection of the two viruses can make the liver disease progress more rapidly.

    The standard therapy has been Peglyated interferon (peg-IFN) and ribarvin (RBV) in combination. It involves 48 weeks of therapy, including injections, and is effective against all the genotypes of hepatitis. But it is poorly tolerated in some patients, causing flu-like symptoms, headaches, and others. These side effects should not be minimized, as they can go on for a year. As such, many people do not complete their treatment.

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    The new drugs, called DAA, are safer, more effective and better tolerated They involve a once or twice a day pill. The DAAs are also used in combination, and cure rates >95% were reported recently following several clinical trials using different regimens of oral medications.

    Since these regimens involve several different pills, similar to multiple drug regimens for HIV care, multiply each pill by $1,000 and see what you get. It’s expensive, but still cheaper than a liver transplant. Despite the price tag, which is truly something to consider, the new treatments are rapidly changing the lives of those with HCV.

    Have a safe and fun Pride season!

    Dr. Naomi Jay is a nurse practitioner in the department of Infectious Disease at UCSF.