Currently India harbours an estimated 10 -15
million chronic carriers of HCV, which is a major cause of liver related
mortality and morbidity of the country 1. Genotype 3 is the predominant genotype
(63.85%) followed by genotype 1 (25.72%) in India (1) Beside this, there
is also a trend of increased prevalence of genotypes 4 and 6 in certain regions
of the country whereas Genotype 2 has rarely been reported from India (1)
With the rapid development of newer drugs in the
armamentarium against HCV the management of HCV is undergoing a global
revolution. Drugs like sofosbuvir are destined to change the current treatment
policies and bring about a revolution in the way we think of HCV treatment.
However, in the Indian scenario, one needs to consider the genotype patterns,
the stage of the disease and affordability of treatment before implementation
of the proposed international guidelines. Unlike in western countries where
genotype 1 is more common, the most prevalent HCV genotype in India is genotype
3. Prior to the AASLD-IDSA-IAS-USA guidelines of 2015, most guidelines had
clubbed together “genotype 2 and 3” as easier to treat genotypes. However
experience from India has shown that genotype 3 is a comparatively difficult
genotype to treat ( 2) Studies have shown that this genotype is associated with
higher steatosis, has a faster progression to fibrosis 3 and has higher incidence of
hepatocellular carcinoma 4 along with a poorer treatment response as
compared to genotype 3.
In an attempt to follow the western guidelines, although it
is often presumed that the Indian population would respond in a similar way as
Americans or Japanese respond, but it has been shown to be otherwise 3. It is with this background that one must
consider the consensus statement of 2014 recommended by the HCV task force of
the Indian National Association for Study of the Liver on HCV infection in
AASLD-2015 guidelines considering Peg-IFNa/RBV therapy as “not
recommended”, local compulsions in resource limited countries like India
would probably still require the continued use of standard treatment regimes
and would even consider use of conventional IFN. Where cost is a limiting
factor in developing countries like India, relatively less efficacious but
cheaper modes of therapies like INF may still be considered as an alternative
option, as long as newer DAAs are unaffordable to the majority of the patients.
Another major point of discordance in the Indian guidelines,
as compared to international guidelines, has been the recommendation to
consider deferring treatment for certain groups of patients like those with (i)
low levels of fibrosis, (ii) those with failed interferon therapy,
(iii) are interferon-intolerant and (iv) stable patients after liver
and kidney and liver transplant. For such patient groups it will probably be
better to wait till such safer therapies become freely available and affordable
The pattern of distribution in India too is diverse with a
distinct geographic heterogeneity in distributions of the different genotypes.
Furthermore, an enigmatic presence of HCV genotype 6 in a certain ecologic
niche in the northeastern part of the country makes the management more
challenging. As the treatment undergoes dramatic changes with newer drugs
revolutionizing the management protocols, India too has to incorporate these
newer changes. Nevertheless, keeping in mind the accessibility and
affordability of the newer regimens in a lower-middle income country like
India, it is perhaps not yet times to completely abandon the conventional modes
of therapy which are currently being used.
Christdas J, Sivakumar J, David J, Daniel H, Raghuraman S, et al.
(2013) Genotypes of
hepatitis C virus in the Indian subcontinent: A decade long experience from a
tertiary care hospital in South India. Indian J Med Microbiol 31:349-353.
P, Anand AC, Saraswat VA, Acharya SK, Dhiman RK, et al. (2014) Consensus
Statement of HCV Task Force of the Indian National Association for Study
of the Liver (INASL). Part I: Status Report of HCV Infection in India.
Journal of clinical and experimental hepatology4:106-116.
PY, Cai T, Overbeck K, Bochud M, Dufour JF, et al. (2009) Genotype 3 is
associated with accelerated fibrosis progression in chronic hepatitis C. J
G, Ziol M, Aout M(2011) HCV genotype 3
is associated with a higher hepatocellular carcinoma incidence in patients
with ongoing viral C cirrhosis. J Viral Hepat18:516-522.