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Hepatitis C Deaths Now Outnumber Deaths from HIV; Screening Cost-Effective for Baby Boomers

More people are now dying due to hepatitis C than due to HIV in the U.S., according to CDC researchers, a shift attributable to both the aging of "baby boomers" infected with hepatitis C virus (HCV) many years ago and the large reduction in HIV/AIDS-related mortality; hepatitis B deaths, however, are far lower than either hepatitis C or HIV. Another recent study showed that HCV screening for everyone in the 45-65 age range is likely to be cost-effective.

Over years or decades chronic hepatitis B or C can lead to serious liver disease including cirrhosis and hepatocellular carcinoma, a form of primary liver cancer. The burden of liver disease related to viral hepatitis is increasing in the U.S. as people infected many years or decades ago reach the stage of advanced disease.

As described in the February 21, 2012, Annals of Internal Medicine, Kathleen Ly, Scott Holmberg and colleagues from the Centers for Disease Control and Prevention (CDC) looked at death certificate data from the National Center for Health Statisticsto assess trends in deaths due to hepatitis B, hepatitis C, and HIV.

The analysis included approximately 22 million peoplein all 50 states and Washington, DC, who died between 1999 and 2007.

Results

• Between 1999 and 2007, recorded deaths due to hepatitis B were relatively low, settling at 1,815 by 2007, or 0.56 deaths per 100,000 person years.
• Deaths due HCV increased significantly during this period to 15,106, or 4.58 deaths per 100,000 person-years.
• Deaths due to HIV declined dramatically, to 12,734 by 2007, or 4.16 deaths per 100,000 person-years.
• Factors associated with hepatitis C-related death included chronic liver disease, HBV coinfection, HIV coinfection, alcohol-related conditions, and being a racial/ethnic other than white.
• Factors associated with hepatitis B-related death included chronic liver disease, HCV coinfection, HIV coinfection, alcohol-related conditions, and Asian or Pacific Islander descent.
• A majority of deaths due to hepatitis B (59%) and hepatitis C (73%) are concentrated among middle-aged people, or "baby boomers."

"By 2007, HCV had superseded HIV as a cause of death in the United States, and deaths from HCV and HBV disproportionately occurred in middle-aged persons," the investigators concluded. "To achieve decreases in mortality similar to those seen with HIV requires new policy initiatives to detect patients with chronic hepatitis and link them to care and treatment."

Rates of new HBV and HCV infections have both fallen substantially in recent decades. An effective hepatitis B vaccine is now routinely administered to infants, and increased awareness and harm reduction efforts have helped curb the spread of hepatitis C.

Treatment for both diseases remains suboptimal, but recent improvements -- including use of tenofovir (Viread) for hepatitis B and the advent of the first direct-acting antiviral drugs (DAAs) for hepatitis C -- are expected to reduce the burden of advanced disease and death in the years to come.

Treatment can only be effective, however, if people know they are infected and access care.

As described in another report in the same issue, David Rein from the University of Chicago and colleagues estimated the cost-effectiveness of hepatitis C birth-cohort screening of adults born between 1945 and 1965.

Compared with current practice of mainly testing people with known or suspected HCV risk factors, the researchers calculated that birth-cohort screening would identify 808,580 additional cases of chronic hepatitis C, at a cost of $2874 per case.

Assuming screening was followed by standard therapy with pegylated interferon (Pegasys or PegIntron) plus ribavirin, "quality-adjusted life-years" (QALYs) would increase by 348,800 and total cost by $5.5 billion, yielding an incremental cost-effectiveness ratio of $15,700 per QALY.

If birth-cohort screening was followed by triple therapy using pegylated interferon/ribavirin plus one of the newly approved DAAs -- boceprevir (Victrelis) or telaprevir (Incivek) -- QALYs would increase  532,200 and total cost by $19.0 billion, for an incremental cost-effectiveness ratio of $35,700 per QALY saved.

"Birth-cohort screening for HCV in primary care settings was cost-effective," Rein's team concluded -- an equation that should become even more favorable with the development of better DAA drugs that can be taken for a shorter period, ideally without interferon.

"On the basis of this analysis of multiple causes of death, the increasing trend in viral hepatitis-associated deaths sharply contrasts with the decreasing trend in HIV-related deaths," the CDC team wrote in their discussion.

"The decrease in deaths from HIV infection in the past decades reflects the availability and utilization of highly effective therapies, as well as effective national implementation of programs for prevention and care," they continued. "The experience with HIV mortality reduction suggests that a similar approach to HBV and HCV prevention might lead to similar reductions in mortality from viral hepatitis over time."

Investigator affiliations:

Ly study: Centers for Disease Control and Prevention, Atlanta, GA;

Rein study: NORC, University of Chicago, Chicago, IL; Centers for Disease Control and Prevention, Atlanta, GA; RTI International, Atlanta, GA; Kaiser Permanente Georgia, Atlanta, GA; University of North Carolina, Chapel Hill, NC.

2/28/12

References

KN Ly, J Xing, RM Klevens, SD Holmberg, et al. The Increasing Burden of Mortality From Viral Hepatitis in the United States Between 1999 and 2007.Annals of Internal Medicine 156(4):271-278. February 21, 2012.

DB Rein, BD Smith, JS Wittenborn, et al. The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. Annals of Internal Medicine 156(4):263-270. February 21, 2012.

HJ Alter and TJ Liang. Hepatitis C: The End of the Beginning and Possibly the Beginning of the End. Internal Medicine156(4):317-318. February 21, 2012.