Among People with Hemophilia, HCV Prevention is Working, But Eradication Remains Elusive

Clotting factor concentrates were a “revolutionary” breakthrough for the treatment of hemophilia, but the therapy initially led to an increased risk of blood-borne viral infections, such as hepatitis C virus (HCV).

In a new review article, investigators explained how the introduction of viral inactivation procedures have helped cut the infection risk, and how the development of direct-acting antivirals (DAAs) have led to sustained responses in people who have become infected with hepatitis C virus.

The review was published in the Journal of Multidisciplinary Medicine by corresponding author Nikolaos Papadopoulos, of the 417 Army Share Fund Hospital, in Greece, and colleagues.

The investigators began by noting the high stakes of HCV. They pointed out that roughly 8 in 10 people who become infected with HCV will eventually develop chronic infection, which in turn could lead to a number of other liver-related problems. And while the global prevalence of HCV is decreasing, the investigators said the global public health community is not on pace to achieve the World Health Organization’s (WHO) goal of eradicating HCV by the year 2030. One way to get closer to that goal, Papadopoulos and colleagues explained, is by “micro-elimination,” which involves attempting to eradicate the disease by focusing on certain high-risk subpopulations.

“These tailored interventions can accelerate the implementation of prevention and treatment strategies in specific subpopulations and settings,” they explained.

A major prong of HCV elimination is prevention, and the authors said universal screening of blood-derived clotting factors and effective prevention planning have combined to significantly reduce the risk of accidental transmission of transfusion-associated viral infections among people with hemophilia.

“Nevertheless, this is the case in industrialized countries, whereas in developing countries, the prevalence of HCV infection still remains high due to the inadequate application of universal precautions in healthcare,” they wrote.

When a patient with hemophilia does become infected with HCV, they face a lower chance of naturally clearing the infection compared to the general population. If their infection becomes chronic, they face a 1-in-5 risk of cirrhosis, and those with cirrhosis are expected to develop hepatocellular carcinoma (HCC) at a rate of 1-5% per year, Papadopoulos and colleagues said. They added that one study made up primarily of people with hemophilia found that 13% of people with chronic HCV eventually developed end-stage liver disease (ESLD) and 3% were diagnosed with HCC.

When it comes to managing patients with hemophilia who develop chronic HCV, the authors said the existing data—though limited—suggests DAAs prompt similar responses in people with hemophilia as in the general population.

“Although patients with hemophilia were not included in initial major studies on DAAs, there are studies confirming their efficacy in this specific group of patients,” the authors said.

DAAs similarly appear to be effective in patients co-infected with HCV and HIV.

“The most extensive real-world study included 200 hemophilia patients treated with different DAA regimens in two large Italian Hemophilia Treatment Centers,” Papadopoulos and colleagues said. “Patients showed an SVR-12 [sustained virological response at 12 weeks] rate of 99% with no significant side effects. Forty patients among them were HCV/HIV co-infected.”

The authors concluded by arguing that the efficacy of prevention measures implemented around hemophilia treatment have “practically led to almost no new cases of transfusion-associated HCV infections in hemophilia patients.”

Still, the authors said it is important to remember that older patients who already have chronic HCV are still at risk of liver complications and thus physicians should make it a priority to treat those patients with DAAs when possible, they said.

“The WHO HCV elimination goal for 2030 is feasible in patients with hemophilia and other bleeding disorders, via micro-elimination projects,” they concluded.