The trouble with the expense of treating hepatitis C virus (HCV) infections is that very few patients are acutely “choking” on it, since the largest pool of HCV patients are asymptomatic. Progression to end-stage liver disease, liver transplantation, and hepatocellular carcinoma — the three most dreaded HCV consequences — may seem distant to the asymptomatic or even modestly symptomatic patient. The current costs of some HCV regimens appear, at least at first glance, extraordinary. For instance, once-daily oral sofosbuvir, one of the most highly effective HCV treatments, is a startling $84,000 for a standard 12-week course ($1000 per pill)!

Although neither the public nor clinicians are readily aware of the per-tablet costs of actually creating a new therapeutic entity, it is perhaps noteworthy that the initial purchase of the company that first developed sofosbuvir was $11 billion. This number does not include any of the costs for subsequent manufacture and marketing, and of course it will take many, many courses of sofosbuvir to recoup even these initial expenses. On the other hand, if every HCV patient in the United States were to enjoy a curative treatment course of sofosbuvir at the standard price, that could generate as much as $250 billion.

Certainly the costs of treatment for liver transplantation, end-stage liver disease, and hepatocellular carcinoma would readily eclipse even this apparently extravagant tariff for sofosbuvir and some other agents like it, such that in the long-term perspective, it becomes “pay me a lot now or pay a lot more later.” In any case, many voices are calling for the industry to be economically and socially responsible stewards of the treatments they offer.