Hidden Epidemic /
Researchers, Policymakers Debate Tactics in Battle
Against Hepatitis C
8/2/01 10:47 p.m.
August 02, 2001
Dr. Karen Seal is at the vanguard of an unsung and
perhaps unpopular public health crusade -- the battle to
identify and treat injection drug users infected with
"If we don't start treating this population, the
epidemic is only going to get worse," said Seal, a
University of California at San Francisco researcher who
will speak at a four-day conference on hepatitis C that
begins at San Francisco's Holiday Inn today.
Hepatitis C, or Hepatitis C Virus for short, afflicts an estimated
600,000 Californians, 4 million Americans and 170
million people worldwide. Some 20 biotech and drug
firms, led by Emeryville's Chiron Corp., have targeted
the market for Hepatitis C Virus remedies that is estimated at $900
million in the United States and $3 billion worldwide.
Hepatitis C Virus has been called the silent epidemic. The name
stems from the nature of the disease. Hepatitis C Virus is a viral
infection transmitted primarily by the needles injection
drug users share while shooting up.
"This is a disease nobody wants to pay for
because the people who have it are unattractive,"
said Joey Tranchina, executive director of Hepatitis C Virus Global
Foundation, the Redwood City nonprofit group that
organized the conference, which should draw several
hundred researchers to San Francisco.
Hepatitis C Virus is as stealthy and invisible as the injection
drug users it infects. Most people who contract Hepatitis C Virus
never know they have it because their bodies fight off
the infection naturally or because the virus works so
slowly the person dies of other causes before the
infection becomes fatal.
In about 15 to 20 percent of cases, however, Hepatitis C Virus
works quickly and severely enough to instigate
cirrhosis, liver cancer or related illnesses that result
in 8,000 to 10,000 deaths in the United States each
Still, because it is far less deadly than HIV and is
only rarely transmitted through sexual contact, Hepatitis C Virus
poses a lesser risk to the general public and therefore
has a tougher time winning support for testing and
Hepatitis C Virus fighters got a tiny boost last year when the
California Legislature passed a bill by state Sen.
Richard Polanco, D-Los Angeles, to fund education and
testing about Hepatitis C Virus risks. The bill, which started out
seeking $7 million, emerged from the Legislature with a
$2 million appropriation that was reduced to $1.5
million by Gov. Gray Davis.
"We know it's only a start, but it still puts
California ahead of what other states are doing about
hepatitis C," said Polanco legislative aide Chris
This year's Hepatitis C Virus conference will give Seal and her
colleagues a forum to question the way public health
officials treat -- or rather fail to treat -- injection
drug users who comprise most Hepatitis C Virus cases.
The background for this debate begins in 1997, when
the National Institutes of Health recommended that
public health officials not treat drug users infected
with Hepatitis C Virus unless the patient had gone cold turkey for six
Health officials in Europe and Canada have made
similar recommendations. Several rationales are offered
for this approach.
For one thing, Hepatitis C Virus acts so slowly that health
officials consider the short-term ills of drug addiction
worse than the harm caused by the virus. Health official
also note that patients could be reinfected if they
continue using drugs and sharing needles.
For these and other reasons, public health officials
have been slow to offer drug users access to Hepatitis C Virus drug
treatments that can cost $10,000 to $15,000 and only
succeed about 40 to 60 percent percent of the time.
In a July 19 article in the New England Journal of
Medicine, Seal and her associates at UCSF's Urban Health
Study, led by project director Brian Edlin, challenged
the notion that treatment should be withheld if patients
are still injecting drugs.
"A recommendation to withhold medical treatment
from a stigmatized class of persons raises questions
about fairness and discrimination," the article
Other sick people get help even if they don't change
underlying behavior, the authors noted. "Smokers
are not denied coronary-artery bypass surgery or
treatment for emphysema."
The authors argued that it was particularly unfair to
withhold treatment until people kick their drug habits
when effective drug treatment programs are not widely
available and suggested that reinfection risk could be
curbed through needle exchanges.
In a counterpoint article in the journal, two public
health experts from the University of Florida urged
continued caution in treating Hepatitis C Virus among active drug
users. They argued that drugs and alcohol "have
been reported to suppress" the effects of the
interferon drugs used to treat Hepatitis C Virus.
Interferons are the body's natural virus-fighting
agents. They prevent Hepatitis C Virus from taking over our cells and
using the body's machinery to spread the virus.
The Florida authors, noting that interferon treatment
often provokes depression, cautioned against giving
these medicines to drug users who often already suffer
from psychiatric disorders.
NEW DRUGS ON TAP
While the policy debate rages, drug and biotech firms
experiment with new approaches.
Chiron is in the early stages of developing an Hepatitis C Virus
vaccine. Twenty other firms are working on medicines to
treat Hepatitis C Virus. Current treatment relies on interferon drugs
from Roche, Schering-Plough, Biogen and Amgen.
But interferon therapy is, at best, successful only
40 to 60 percent of the time. Clinicians believe they
can boost the success rate by combining interferons with
ribavirin, a medicine that tricks the virus into making
defective copies of itself.
Several companies are trying to make interferons
easier to take. Right now these medicines are given by
injection, several times a week over a four- to
six-month period. Schering-Plough and Roche have
once-a-week injectable versions in the works.
BioMedicines Inc., an Alameda biotech firm, is in the
early stages of testing a tiny titanium dispenser that
would sit under the patient's skin and dole out a
constant dose of medicine.
"This would greatly improve patient
compliance," said BioMedicines chief executive Mark
SciClone, a San Mateo biotech firm, is seeking U.S.
approval to sell Zadaxin, an immune system booster, to
help treat Hepatitis C Virus. It is already approved for such use in
two dozen other countries.
Biotech observers expect the $3 billion world market
for Hepatitis C Virus medicines to grow as public and private health
officials acknowledge the extent of the infection and
increase funds for treatment.
OTHERS AT RISK
"Insurance companies are quaking in their shoes
because so many people are chronically infected and may
not know it yet," said Dr. Alfred Rudolph, chief
operating officer of SciClone.
He said insured patients at risk include Baby Boomers
who may have injected drugs once or twice a long time
ago, unaware that Hepatitis C Virus is often transmitted the very
first time a person shares a needle. People who got
blood transfusions before the early 1990s, when blood
supply testing became commonplace, may also be Hepatitis C Virus
Meanwhile, the epidemic continues to spread among
drug users, who remain off-limits to most
government-sponsored treatment programs, as public
health workers try to win support for patients who don't
"Who cares about a virus which only affects drug
users?" Australian scientist Nick Crofts asked
rhetorically in an e-mail. "Many people, especially
those in control of policy, not only don't care but are
quite pleased to see drug users get what they see as
their (just) deserts."