Showing posts with label Treat All. Show all posts
Showing posts with label Treat All. Show all posts

Friday, May 25, 2018

UK - Increasing treatment uptake to eradicate hepatitis C infection

Nursing Times [online]; 114: 6, 38-42.
Review
Increasing treatment uptake to eradicate hepatitis C infection
Gemma Botterill
25 May, 2018

Full Article:
View Online

Abstract
Viral hepatitis is a major cause of death across the world and hepatitis C virus infection represents a large share of the burden. Curing hepatitis C has become more feasible since the emergence of direct-acting antivirals, which have cure rates of >95%. NHS England has set up a national network of treatment services and, since February 2017, treatment has been available to all infected patients, regardless of genotype and liver fibrosis staging. Today the challenge is not so much how to treat patients, but how to identify them in the first place, as many are not known to health services. This is because they are unaware of their infection, they do not feel they need treatment, do not know about the new treatments available, or they belong to hard-to-reach groups such as homeless people, prisoners and injecting drug users. This article looks at the methods used at Queen Elizabeth Hospital Birmingham to re-engage with patients lost to follow-up and to engage with local drug users and prison inmates.

Extending DAA regimens
At the beginning of 2016, patients without cirrhosis became eligible for the new all-oral DAA regimens, except for genotype 3 patients, which led to many becoming disengaged from health services and lost to follow-up.

Finally, in February 2017, NHSE made DAA regimens available to all patients infected with HCV, regardless of genotype or liver fibrosis staging. The number of patients to treat in 2017/18 was increased by a quarter, with a corresponding increase in funding for the drugs, so 12,500 patients could be treated with an excellent chance of cure (Vine et al, 2015). The primary aim was to continue engaging with patients, particularly those without cirrhosis who could now be offered an all-oral treatment regimen (NHSE, 2016b).

Removing the Barriers from the Path to Eliminate Hepatitis C


Overcoming Barriers to Eliminate Hepatitis C

Happy Friday folks, hope you have some great plans for the upcoming holiday weekend!

If you get a chance check out this special issue on HCV elimination published in the June issue of Infectious Disease Clinics Of North America.

For your reading pleasure a few open access articles: 

Removing the Barriers from the Path to Eliminate Hepatitis C
Camilla S. Graham, Stacey B. Trooskin
Published in issue: June 2018

New Treatments Have Changed the Game: Hepatitis C Treatment in Primary Care
Shelley N. Facente, Katie Burk, Kelly Eagen, Elise S. Mara, Aaron A. Smith, Colleen S. Lynch
p313–322
Published in issue: June 2018

Hepatitis C Virus Diagnosis and the Holy Grail
Tanya L. Applegate, Emmanuel Fajardo, Jilian A. Sacks
p425–445
Published in issue: June 2018

Begin here.....

Thursday, May 24, 2018

Localized US Efforts to Eliminate Hepatitis C

Localized US Efforts to Eliminate Hepatitis C
https://doi.org/10.1016/j.idc.2018.02.009 

The following full-text article is available for download, shared by Henry E. Chang via twitter

Download Full Article:
https://jumpshare.com/v/3435iY7I8aaJIxv9Nk3w

Elimination of Hepatitis C Virus in Australia: Laying the Foundation

The following full-text article is available for download, shared by Henry E. Chang via twitter

Elimination of Hepatitis C Virus in Australia: Laying the Foundation
Gregory J. Dore BSc, MBBS, MPH, FRACP, PhD Behzad Hajarizadeh MD, MPH, PhD

https://doi.org/10.1016/j.idc.2018.02.006

INTRODUCTION
The development of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection is one of the great advances in clinical medicine in recent decades. Involving simple (once daily oral dosing), tolerable, short duration (8–12weeks), and highly efficacious (cure rates of >95%) regimens, DAA therapy has the potential to markedly increase HCV treatment uptake and turn around the escalating global disease burden associated with chronic HCV infection.1 The transformative nature of DAA therapy underpinned the development of World Health Organization(WHO) goals to eliminate HCV as a public health threat, which include 80% of eligible patients treated, a 65% decrease in HCV-related mortality, and an 80% decrease in new HCV infections by 2030.

KEY POINTS
-Australia has laid the foundation for hepatitis C virus elimination within the next decade.
-Key aspects of this foundation include high levels of screening and diagnosis, unrestricted access to direct-acting antiviral therapy, a diverse range of models of care, and high coverage of harm reduction strategies.
-Key features include government risk-sharing arrangement with the pharmaceutical companies, minimal out-of-pocket cost, no restrictions based on liver disease stage or drug/ alcohol use, prescribing authorization for all registered medical practitioners; and retreatment is allowed.
-Although initial uptake of direct-acting antiviral therapy was high, more efforts are required to continue the momentum.
-An hepatitis C virus elimination monitoring and evaluation program is in progress to inform further strategies required to achieve hepatitis C virus elimination targets

Article: https://jumpshare.com/v/Iu5mE4qtidIUDyEpjMz2

Friday, May 18, 2018

New Treatments Have Changed the Game: Hepatitis C Treatment in Primary Care

Infectious Diseases Clinics of North America June 2018 Volume 32, Issue 2, Pages 313–322

New Treatments Have Changed the Game
Shelley N. Facente, Katie Burk, Kelly Eagen, Elise S. Mara, Aaron A. Smith, Colleen S. Lynch

Key Points
• Although direct-acting antiviral regimens have driven up demand for hepatitis C virus (HCV) treatment, only a fraction of HCV-infected individuals are offered treatment within specialty settings.
• In 2016 to 2017, the San Francisco Health Network (SFHN) worked to improve treatment access and better understand barriers still inhibiting SFHN primary care providers from prescribing HCV treatment.
• Through SFHN’s HCV treatment expansion intervention, primary care providers were offered a 4-hour overview training about HCV treatment, an electronic referral system, and a team of HCV champions providing technical assistance within each clinic.
• Among SVHN patients tested for HCV over 3 years, 13.0% were found chronically infected; 578 patients were treated (19.9%), with no statistically significant differences between age, gender, or race/ethnicity of those treated and untreated.
• With minimal financial and time commitments, the SFHN primary care–based HCV treatment initiative resulted in a 3-fold increase in the number of patients treated for HCV in primary care.

Introduction
San Francisco residents are profoundly impacted by the hepatitis C virus (HCV), with approximately 2.5% of the general population seropositive for HCV as of 20151 compared with a national seroprevalence estimate of 1.4% (95% CI, 0.9%–2.0%).2 HCV is a significant driver of morbidity, liver cancer, and death3 and disproportionately has an impact on marginalized populations, including people of color, homeless individuals, people with a history of incarceration, and people who inject drugs.4, 5, 6, 7, 8 The availability of highly effective oral HCV treatment with few side effects, known as direct-acting antivirals (DAAs), makes HCV cure possible in nearly all infected patients.8

In the pre-DAA era, HCV treatments were complex and largely managed by hepatologists, gastroenterologists, and infectious disease physicians. As tolerable and highly effective DAA regimens have driven up demand for treatment, the relative scarcity of these specialists to the large number of infected individuals has created a bottleneck effect, resulting in only a fraction of HCV-infected individuals offered treatment in any given year.9 Even with reasonable capacity in the specialty setting, travel to specialty clinics or even the idea of attending appointments in unfamiliar settings with unfamiliar providers can be a barrier for marginalized populations disproportionately impacted by HCV.10 As treatment courses in the DAA era have become shorter, simplified, and remarkably well tolerated, recent studies have demonstrated the efficacy of treating HCV in high-prevalence primary care settings.11, 12

The San Francisco Health Network (SFHN) is San Francisco’s safety net system of care, and serves the majority of the low-income and homeless populations of San Francisco. The percentage of all active adult SFHN primary care patients who have been diagnosed with HCV is 5.5%. Part of the San Francisco Department of Public Health, the SFHN includes primary care in 10 community-based and 4 hospital-based clinics throughout the city. In 2016, in an effort to increase HCV treatment access for all patients, SFHN leadership committed to training its primary care providers to treat uncomplicated cases of HCV in the primary care setting using a team-based model of care.

In 2017, the primary care–based HCV treatment initiative team at SFHN undertook an analysis to measure the impact of these efforts to improve treatment access within the SFHN primary care system and to better understand barriers still inhibiting SFHN primary care providers from providing HCV treatment to their patients.

Continue to article online:
Download PDF: 
https://www.id.theclinics.com/article/S0891-5520(18)30022-9/pdf

Saturday, March 31, 2018

Strategies for the elimination of HCV infection as a public health threat in the United States

Strategies for the elimination of HCV infection as a public health threat in the United States
Charitha Gowda & Vincent Lo Re III

Full-text shared via Twitter by Henry E. Chang
View PDF
Charitha Gowda
1,2
&
Vincent Lo Re III
2,3,4

Abstract
Purpose of Review Direct-acting antiviral regimens for chronic hepatitis C virus (HCV) infection became available in 2014, and these highly curative therapies have the potential to reduce HCV-associated morbidity and mortality, decrease HCV transmission, and eliminate HCV infection as a public health problem. This review summarizes the recommendations by the National Academies of Sciences, Engineering, and Medicine for a US strategy for HCV elimination.

Recent Findings
To achieve proposed targets of reducing HCV incidence by 90% and decreasing HCV-related mortality by 60% by 2030, there is a critical need to improve HCV diagnosis and linkage to care, reduce HCV-related disease by antiviral treatment scale-up, reduce HCV incidence, and strengthen HCV surveillance to determine achievement of HCV elimination targets over time.

Summary
While HCV elimination is feasible, success of this national effort will require ongoing collaboration and critical resource investment by key stakeholders, including medical and public health communities, legislators, community organizers, and patient advocates



View complete article:
https://jumpshare.com/v/poLU2Wzhg8COI6ACxY5D

Current Hepatology Reports
https://doi.org/10.1007/s11901-018-0394-x

Monday, February 12, 2018

For Viral Hepatitis Elimination One Size Does Not Fit All

A blog about Global Health. An open space for discussing equitable access to health for everyone, everywhere.

For Viral Hepatitis Elimination One Size Does Not Fit All
Jeffrey Lazarus
12 February 2018

“For elimination, one size does not fit all” was a refrain repeated in a number of different ways throughout the presentations and discussions at the European Association for the Study of the Liver (EASL) Monothematic conference on “Striving towards the elimination of HCV infection” that has just come to a close in Berlin.

Whether in discussions about prevention, interventions in drug users, improving linkage to care, or treatment itself, attendees agreed that there is no golden ticket for hepatitis C elimination. However, there are a number of evidence-based strategies for impact that were presented very effectively by over 30 speakers in the six thematic panel sessions.


Links

Mortality Benefit of Successful Anti-HCV DAA Therapy in Patients Without Advanced Liver Disease

NEJM Journal Watch
February 9, 2018
Mortality Benefit of Successful Anti-HCV DAA Therapy in Patients Without Advanced Liver Disease 
Atif Zaman, MD, MPH reviewing Backus LI et al. Hepatology 2018 Jan 29.

Compelling evidence supports elimination of insurers' restrictions on providing direct-acting antiviral therapy to these patients.

Although direct-acting antiviral (DAA) regimens are effective in eradicating hepatitis C virus (HCV), their effect on long-term survival is unclear. Early studies in the interferon-based treatment era noted improved survival among HCV patients with advanced fibrosis, but studies in those with milder fibrosis are lacking.

In an observational cohort analysis, researchers assessed mortality in over 40,000 patients of Veterans Affairs facilities who received all-oral DAA therapy for genotype 1, 2, or 3 HCV infection and did not have advanced liver disease (FIB-4 score ≤3.25 and no evidence of overt compensated or decompensated cirrhosis or hepatocellular carcinoma).

In patients who achieved sustained virologic response (SVR; rate, 97%), the mortality rate (1.2 deaths/100 patient-years) was significantly lower compared with nonresponders (2.8) and some 60,000 untreated patients (3.8). In subgroup analyses by FIB-4 score, responders with a FIB-4 score <1.45 had mortality reductions of 46% and 67% compared with nonresponders and untreated patients, respectively, and those with a FIB-4 score of 1.45 to <3.25 had mortality reductions of 63% and 71% compared with those respective groups. In multivariate analysis, SVR was independently associated with reduced risk for death.

Comment
This is the most direct and compelling evidence showing that DAA treatment in HCV-infected patients who have early fibrosis/nonadvanced liver disease improves overall survival. Strengths of this study include a large sample size, a well-defined population, and the fact that all patients were offered HCV treatment. These results should be enough evidence to lift restrictions imposed by public and private payers who base treatment candidacy on degree of liver fibrosis.

Citation(s):
Backus LI et al. Direct-acting antiviral sustained virologic response: Impact on mortality in patients without advanced liver disease. Hepatology 2018 Jan 29; [e-pub]. (https://doi.org/10.1002/hep.29811)

Tuesday, February 6, 2018

Podcast - Referring, and Managing Patients with HCV

Consultant360.com

Published - January 26, 2018
Dr. Jorge Herrera, director of the Section of Hepatology and professor of Internal Medicine at the University of South Alabama, discusses screening, referring, and managing patients with hepatitis C virus.

Overview
Hepatitis C Risk Factors
Testing
Primary Care Physicians Treating HCV
Referral Process
Drug interactions
Define Cure
Treat Early
Quality of life after SVR
Treat All




Find more hepatitis-related content at our specialty site here.

Ethnic disparities evaporate with DAA treatment of hepatitis C infections

Hepatology,  Resource Center

Ethnic disparities evaporate with DAA treatment of hepatitis C infections
Mark Fuerst
Early diagnosis and treatment of hepatitis C virus (HCV) infections can prevent liver cancer and end-stage liver disease even in high-risk ethnic minorities, according to a new study.

There is a well-known ethnic disparity in the U.S. among HCV patients, with a higher risk of cancer, cirrhosis and long-term outcomes among Hispanic and Asian patients as compared to Caucasians. In the interferon era, studies showed Asians had the lowest rate of treatment, and African Americans and Hispanics were also less likely to receive care than Caucasians.

Wednesday, January 17, 2018

Treating Chronic Hepatitis C Infection: A Call to Action for Primary Care Providers

Experts And Viewpoints, January 2018
Treating Chronic Hepatitis C Infection in Primary Care
New treatment guidelines aim to support primary care clinicians in the treatment of hepatitis C infection. 

COMMENTARY
Treating Chronic Hepatitis C Infection: A Call to Action for Primary Care Providers

Christine A. Kerr, MD; Josh S. Aron, MD
January 17, 2018

Despite a revolutionary opportunity to end the global HCV epidemic, there clearly is a need for a concerted effort to help many more people benefit from curative therapy. It is evident that we, as healthcare providers, must step up our efforts to reach and treat patients who can benefit from DAA therapy. Only 9% of the 4 million Americans living with HCV have been successfully treated.


Thursday, January 4, 2018

How Injection Drug Use Affects HCV Treatment

Clinical Care Options
How Injection Drug Use Affects HCV Treatment
Norah Terrault MD, MPH - 1/3/2018
Here’s my take on why colocalization of HCV treatment with other medical and social services may be ideal for persons who inject drugs.

In this viral hepatitis case series, we highlight common patient case scenarios and the critical decision making that informs selection of optimal patient management strategies. This commentary features a young woman recently diagnosed with HCV infection after initiating medication-assisted treatment for heroin use. Key considerations for her care are discussed, including how former injection drug use affects her candidacy for HCV treatment.
Free registration required

Wednesday, January 3, 2018

Improvements in Quality of Life: A New Hepatitis C Virus Treatment Indication in Persons with Substance Use Disorders

Accepted Manuscript
The Journal of Infectious Diseases, jix682, https://doi.org/10.1093/infdis/jix682
Published: 26 December 2017

Editorial
Improvements in Quality of Life: A New Hepatitis C Virus Treatment Indication in Persons with Substance Use Disorders
Ponni V Perumalswami, MD Andrew H Talal, MD, MPH

Globally, hepatitis C virus (HCV) infection occurs in an estimated 52% of the 15 million injection drugs users (IDUs) between 15 and 64 years (1). In the United States (US), HCV prevalence estimates range from 43% to 95% of the 6.6 million IDUs (2-4). Recent increases in opioid use have had unintended consequences, a 294% increase in HCV incidence in the US between 2010 and 2015 (5). HCV infection demographics have also shifted with increases in those 30 years or younger who reside in rural areas (6). Elimination of HCV infection has been prioritized in persons with substance use disorders (PWSUD) with the recent development of a national HCV elimination strategy (7). Many challenges, unfortunately, remain toward achieving this goal including insurance coverage restrictions, limited availability of harm reduction services, restrictive HCV medication policies, and low rates of engagement by PWSUD into HCV screening and linkage-to-care....

Full Article : PDF available for download 

Wednesday, December 13, 2017

Access to hepatitis C treatment for patients in drug substitution programmes: the fight is far from over

Viewpoint
Access to hepatitis C treatment for patients in drug substitution programmes: the fight is far from over
Francesco Negro, Liudmyla Maistat
DOI: 10.4414/smw.2017.14570
Swiss Med Wkly. 2017;147:w14570

Hepatitis C virus (HCV) is a parenterally transmitted human pathogen of global concern. Chronic HCV infection is associated with progressive liver disease culminating in an estimated yearly toll of around 400 000 deaths, mostly due to liver failure and hepatocellular carcinoma. Thus, in 2016, the World Health Organization issued a declaration aiming at the elimination of viral hepatitis as a global public health threat by 2030 [1]. Six indicators were identified to measure the progress in this ambitious effort: infant vaccination against hepatitis B virus (HBV), prevention of mother-to-child transmission of HBV by birth dose vaccination, blood and injection safety, harm reduction measures for people who inject drugs (PWID), identification of infected patients by means of appropriate screening strategies, and treatment of patients with potent antivirals.

Full Text
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Thursday, November 2, 2017

Estimation of Direct Medical Costs Related to Chronic Hepatitis C: A Rationale for Early Antiviral Therapy

Gut and Liver 2017; 11(6): 745-746

Editorial
Estimation of Direct Medical Costs Related to Chronic Hepatitis C: A Rationale for Early Antiviral Therapy
Do Young Kim Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

See “Healthcare Costs for Chronic Hepatitis C in South Korea from 2009 to 2013: An Analysis of the National Health Insurance Claims’ Data” by Moran Ki, et al. on page 835, Vol. 11. No. 6, 2017

In medicine, cost-of-illness studies play a role as they might be used as references for resource allocation, development of policy, and for determination of the cost-effectiveness of new therapies.1 Chronic hepatitis C (CHC) is a serious worldwide health-related burden, and recent development and introduction of direct-acting antivirals (DAAs) for CHC has made a substantial push toward looking the disease from the economic point of view.2 Economic impact of CHC and its management can be evaluated by two different approaches. The first is cost-of illness study, where only immediate costs of treatment for CHC are considered. Whereas, cost-effectiveness study usually needs more assumptions and should include clinical outcomes such as disease related morbidity or mortality. Thus, cost-of-illness studies may provide actual and fundamental data to properly conduct cost-effectiveness studies.

Various methodologies in the area of health economy can be applied to cost-of-illness studies, each having its own advantages and disadvantages. Furthermore, because of divergence in healthcare system and reimbursement policy, it is almost impossible to compare directly the costs incurred by a disease among countries. It is also noteworthy that many of the studies estimate only direct costs related to the disease, excluding indirect costs such as loss of productive job and transportation fees due to absent or incorrect data.3

Cost-estimation studies related to CHC have not been presented in Asian region, even though such countries as Japan and Taiwan have a high prevalence of hepatitis C virus (HCV) infection. In this regard, the article by Ki et al .4 in this issue might be relevant, which examined the annual per-patient costs for CHC, cirrhosis and hepatocellular carcinoma (HCC) using Korean public data. The National Health Insurance (NHI) and Health Insurance Review and Assessment (HIRA) claim data between 2009 and 2013 were the sources for the investigation. Indeed, the NHI in South Korea is an unique healthcare system, where both costs incurred by inpatient and outpatient care are co-paid by government and patient himself, leaving some items such as practices, drugs and devices still nonreimbursed. The merit of including all the people in Korean national insurance system pushed the ex-president of the U.S., Mr. Obama, to revolve U.S. healthcare system and to make “Patient Protection and Affordable Care Act,” the so called “Obama Care.” In real practice, however, Korean NHI system has produced lots of abnormal and deviated medical practices due to limited resources, budget and non-optimal insurance costs given to the physicians. Anyhow, the national universal insurance system enabled the authors to perform a comprehensive and uniform cost-of-illness study regarding HCV infection, encompassing all the disease states from hepatitis to HCC, and all the classes of hospitals from private clinic to tertiary university hospital.

In the article of Ki et al .,4 a total of 181,768 patients were identified during the study period, and the direct annual per patient medical costs, which were calculated by prevalence based approach, increased from CHC to cirrhosis, HCC and the first year post-liver transplantation; 895, 1,873, 6,945, and 67,359 USD, respectively. As expected, the direct medical costs increased with progression of CHC, because complications of cirrhosis such as ascites, variceal bleeding or HCC required hospitalization and resource utilization. Increasing direct medical costs per patient with more advanced CHC-related disease were also shown in a previous Korean study, where cost data on 445 CHC patients from eight institutions were retrospectively reviewed and the monthly direct costs per patient in CHC, compensated cirrhosis and HCC were estimated to be 77, 98, and 504 USD, respectively.5 Thus, annual costs per patient in each disease state are calculated to be 924, 1,176, and 6,048 USD, respectively, which are similar to the estimates in Ki’s study.

The number of patients who received antiviral therapy with interferon (or pegylated interferon) and/or ribavirin at least once was 25,223 accounting for 13.9% of all the patients between 2009 and 2013. Interestingly, the costs per patient during the study period were 19,743 USD in those who underwent antiviral therapy, while the costs in those who did not undergo antiviral therapy were 3,126 USD. A substantial proportion (78.5%) of costs in patients who received antiviral therapy was incurred by drugs including pegylated interferon. However, 37.2% of the total costs were incurred by drugs other than antiviral agents in those who did not undergo antiviral therapy. What should be kept in mind is that cost-of-illness study just estimates immediate costs, and it might be addressed by another kind of cost study whether antiviral treatment-related high costs could lower overall costs in long-term outcomes.

The authors in their study highlighted low rates of anti-HCV treatment uptake (13.9%) over 5-year period. Though these figures might underestimate the real rates of treatment because some patients had already underwent antiviral therapy before the study period, indeed a significant proportion of CHC patients did not received therapy in the interferon era due to various reasons including advanced liver fibrosis, old age and fear of adverse events. Additional finding related to antiviral therapy is that 1,471 patients received ribavirin monotherapy without interferon or pegylated interferon, which is not a recommended regimen. There is a need of advertisement and education on the proper anti-HCV regimen for physicians in the community utilizing this analysis.

Claim data have its own limitations, resulting in inaccuracy and ambiguity. As the authors stated, it may be argued whether diagnosis of CHC, cirrhosis and HCC was accurately made with ICD-10 codes. Unfortunately, the costs related to management of decompensated cirrhosis were not separately estimated due to this limitation. Exclusion of non-reimbursed costs from the estimation, and the possibility of including costs incurred by comorbidities not by CHC itself are also disadvantages.

It has been apparent that healthcare costs increase if CHC related diseases are not properly controlled. Overall, the increase of costs per person for HCC seems to be greater compared to CHC or cirrhosis; from 5,838 to 6,945 USD in HCC versus from 1,470 to 1,873 USD in cirrhosis versus from 813 to 895 USD in CHC (from 2009 to 2013). Therefore, the issue of whether stopping progression of disease with DAAs could decrease healthcare costs needs to be further studied using these data.

https://www.ncbi.nlm.nih.gov/pubmed/29081211?dopt=Abstract

CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.

REFERENCES
1. El Khoury AC, Wallace C, Klimack WK, Razavi H. Economic burden of hepatitis C-associated diseases: Europe, Asia Pacific, and the Americas. J Med Econ 2012;15:887-896. 2. Jeong SH, Jang ES, Choi HY, Kim KA, Chung W, Ki M. Current status of hepatitis C virus infection and countermeasures in South Korea. Epidemiol Health 2017;39:e2017017. 3. Rein DB, Borton J, Liffmann DK, Wittenborn JS. The burden of hepatitis C to the United States Medicare system in 2009: descriptive and economic characteristics. Hepatology 2016;63:11351144. 4. Ki M, Choi HY, Kim KA, Jang ES, Jeong SH. Healthcare costs for chronic hepatitis C in South Korea from 2009 to 2013: an analysis of the National Health Insurance claims’ data. Gut Liver 2017;11:835-842. 5. Kim DY, Yoon KT, Kim W, et al. Estimation of direct medical cost related to the management of chronic hepatitis C and its complications in South Korea. Medicine (Baltimore) 2016;95:e3896.

Monday, October 30, 2017

Modeling cost-effectiveness and health gains of a “universal” versus “prioritized” hepatitis C virus treatment policy in a real-life cohort

In Case You Missed It

Hepatology 2017

Modeling cost-effectiveness and health gains of a “universal” versus “prioritized” hepatitis C virus treatment policy in a real-life cohort
Loreta A. Kondili, Federica Romano, Francesca Romana Rolli, Matteo Ruggeri, Stefano Rosato, Maurizia Rossana Brunetto, Anna Linda Zignego, Alessia Ciancio, Alfredo Di Leo, Giovanni Raimondo,

First published: Full publication history
DOI: 10.1002/hep.29399

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Abstract
We evaluated the cost-effectiveness of two alternative direct-acting antiviral (DAA) treatment policies in a real-life cohort of hepatitis C virus–infected patients: policy 1, “universal,” treat all patients, regardless of fibrosis stage; policy 2, treat only “prioritized” patients, delay treatment of the remaining patients until reaching stage F3. A liver disease progression Markov model, which used a lifetime horizon and health care system perspective, was applied to the PITER cohort (representative of Italian hepatitis C virus–infected patients in care). Specifically, 8,125 patients naive to DAA treatment, without clinical, sociodemographic, or insurance restrictions, were used to evaluate the policies’ cost-effectiveness. The patients’ age and fibrosis stage, assumed DAA treatment cost of €15,000/patient, and the Italian liver disease costs were used to evaluate quality-adjusted life-years (QALY) and incremental cost-effectiveness ratios (ICER) of policy 1 versus policy 2. To generalize the results, a European scenario analysis was performed, resampling the study population, using the mean European country-specific health states costs and mean treatment cost of €30,000. For the Italian base-case analysis, the cost-effective ICER obtained using policy 1 was €8,775/QALY. ICERs remained cost-effective in 94%-97% of the 10,000 probabilistic simulations. For the European treatment scenario the ICER obtained using policy 1 was €19,541.75/QALY. ICER was sensitive to variations in DAA costs, in the utility value of patients in fibrosis stages F0-F3 post–sustained virological response, and in the transition probabilities from F0 to F3. The ICERs decrease with decreasing DAA prices, becoming cost-saving for the base price (€15,000) discounts of at least 75% applied in patients with F0-F2 fibrosis.

Conclusion: Extending hepatitis C virus treatment to patients in any fibrosis stage improves health outcomes and is cost-effective; cost-effectiveness significantly increases when lowering treatment prices in early fibrosis stages. (Hepatology 2017)

Sunday, October 8, 2017

Pathways to the elimination of hepatitis C: prioritising access for all

In Case You Missed It

Journal - Expert Review of Clinical Pharmacology

Editorial
Pathways to the elimination of hepatitis C: prioritising access for all
Alisa E. Pedrana, Rachel Sacks-Davis, Joseph S. Doyle & Margaret E. Hellard

Received 09 Aug 2017, Accepted 20 Sep 2017, Accepted author version posted online: 25 Sep 2017, Published online: 28 Sep 2017

http://dx.doi.org/10.1080/17512433.2017.1383894       

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While momentum for hepatitis C elimination grows, debate continues about the most cost-effective pathway for achieving it. Much of this debate has focused on the prohibitive initial costs of direct-acting antivirals (DAAs) [1,2], which have resulted in treatment prioritization and rationing in many countries [3,4]. While some countries have successfully negotiated reduced DAA prices [5], price remains a significant barrier to scaling up access to treatments, disproportionately affecting low-middle income countries (LMICs) with high prevalence [2,4]. Modeling suggests that if treatment can be scaled to need, hepatitis C prevalence and incidence can be reduced in line with elimination targets. However, recent empirical data [2,4,6] have identified barriers to elimination, including restrictive prescribing patterns, healthcare system limitations, and inadequate national testing programs, preventing adequate treatment scale-up.

As the costs of DAAs decrease [7], other hepatitis C treatment-associated costs, and health systems limitations which have largely been overlooked until now, will become increasingly important considerations for elimination planning. In particular, effective strategies are required to increase access to testing as the necessary entry point to treatment. Routine screening and monitoring is also required to prevent endstage liver disease, reduce the risk of reinfections and prevent new infections. To achieve disease elimination for hepatitis C by 2030 we must prioritize access for all affected people, alongside delivering more integrated and flexible models of care that increase opportunities for testing and treatment across low, middle, and high-prevalence settings.

Continue reading editorial - http://www.tandfonline.com/doi/full/10.1080/17512433.2017.1383894?scroll=top&needAccess=true

Recommended Reading
Lancet
Marshall AD, et al. Lancet Gastroenterol Hepatol. 2017
http://dx.doi.org/10.1016/S2468-1253(17)30284-4
Published: 03 October 2017
Restrictions for reimbursement of interferon-free direct-acting antiviral drugs for HCV infection in Europe
All-oral direct-acting antiviral drugs (DAAs) for hepatitis C virus, which have response rates of 95% or more, represent a major clinical advance. However, the high list price of DAAs has led many governments to restrict their reimbursement. We reviewed the availability of, and national criteria for, interferon-free DAA reimbursement among countries in the European Union and European Economic Area, and Switzerland. Reimbursement documentation was reviewed between Nov 18, 2016, and Aug 1, 2017. Primary outcomes were fibrosis stage, drug or alcohol use, prescriber type, and HIV co-infection restrictions. Among the 35 European countries and jurisdictions included, the most commonly reimbursed DAA was ombitasvir, paritaprevir, and ritonavir, with dasabuvir, and with or without ribavirin (33 [94%] countries and jurisdictions). 16 (46%) countries and jurisdictions required patients to have fibrosis at stage F2 or higher, 29 (83%) had no listed restrictions based on drug or alcohol use, 33 (94%) required a specialist prescriber, and 34 (97%) had no additional restrictions for people co-infected with HIV and hepatitis C virus. These findings have implications for meeting WHO targets, with evidence of some countries not following the 2016 hepatitis C virus treatment guidelines by the European Association for the Study of Liver.
Continue to article online....
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IDWeek 2017 Coverage - Brianna Norton, DO: Hepatitis C Treatment



Brianna Norton, DO: Hepatitis C Treatment
OCTOBER 07, 2017
Jenna Payesko
I think that really the majority the core of the Hep C epidemic is among people who use drugs. For a long time, the largest population was baby boomers and now because of the expanding opioid epidemic in the US there's actually a lot of younger people who are acquiring Hep C...


Conference News 
MD Magazine 
Oct 4 - 8

NATAP Conference Coverage - ID Week
ID Week San Diego CA
October 4-8, 2017
Barriers to Hepatitis C Treatment in HIV co-infected Patients in the Era of New Direct-Acting Antiviral Therapy (Philadelphia): Just Over Half With HCV/HIV at Academic Center Get DAAs for HCV
Just over 50% of HCV/HIV-coinfected people in care at a Philadelphia academic center got treated for HCV with direct-acting antivirals (DAAs) in 2016 [1]. A detectable HIV load and substance abuse emerged as apparent barriers to DAA therapy.
View coverage - http://www.natap.org/2017/IDWeek/IDWeek.htm

Wednesday, September 27, 2017

Barriers to hepatitis C treatment in the era of direct-acting anti-viral agents

Barriers to hepatitis C treatment in the era of direct-acting anti-viral agents
Article Summary @ GastroHep
Reasons for lack of treatment included waiting for newer therapy, co-morbidities and alcohol/drug abuse. Dr Kanwal's team comments, "Half of patients with established HCV care were followed-up in the direct-acting anti-virals era and only 29% received DAAs."

Alimentary Pharmacology & Therapeutics
ORIGINAL ARTICLE

Full Text Article:  Available Online

Barriers to hepatitis C treatment in the era of direct-acting anti-viral agents
Authors M. Lin, J. Kramer, D. White, Y. Cao, S. Tavakoli-Tabasi, S. Madu, D. Smith, S. M. Asch, H. B. El-Serag, F. Kanwal

First published: 26 September 2017
DOI: 10.1111/apt.14328

Summary
Background
Direct-acting anti-virals (DAA) are safe, effective treatment of hepatitis C virus (HCV). Suboptimal linkage to specialists and access to DAAs are the leading barriers to treatment; however, data are limited.

Aim
To determine predictors of follow-up, receipt of DAAs, and reasons for the lack thereof.

Methods
We used clinical data from retrospective cohort of HCV-infected patients with previously established HCV care in the US Department of Veterans Affairs to examine predictors of follow-up in HCV clinics and DAA treatment (during 12/1/2013-4/30/2015). We then conducted a structured review of medical charts of HCV patients to determine reasons for lack of follow-up and treatment.

Results
We identified 84 221 veterans who were previously seen in HCV clinics during the pre-DAA era. Of these, 47 165 (56.0%) followed-up in HCV specialty clinics, 13 532 (28.7%) of whom received DAAs. Older age, prior treatment, presence of cirrhosis or HCC, HIV/HBV co-infection and psychiatric illness were predictors of follow-up. Alcohol/drug abuse and medical co-morbidity were predictors of lack of treatment. Of the 905 prospectively recruited patients, 56.2% patients had a specialist visit and 28% received DAAs. Common reasons for lack of follow-up were relocation (n = 148, 37.4%) and missed/cancelled appointments (n = 63, 15.9%). Reasons for lack of treatment included waiting for newer therapy (n = 99, 38.8%), co-morbidities (n = 66, 25.9%) and alcohol/drug abuse (n = 63, 24.7%).

Conclusions
Half of patients with established HCV care were followed-up in the DAA era and only 29% received DAAs. Targeted efforts focusing on patient and system-levels may improve the reach of treatment with the new DAAs.

Wednesday, September 6, 2017

People who use drugs require prioritization, not exclusion, in HCV elimination

People who use drugs require prioritization, not exclusion, in HCV elimination

Global health experts are today are calling for the removal of restrictions preventing people who use drugs from accessing new hepatitis C cures. So long as these restrictions exist, the goal of disease elimination will remain out of reach, they say.

They are gathered in Oslo for the 5th International Symposium on Hepatitis Care in Substance Users, where new research continues to highlight not just the pivotal role treatment for people who use drugs plays in reducing hepatitis C transmission, but also how it can be rolled out to achieve best results.

"The science is clear. We now need to focus on overcoming barriers to access, and harness latest research to implement programs that work," said President of the International Network of Hepatitis C in Substance Users (INHSU), Associate Professor Jason Grebely, the Kirby Institute, UNSW Australia.

"To delay further is unethical and undermines public health," he added.

Hepatitis C—which if left untreated can lead to cirrhosis and liver cancer—affects approximately 64-103 million people around the world, resulting in around 700 000 deaths per year. In countries such as the US and Australia, hepatitis C now kills more people than HIV. In the UK, the number of annual deaths due to hepatitis C has quadrupled since 1996.

New, highly effective curative treatments have sparked hope of a world free of hepatitis C. The World Health Organisation (WHO) has set ambitious elimination targets of 90% diagnosed, 80% treated and a 65% reduction in hepatitis C-related mortality by 2030. In most high income countries, the vast majority (80%) of new infections are in people who inject drugs, but this group has faced widespread exclusion from the new therapies.

Reasons given for this exclusion include the price of new medications, fears of poor adherence, fears of reinfection and concerns over efficacy. However, international research debunks these myths.

The world's largest study of new hepatitis c curative therapies – the C-EDGE CO-STAR Clinical Trial – has now found that illicit drug use prior to and during hepatitis C therapy had no impact on the effectiveness of the therapy, and that reinfection is low, at 4%. The results also showed excellent treatment adherence. Cure rates were comparable to results in hepatitis C populations that exclude people who use drugs.

Further, mathematical modelling suggests that even moderate levels of treatment uptake in people who use drugs could offer considerable prevention benefits.

One study looking at settings in Scotland, Australia and Canada indicated a 3-5 fold increase in treatment uptake among people who inject drugs could halve hepatitis C prevalence in 15 years.

Other studies modelled on people who inject drugs in the UK and France concluded realistic treatment scale-up could achieve 15-50% reduction in chronic hepatitis C prevalence in a decade.

To add to the benefits, treating people who use drugs with moderate or mild hepatitis C with new therapies is cost-effective in most settings compared to delaying until cirrhosis.

Several countries have introduced hepatitis C elimination programs, with Australia, France and Iceland offering unrestricted access. All eyes are now turned on Australia, where over 20 000 people (10% of the chronic HCV population) have initiated treatment in the first four months since subsidised treatment has become available.

"Countries such as Australia and France have taken the lead in adopting evidence-based policies that will save lives. Now it's time for other countries, including the US and Norway, to follow their lead and allow all patients with chronic hepatitis C to be treated with the new drugs," said Professor Olav Dalgard, Chair of the INSHU 2016 Symposium.

"We strongly recommend that all restrictions on access to new hepatitis C treatments based on drug or alcohol use or opioid substitution treatment be removed. There is no good ethical or health based evidence for such discriminations. Nor do the restrictions make clinical, public health or health economic sense," he said.

"Providing treatment to people who inject drugs, integrated with harm reduction programs and linkage to care, is the key to hepatitis C program success. And our experience in Copenhagen shows this can work. Such efforts need to be initiated and scaled up globally," added Professor Jeffrey Lazarus, Centre for Health and Infectious Disease Research, Rigshospitalet, University of Copenhagen, Denmark, who is presenting at the Symposium.