Between 2013-2016 in the United States, an estimated 2.4 million people were living with hepatitis C virus (HCV) infection.^[1] The advent of oral, direct-acting antiviral therapy has, in the last decade, transformed HCV care, providing options that cure upward of 90% of patients with treatment durations as short as 8 weeks. In the minority for whom treatment fails, emerging real-world data highlighted at the 2018 American Association for the Study of Liver Diseases (AASLD) conference underscore that retreatment with newer regimens is effective and safe.

As the HCV epidemic evolves away from its previous need for efficacious drugs, a renewed enthusiasm to address gaps in access to testing, care, and cure must be embraced. In particular, achieving HCV elimination will require resources focused on hard-to-treat populations including persons who inject drugs (PWID) and those in incarcerated settings. Studies at AASLD 2018 reinforce that imperfect adherence in PWID does not disallow cure. The completion of treatment is what is important—not that it happens exactly on time or without interruption. Separately, age-stratified analyses revealed that younger PWID (≤ vs > 35 years of age) were less likely to be linked to HCV care or to initiate therapy. Similar age-related disparities were also observed in the general US population where the greatest increases in HCV treatment rates were observed for baby boomers compared with young adults. Finally, specialist vs primary care was associated with a greater likelihood of treatment. Moving forward, acknowledging these points of intervention will enhance patient engagement and move the field closer to its ultimate goal of viral eradication.

Although great progress has been made in HCV, we have farther to go in addressing what has grown to be the main topic at the AASLD meeting this year: nonalcoholic steatohepatitis (NASH). This abnormal accumulation of fat in the liver, marked by inflammation, can progress to advanced fibrosis, cirrhosis, and hepatocellular carcinoma.

Liver biopsy is currently the only way to distinguish between patients with NASH, which is at risk of progressing, and patients with stable, simple steatosis. The AASLD meeting featured several noninvasive tests that are in advanced clinical development, with promising results suggesting that we may soon be able to replace impractical and invasive biopsy with simple tools in family practice.

Although there are no approved drugs for NASH, data from a fascinatingly diverse number of agents in phase II and III clinical trials—including PPAR agonists, ASK1 inhibitors, CCR2/5 agonists, FXR agonists, FGF analogues, THR-β agonists, ACC inhibitors, SCD1 inhibitors, and GLP-1 receptor agonists—continue to dominate these liver meetings.

Reference 1. Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology. 2018;[Epub ahead of print].

Detailed reporting of key data from the conference is available from multiple educational sources, such as Clinical Care Options' conference coverage.