Reply to Walker et al Free

To the Editor—We would like to thank Walker et al [1] for expressing some ethical concerns regarding our suggestion to stratify access to direct-acting antivirals (DAAs), in our article on postpartum spontaneous clearance of chronic hepatitis C virus (HCV) infection [2]. They raise some valid points that we would like to address.

First, we would like to clarify that we completely support the principle of treating every HCV-infected individual when resources are available. Second, we are not in any way proposing that patients be triaged without their consent, nor are we suggesting that they be excluded completely from follow-up or subsequent treatment. Third, we are limiting our suggestion to a specific subset of postpartum women in a resource-limited setting who, despite the lower cost of DAAs, would still not be able to afford them.

In our study, we describe a very specific population of healthy, young, postpartum women who are HCV monoinfected and are at a very low risk for transmission or reinfection within 1 year after delivery. The current clinical practice in Egypt is to refer patients with newly diagnosed HCV infection to a hepatologist, who then treats them if they can afford it or else refers them to a government-funded program. Hence, none of the women would be sent home without a clear plan for referral and treatment. Furthermore, because DAAs are not yet approved for breastfeeding women, and the near-universal practice of breastfeeding in Egypt for 1–2 years postpartum, it would not be possible to treat them until after their child is weaned. Hence, waiting for 1 year after delivery is not only reasonable but is also desirable for most mothers.

We are proposing that when a postpartum woman receives a diagnosis, she would be referred to the appropriate specialist and made aware of the likelihood of spontaneous clearance by the time she completes breastfeeding of her child. If she decides to wean her child early and start treatment immediately, then her decision should be honored. As Walker et al agree, viremia may clear spontaneously in 36% of patients with the favorable genotype (a considerable proportion). The remaining two-thirds would then be treated.

Although immediate treatment is optimal if resources are available, we should also consider the ethical implications of subjecting a third of this patient population to the potential adverse effects of a medication when spontaneous clearance is a possibility. This is particularly relevant in a setting where treating such a patient may unnecessarily deprive another patient from receiving treatment owing to paucity of resources.

In summary, our suggestion for triage should be considered only a voluntary option for postpartum women in certain resource-limited settings, where patients are at low risk for transmission or reinfection and have a reasonable likelihood of spontaneous clearance. Ultimately, the best option would be universal treatment when therapy becomes available and affordable to all patients worldwide.

Notes

Potential conflicts of interest. S. S. E., M. H., R. J., and H. E. received grants from the US-Egypt Science and Technology Joint Fund and the Merck Investigator Studies Program. R. J. also notes grants from Gilead, AbbVie, MedImmune, GenMark, Alios, and Merck, as well as consultancy fees from AbbVie and MedImmune. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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