We work at a fast pace in the hepatitis C clinic. Since arriving in Phnom Penh two months ago, I’ve seen 350 patients at various stages of their treatment. I run through one pen refill per week in Cambodia, whereas I could get by with one pen every two to three weeks in the United States. (I mention this in case there are any statisticians out there interested in the impact of paper charting upon ink consumption...)
Because we’re gearing up to enroll 1,000 people into direct-acting anti-viral (DAA) treatment between now and the end of June, the most common clinic visit I do is a baseline evaluation. At this visit, I get a quick medical history, with special attention to any prior treatments for hepatitis C. This is important, because people who have been incompletely treated with DAAs before, or who have had recurrent hepatitis C despite DAAs, need special evaluation and may need longer or more complex treatment regimens.
When I ask if our patients have been treated for hepatitis C in the past, I get a range of answers. Most people aren’t able to afford DAAs, so most often the answer is no. Sometimes people say yes, and then I have to put on my detective hat and ask what the name of the medicine was (they usually don’t know), how many times a day they took it, and how many pills per day the treatment consisted of. I ask these questions because DAAs usually consist of one or two pills taken daily, so if a patient tells me he took thirteen pills three times a day, I’ll know it was probably a course of vitamin supplements.
Vitamin van parked outside our screening area. I hope this isn't direct marketing! Photo: Theresa Chan/MSF.
Some patients are able to tell me they took vitamin supplements because they were told it would “slow the progress of hepatitis C.” I am disturbed by this, because there is no evidence that anything influences the natural history of hepatitis C other than individual factors which are not well understood, the presence or absence of infection with hepatitis B or HIV, and alcohol or drug intake. I worry that hepatitis C patients are easy targets for manipulative marketing of vitamins and other interventions with no proven benefit. I don’t think vitamins are harmful, but patients tell me they cost $20-50 every month, and that is big money in this country: unskilled laborers here, like garment or construction workers, only make $5-6 per day.
People can be led to make even more expensive decisions that won’t help their hepatitis C status. One man spent several hundred dollars for three months of DAA treatment with sofosbuvir and ribavirin, two medicines we use in our treatment regimens, but usually in combination with another medicine such as daclatasvir or ledipasvir. A general principle of hepatitis C treatment is that you must use combinations of drugs that work via different mechanisms to combat the virus. Failing to do so risks breeding resistance and is likely to result in treatment failure.
The right medicines, the wrong combination. Photo: Theresa Chan/MSF.
Which is what happened to this patient. He took these medicines for three months, but he purchased them privately and was not under a doctor’s care. He had no way of knowing that the combination of medicines was never going to eliminate his hepatitis C. Now he is enrolled in our program, several hundred dollars poorer and still with detectable virus in his bloodstream.
“I wanted to be cured,” he explained when I asked him how he chose these medicines.
I don’t blame him for wanting to be cured of hepatitis C. I want him to be cured, too. I want all of these hundreds of patients we see every day to be cured of hepatitis C. What I don’t want is for people to spend money they can’t spare on ineffective treatments, which is a common story heard in our clinic when people speak of the time before MSF arrived.