Remaining clinical issues in hepatitis C treatment

Abstract

Key advances in the evaluation and treatment of hepatitis C virus (HCV) infection have positively transformed the management and outcomes of those living with this chronic viral infection. Previously difficult-to-cure populations, including those coinfected with HIV infection, now enjoy similarly high success rates with interferon-free, orally administered direct-acting antiviral (DAA) therapies. Nonetheless, relevant unresolved clinical questions remain. The role and impact of viral resistance testing on treatment selection and outcome remain to be fully determined. The consequences of developing resistance while on DAA treatments that ultimately prove unsuccessful requires further evaluation. Optimal HCV management strategies in decompensated liver disease are unclear, and the role for ribavirin in DAA treatment-naïve and treatment-experienced patients is uncertain. A chief concern for those with cirrhosis relates to the risk for de novo and recurrent hepatocellular carcinoma among DAA recipients. In this article, we present and interpret current data and consider pragmatic, clinically useful options.