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Real-life experience drives HCV innovation
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Douglas T. Dieterich, MD, director of the Institute for Liver Medicine at Mount Sinai Health Systems, and professor of medicine at the Icahn School of Medicine at Mount Sinai in New York, brings a unique perspective with him to work every day.
With a medical history that includes hepatitis C, helping to find a cure became one of his passions. However, once direct-acting antivirals entered the scene, his work was far from complete. Here, Healio presents a brief conversation with Dieterich during which he shares his perspectives on the past and present of HCV therapy and research.
What is unique about you and your teachings at Mount Sinai? How do you approach your work in a way that stands out from others in your field?
While in medical school at the VA Medical Center New York in Manhattan in 1977, I accidentally stuck myself with a needle. Six weeks later, I fell ill, became severely jaundiced and learned that I had contracted HCV, which at the time was an unknown type referred to as non-A, non-B hepatitis. From then on, living with the disease — and knowing there was no treatment or progress in that area — I began to shift my career focus to gastroenterology while developing a strong interest in HCV research.
In the spring of 1981, I had transitioned to Bellevue Hospital in Manhattan as a first-year gastroenterology fellow. I read the landmark series published in Morbidity and Mortality Weekly Report about an epidemic of Kaposi’s sarcoma found in young men who have sex with men, just 2 weeks after MMWR published another article about five cases in Los Angeles of Pneumocystis carinii pneumonia, also reported in previously healthy MSM. From then on, the HIV/AIDS epidemic broke out as physicians around the country reported the same conditions in their own patients. I essentially “grew up” with HIV and fell in among the AIDS clinical trials, doing extensive work in HIV and gastroenterology while waiting for something to happen in the hepatitis world. I understood immunology and viruses from my experience with HIV long before treatment became available for hepatitis B or HCV, so this uniquely prepared me for my later work with hepatitis. Fortunately, after two rounds of treatment, I was cured of HCV in 1999.
With such rapid progression of HCV-curing treatment options, what else about the disease is important to focus on?
Clinical research in this area has slowed down since the approval of direct-acting antivirals, but now our challenges lie in identifying individuals with HCV — particularly baby boomers — and then connecting them to care, because so many people do not know they are infected.
In addition, physicians have two fairly new HCV epidemics they must urgently address: the spread of acute HCV among HIV-positive MSM, which is the newest sexually transmitted infection, and among people younger than age 30 who inject drugs. The latter population is now the same size or larger than the baby boomer population and, tragically, more than 60% of them are women, thus exponentially increasing the incidence of mother-to-child HCV transmission. At Mount Sinai, my colleagues and I have attempted to test every patient coming through our emergency room and department of obstetrics and gynecology; however, patients can opt out of HCV testing, so we are still not reaching as many people as possible.
What research efforts are showing the most promise for the future of HCV?
The next major push for future research is to take what we have learned from curing HCV in patients with and without HIV and implementing that into finding a cure for HBV. There is significant overlap between HIV therapies and treatments used for hepatitis B, including a combination therapy of antivirals and immunostimulators. However, unlike HCV, hepatitis B can integrate into the hepatocyte genome, leading to a covalently closed circular DNA molecule that is extremely difficult to eradicate, as it causes persistent infection.
What additional remarks would you like to share with our readers?
If there is a good time to have HCV, it is now because we can cure almost any patient with one round of treatment. Our biggest problems now are educating the public to get tested and getting primary care physicians to refer patients who have elevated liver enzymes to specialists. Education is a real challenge, but I believe physicians are beginning to understand that this is a curable disease, and that there is no reason not to refer patients for treatment.