Chronic diseases are long-term conditions, with Donoso (2023) noting not only that ‘around 50% of people follow long-term treatment recommendations in high-income countries and presumably even less in low-income and middle-income countries’, but also that living with chronic disease requires effort to remember that symptoms can improve when individuals feel unwell and can return when they feel better.
Given this bleak context, one might speculate on how those suffering from chronic diseases might have reacted to a news item from Consumer News and Business Channel (CNBC). It revealed that in, April 2018, Salveen Richter, an analyst from financial services company Goldman Sachs, in a report titled The Genome Revolution, asked, ‘Is curing patients a sustainable business model?’ (CNBC, 2018). Ms Richter further opined that ‘one-shot cures’ like gene therapy ‘offer a very different outlook with regard to recurring revenue versus chronic therapies.’
One might venture that certain ethical questions arise; like, is medicine grounded in humanitarian endeavour or the pursuit of cash? Citing Gilead Science's hepatitis C treatments that achieved cure rates of over 90%, Ms Richter's observation that ‘the success of its hepatitis C franchise has gradually exhausted the available pool of treatable patients’ (CNBC, 2018) seems tinged with disappointment. Leaving aside Ms Richter's undeniable keen sense of financial stewardship, how has hepatitis C virus (HCV) infection been faring in the face of a diminishing pool of treatable patients?
Taha et al (2023) cite a global prevalence of 58 million people with chronic HCV infection; approximately 1.5 million new infections per year; and in 2019, 290 000 people died of hepatitis C. Yet, although direct-acting antiviral (DAA) medications cure HCV infection in most cases, ‘[p]ertinent barriers include inadequate availability of screening, ill-equipped laboratory testing before treatment, and insufficient access to treatment’ (Taha et al, 2023). Further, Austin et al (2023) note that while a goal of the World Health Organization is the elimination of HCV infection by 2030, since DAAs were introduced in 2013, the number of patients prescribed HCV DAAs annually in the US ‘falls short of goals for achieving HCV elimination.’
Since people who inject drugs (PWID) are disproportionately affected by HCV incidence and treatment disparities, HCV elimination depends on PWID having access to DAA treatment, which prompted Austin et al (2023) to develop and pilot a pharmacist, physician, and patient navigator-collaborative care model (PPP-CCM) in which pharmacists delivered HCV care directly at community organisations serving PWID. Their study not only demonstrated the feasibility and acceptability of PPP-CCM for HCV care delivery among PWID, but showcased ‘the ways in which pharmacist-led models of care delivery can offer a novel and promising approach to increasing access and utilisation of HCV care’ (Austin et al, 2023).
So while Ms Richter might harbour regrets that the success of anti-HCV medication ‘has gradually exhausted the available pool of treatable patients’ (CNBC, 2018), there is much work that remains to be done by those with less finely tuned financial antennae. For example, in the context of treating those infected with both HIV and HCV, Soriano et al (2023) point out that four main challenges may arise from using anti-retroviral medication and DAA in HIV-HCV coinfected patients: overlapping drug-related side effects, hepatitis B reactivation, immune reconstitution syndromes, and drug interactions.
The possibility of hepatitis B virus (HBV) reactivation cited by Soriano et al (2023) is worth exploring further, with Sugarman et al (2017) acknowledging that the advent of successful therapies for both HIV and HCV has ‘led to international calls seeking a cure for chronic infection with HBV’, and pointing out that more than 240 million people live with chronic HBV, with an annual mortality of some 780 000 deaths ascribed to hepatic fibrosis/cirrhosis and hepatocellular carcinoma (HCC). Sugarman et al (2017) explain that those ‘chronically infected with HBV who do not receive treatment have a lifelong risk of developing HCC, the third most common cause of disease globally.’
They also emphasise the need for fairness, such as engaging with those infected with different HBV genotypes, as different genotypes are found in different regions of the world where different burdens of HBV infection and comorbidities are found.
We live in a time when some medical scientists strive to marshal resources that facilitate cures for diseases, while others question the business sense of providing those resources. The need for the cultivation of an ethical approach to applied medical science is acute.