In Puerto Rico, while more than 3,000 new probable or confirmed cases have been identified since 2022-2023, there is still work to be done in terms of linkage to care and treatment.
By: Jorge L Santana Bagur, MD, FIDSA Director of the ACTU Project – University of Puerto Rico School of Medicine, Medical Sciences Campus MCS Collaborator
As one of the leading causes of liver transplants in many countries around the world, the hepatitis C (HCV) infection remains a major global health issue that impacts millions of people, and often leads to serious liver disease.
According to 2022 data from the World Health Organization (WHO), an estimated 50 million people are living with hepatitis C (HVC), with one million new infections, and nearly 242,000 deaths. In the U.S., and according to 2022 data from the Centers for Disease Control and Prevention (CDC), 93,800 new cases of chronic HCV were reported, nearly 4,850 new acute cases were documented, and 12,700 patients died.
In Puerto Rico, we’ve made substantial progress over the past three years in terms of case reporting, incidence and prevalence parameters. While more than 3,000 new probable or confirmed cases have been identified since 2022-2023, there is still work to be done in terms of linkage to care and treatment.
Unfortunately, many people, whether at risk or not, are unaware of their infection, and diagnoses are complicated by the asymptomatic nature of early infections, leading to underdiagnoses. However, innovative screening strategies that include point-of-care testing with the inclusion of serological and viral replication PCR (Reflex tests), present opportunities to improve early detection. In addition, educational initiatives aimed at healthcare providers and the public can improve awareness and reduce stigma.
Simplification strategies led by the WHO include minimally monitored intervention therapy (coined MINMON), which essentially supports the use of pan-genotypic therapies with 1 or 3 oral tablets daily for a total of 8 to 12 weeks, achieving cure rates of more than 96%. These oral therapy options without the need for injectable agents also avoid the need for expensive viral genotype testing, PCR viral load assays, and liver biopsies, resulting in fewer office visits with the use of telemedicine.
It’s important to emphasize that the role of the physician at the community level is based on three essential steps: identifying, educating, and treating or referring. These days, it’s simplified to stratify the patient’s stage of fibrosis or cirrhosis, and treating the person or referring them to an expert or academic center if it’s a complex case. The technological advances found in smart platforms and devices allow the patient to be easily stratified using applications such as Fib-4 or the APRI score, which allow for establishing a reliable framework between F0-F4 using the patient’s own results of liver transaminases, number of platelets, and age to then proceed with the treatment.
In addition, the basic assessment of the patient for treatment entails a series of simple tests that complement the therapy’s decision-making process.
To rule out cirrhosis of the liver:
CBC Differential
Comprehensive Metabolic Panel (AST, ALT)
AST to Platelet Ratio Index (APRI) or Fib 4 score*
Fibro Test (ex. Fibrosure) score (optional)
Fibro Scan (if available)
Hepatic Ultrasound Imaging (to evaluate and/or rule out masses, fat infiltration, or lesions that warrant evaluations by a gastroenterologist/hepatologist)
Physical Findings Consistent with Cirrhosis (ex. angiomas, jaundice, ascites, palmar erythema)
Serologies for HIV 5th generation (Ag p24, Ab)
Hepatitis B Serology (Ag surface and Ab core)
Pregnancy Test
Previous Hepatitis C Documentation related to the treatment and history of any liver and/or kidney transplant
*Note: A liver biopsy is no longer required as an initial evaluation for treatment decisions.
While advances with all direct-acting oral antivirals (DAAs) have revolutionized treatment, ensuring widespread access remains a pressing challenge, especially in low-income countries. On the treatment front, DAAs have high efficacy profiles, tolerability, safety, and few drug-to-drug interactions. However, challenges such as cost, accessibility, patient adherence and reinfection monitoring still remain.
In Puerto Rico, we’re currently at a historical moment where therapies with these new agents are more accessible to the population. This means that with our combined efforts and those of the medical community, we can turn this disease into a very rare or nearly eradicated infection in the coming years. While there are significant challenges in the diagnosis and treatment of hepatitis C, there are also promising opportunities to improve patient outcomes through better screening, accessibility to care, curative treatment, and continuing education. Addressing these challenges holistically is crucial to achieving global hepatitis eradication goals.
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