We read with great interest the article by Stepanova et al. 1 In this report from the United States with 10,582 eligible individuals (1.52% of whom were positive for hepatitis C virus [HCV] antibody [anti-HCV]), the rate of insurance coverage was significantly lower in patients with HCV infection (61.2%), particularly in 66.7% patients who could be candidates for treatment (54.3%), than in subjects without HCV infection (81.2%). Only 36.3% of HCV-infected patients were potentially eligible for treatment and had health insurance. The authors considered that access to care for patients infected with HCV is critical, and their results can have important implications for health insurance coverage of HCV-infected patients and should be considered under the new health care reform legislation.
With the current standard-of-care (SOC) regimen with a combination of pegylated interferon-alfa (PegIFN) and ribavirin, sustained virological response (SVR) rates in Western countries were around 50% and 83% for genotype 1 and 2/3 patients, respectively. 2,3 In addition to the well-known adverse effects of the PegIFN/ribavirin, which might terrify both physicians and patients and need careful monitoring as well as management, another important barrier that prevents patients from receiving SOC is the high cost of treatment of HCV, which the authors estimate is up to $48,000 per year in the United States. Insurance coverage to reduce the economic impact is critical in these patients, given the inability of most to afford the treatment. Recently, Yan et al. also reported that concern about cost is one of the most common causes (37%) for nontreatment before the government reimbursed all treatment for chronic hepatitis C (CHC) in Hong Kong. 4 Reduction of the economic burden for HCV therapy helps improve the treatment uptake of patients with CHC.
In Taiwan, patients with CHC who are infected with genotype 1 and 2, and who are treated with PegIFN/ribavirin, achieve high SVR rates in our previous randomized trials (80% and 95%, respectively). 5,6 In addition, Asian patients had the highest frequency of the advantageous allele in the gene for interleukin-28B, with up to 88% of Taiwanese patients with CHC having the rs8099917 TT genotype in our reports, 7,8 which has been shown to be an important predictor of response. It seems reasonable to encourage Taiwanese patients with CHC to undertake the SOC regimen. In Taiwan, National Health Insurance (NHI) commenced in 1995, with a very high universal coverage rate of 99.5% by the end of 2008, resulting in a narrowed disparity in health care between the wealthy and the poor. 9 The reimbursement for anti-HCV therapy by the Taiwanese NHI started in 2003 if patients meet all the criteria: (1) positive for anti-HCV; (2) the alanine aminotransferase levels !2Γ upper limit of normal on two occasions 3 months apart during the 6-month period; and (3) fibrosis stage !2 (revised to stage 1 or greater since 2004). The criteria were further revised in 2009: (1) patients with positive anti-HCV and serum HCV RNA and (2) abnormal alanine aminotransferase levels. Accordingly, more Taiwanese patients with CHC can be expected to receive therapy under this permitted reimbursement claim.
We have constructed the ''roadmap'' concept with the determined duration of therapy in Taiwan 10 and using the strategy to truncate treatment, the estimated cost saving of drugs achieves 11.8% and 29% per SVR for HCV genotype 1/4 and genotype 2/ 3 patients, respectively. We can make more efforts to help patients. For instance, the NHI program in Taiwan, which is given unanimous praise, does not yet reimburse the use of hematopoietic agents such as erythropoietin or granulocyte colony stimulating factor in treating anemia or neutropenia caused by PegIFN/ribavirin. Here, we share the status of Taiwan's NHI, which has made Taiwanese patients with CHC more fortunate than patients in nations that have a lower rate of insurance coverage. When welcoming the new era of emergence of direct-acting antivirals that effectively enhance SVR rates when combined with SOC, we have tried our best to remove all barriers for receiving therapy, particularly the insurance obstacle in terms of financial burden for patients.