Let the hepatitis C treatment wars begin.
Prince Edward Island has quietly announced that it will fund a costly new treatment for sufferers of the disease – an announcement with potentially dramatic public-policy repercussions.
For patients infected with hepatitis C virus, a potentially deadly liver disease, this is good news. The new antiviral treatments are the closest thing to miracle drugs that have come along in a long while – with a cure rate in the range of 95 to 97 per cent.
But these drugs come with a hefty price tag – about $60,000, a reality that will send a shiver down the spines of finance ministers from coast to coast to coast, especially when they consider that there are an estimated 242,500 Canadians living with hepatitis C.
So far, PEI has committed to spend $1.6-million a year for three years to purchase a drug combo called Holkira Pak, a product of AbbVie Canada with a list price of $55,860.
About 400 Islanders are infected with HCV, including 60 in the advanced stages of the disease, which suggests that PEI is getting the drug at a deep discount – about $25,000.
This will put intense pressure on the other main producer of the new generation HCV drugs, Gilead Sciences Inc., to discount its product, known as Harvoni. Its list price is roughly $67,000.
Of course, it's utterly absurd that PEI would go it alone in price negotiations. It would make sense for all the provinces and territories to form a common front and make a bulk purchase of Harvoni or Holkira Pak.
But in our fragmented health system (and our even more fragmented drug insurance system), companies tend to target one jurisdiction – usually a small one like PEI – and push to get their drug on the provincial formulary (the list of drugs that are reimbursed from the public treasury). Then, they use that as a cudgel to push the others to follow suit.
As a result, different jurisdictions often pay different prices for drugs. More importantly, access to treatment can vary considerably between provinces and territories.
There's no question that these new treatments should be available to some hepatitis C sufferers – and not just those in PEI. The difficulty will be determining where to draw lines to get the most bang for the public buck.
Holkira Pak is a combination of four drugs – ombitasvir, paritaprevir, ritonavir, each taken once a day, and dasabuvir, taken twice a day. Harvoni is a much simpler product to take – a single tablet containing ledipasvir and sofosbuvir, taken daily.
Both drugs work only for those who have genotype 1 HCV. (There are six hepatitis C genotypes, and about 70 per cent of those in Canada are type 1.) The most common treatment regime is 12 weeks, but it can be as short as eight weeks for those with few symptoms and as long as 24 weeks for those who don't respond well to the first course of treatment.
These drugs have generated a lot of excitement because the current treatment – a combination of interferon and ribavirin – has to be injected, can last up to 48 weeks, has some nasty side effects and works less than half the time.
The potentially multibillion-dollar question revolves around who should – and who shouldn't – get the new treatment.
Hepatitis C is often described as an illness of injection drug users, but the reality is that the hardest-hit demographic is baby boomers, many of whom were exposed to tainted blood or experimented with injection drugs and had numerous sex partners during their libertine youth. (There is growing evidence that HCV, always described as blood-borne, can be sexually transmitted.)
The Canadian Liver Foundation actually urges everyone born between 1945 and 1975 to be tested for hepatitis C.
For now, treatment will likely be reserved for those with serious symptoms of liver disease – not all carriers who have the potential to develop symptoms some day. Hepatitis C is the No. 1 reason people need liver transplants, and they cost roughly $300,000 each, when organs are available. A sound use of a drug treatment could actually be cost-effective.
What the provinces and territories need to do, in addition to engaging in some hardball negotiations with drug-makers, is to be crystal-clear with the public about who will be eligible for the new treatments and why.
This could be a watershed moment for treatment of hepatitis C and for formulating sound policies for the treatment of chronic illnesses more generally – but no jurisdiction can afford to be an island.