London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H9SH, UK.
Int J Drug Policy. 2017 Sep;47:161-168. doi: 10.1016/j.drugpo.2017.03.015. Epub 2017 Apr 25.
Direct-acting antivirals (DAAs) have transformed the hepatitis C (HCV) treatment landscape. These highly effective drugs are, however, not available to all. In a context of DAA rationing, clinicians are advised to "manage patient expectations" about the benefits of a HCV cure. This directive particularly pertains to people with minimal liver damage and those who have ceased injecting: populations negated in contemporary prioritisation debates.
This paper engages with the assumptions underpinning HCV treatment prioritisation discourses to explore the concept of treatment 'benefit' from patient perspectives. Data are from a qualitative longitudinal study exploring treatment transitions and decision-making from 2012-2015. Participants comprised 28 people living with HCV, ten treatment providers and eight stakeholders, based in London, United Kingdom (UK). One hundred hours of clinic observations were conducted at two HCV treatment hospitals. Thematic analyses pertaining to treatment expectation and outcome inform this paper.
Twenty-two participants commenced treatment. The majority who were unable to access DAAs chose to commence interferon-based treatment immediately rather than wait. Participants accounted for treatment urgency in relation to three interrelated narratives of hope and expectation. HCV treatment promised: social reconnection; social redemption and a return to 'normality'. For many with successful treatment outcomes, these benefits appeared to be realised.
The DAA era heralds a discursive shift: from 'managing [interferon] risk and difficulty' to 'managing [DAA] expense and expectation'. Calls to 'manage patient expectations' about the benefits of HCV cure are predicated on clinical benefits only, negating the social impacts of living with HCV. The public health priorities commonly articulated in treatment prioritisation debates are not consistent with those of people managing illness in their daily lives. During this 'treatment revolution' there is a need to be cognisant of the multiple publics living with the virus and the treatment needs of those who do not fit population-health scenarios.
直接作用抗病毒药物（DAAs）改变了丙型肝炎（HCV）的治疗格局。这些高效药物并非对所有人都可用。在 DAA 配给的情况下，临床医生被建议“管理患者对 HCV 治愈益处的期望”。这一指令尤其适用于肝损伤最小和已停止注射的人群：这些人群在当代的优先排序辩论中被否定。
本文从患者角度探讨了 HCV 治疗优先排序话语所依据的假设，以探讨治疗“益处”的概念。数据来自于一项从 2012 年至 2015 年探索治疗转变和决策的定性纵向研究。研究对象包括来自英国伦敦的 28 名 HCV 感染者、10 名治疗提供者和 8 名利益相关者。在两家 HCV 治疗医院进行了 100 小时的临床观察。本文主要依据治疗期望和结果的主题分析。
22 名参与者开始接受治疗。大多数无法获得 DAA 的人选择立即开始接受基于干扰素的治疗，而不是等待。参与者根据与希望和期望相关的三个相互关联的叙述来解释治疗的紧迫性。HCV 治疗承诺：社交重新联系、社交救赎和回归“正常”。对于许多治疗结果成功的人来说，这些好处似乎得到了实现。
DAA 时代标志着一种话语转变：从“管理[干扰素]风险和困难”到“管理[DAA]费用和期望”。呼吁“管理患者对 HCV 治愈益处的期望”是基于临床益处，否定了 HCV 患者的社会影响。在治疗优先排序辩论中普遍提出的公共卫生重点与那些在日常生活中管理疾病的人的重点不一致。在这场“治疗革命”中，需要认识到受病毒影响的多个群体以及不符合人口健康情景的患者的治疗需求。
