Hepatitis C among intravenous drug users in upper middle-income countries.

Estimating the prevalence of hepatitis C among intravenous drug users in upper middle income countries: A systematic review and meta-analysis
Víctor Granados-García , Yvonne N. Flores, Lizbeth I. Díaz-Trejo, Lucia Méndez-Sánchez, Stephanie Liu, Guillermo Salinas-Escudero, Filiberto Toledano-Toledano, Jorge Salmerón

Published: February 26, 2019

https://doi.org/10.1371/journal.pone.0212558 

Abstract

Aim
This systematic review and meta-analysis characterizes the prevalence of hepatitis C virus (HCV) infection among intravenous drug users (IDUs) in upper middle-income countries.

Methods
Five databases were searched from 1990–2016 for studies that took place in countries with a GDP per capita of $7,000 to $13,000 USD. The data extraction was performed based on information regarding prevalence, sample size, age of participants, duration of intravenous drug use (IDU), recruitment location, dates of data collection, study design, sampling scheme, type of tests used in identifying antibody reactivity to HCV, and the use of confirmatory tests. The synthesis was performed with a random effects model. The Cochrane statistical Q-test was used to evaluate the statistical heterogeneity of the results.

Results
The 33 studies included in the analysis correspond to a sample of seven countries and 23,342 observations. The point prevalence value estimates and confidence intervals of the random effects model were 0.729 and 0.644–0.800, respectively for all seven countries, and were greatest for China (0.633; 0.522–0.732) as compared to Brazil (0.396; 0.249–0.564). Prevalence for Montenegro (0.416; 0.237–0.621) and Malaysia (0.475; 0.177–0.792) appear to be intermediate. Mexico (0.960) and Mauritania (0.973) had only one study with the largest prevalence. A clear association was not observed between age or duration of IDU and prevalence of HCV, but the data from some groups may indicate a possible relationship. The measures of heterogeneity (Q and I2) suggest a high level of heterogeneity in studies conducted at the country level and by groups of countries.

Conclusions

In this systematic review and meta-analysis, we found that the pooled prevalence of HCV was high (0.729) among a group of seven upper middle income countries. However, there was significant variation in the prevalence of HCV observed in China (0.633) and Brazil (0.396). 

Full-text available online:

 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212558

HCV reinfection as a positive indication of high‐risk population treatment access

Recommended Reading
High response and re-infection rates among people who inject drugs treated for hepatitis C in a community needle and syringe programme
We show that it is feasible to recruit people who inject drugs(PWID) from a community-basedneedle and syringe programme (NSP) onto HCV treatment, and achieve over 80% SVR-12 andimpressive treatment adherence.

Commentary
HCV reinfection as a positive indication of high‐risk population treatment access

Gregory J Dore

First published: 25 February 2019
https://doi.org/10.1111/jvh.13092

Strategies to address HCV reinfection and limit its overall impact on HCV elimination are required, but the most important of these is ongoing engagement with high- risk individuals to enable detection of HCV reinfection and its retreatment without stigma and discrimination.

Download full-text article:

https://jumpshare.com/v/e6nm2pXcbAWHvAV3jKSr 

Article shared via Twitter by Henry E. Chang‏.

Mavyret - Safety and efficacy in patients receiving opioid substitution therapy/HCV genotypes 1-6

Int J Drug Policy. 2019 Feb 5;66:73-79. doi: 10.1016/j.drugpo.2019.01.011. [Epub ahead of print]

Safety and efficacy of glecaprevir/pibrentasvir in patients with chronic hepatitis C genotypes 1-6 receiving opioid substitution therapy.
Grebely J1, Dore GJ2, Alami NN3, Conway B4, Dillon JF5, Gschwantler M6, Felizarta F7, Hézode C8, Tomasiewicz K9, Fredrick LM3, Dumas EO3, Mensa FJ3.

Open Access

Full Text Online

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Abstract
BACKGROUND:

International guidelines recommend treatment of hepatitis C virus (HCV) infection in people who inject drugs (PWID), including those on opioid substitution therapy (OST). The pangenotypic combination of glecaprevir and pibrentasvir has shown high sustained virologic response at post-treatment Week 12 (SVR12) in clinical trials. Herein, we evaluate the safety and efficacy of glecaprevir/pibrentasvir in patients receiving OST.

METHODS:

Pooled data from patients with HCV genotypes 1-6 who were treated with glecaprevir/pibrentasvir for 8, 12, or 16 weeks in eight Phase 2 and 3 trials were categorized by use of OST. Treatment completion, treatment adherence, SVR12, adverse events (AEs), and laboratory abnormalities were evaluated for patients receiving and not receiving OST.

RESULTS:

Among 2256 patients, 157 (7%) were receiving OST. Compared with patients not receiving OST, OST patients were younger (mean age, 46.8 vs 52.8 years), male (69% vs 54%), white (93% vs 80%), HCV treatment-naïve (86% vs 72%), had HCV genotype 3 (60% vs 26%), and had a history of depression or bipolar disorder (43% vs 19%). Most patients completed (OST: 98% [n/N = 154/157]; non-OST: 99% [n/N = 2070/2099]) and were adherent (received ≥90% of study drug doses) to glecaprevir/pibrentasvir treatment (OST: 98% [n/N = 121/123]; non-OST: 99% [n/N = 1884/1905] among patients with available data). In the intention-to-treat population, SVR12 rates in OST and non-OST patients were 96.2% (n/N = 151/157; 95% CI 93.2-99.2) and 97.9% (n/N = 2055/2099; 95% CI 97.3-98.5), respectively. For OST patients, reasons for nonresponse included virologic relapse (<1%; n = 1), premature study drug discontinuation (<1%; n = 1), and loss to follow-up (3%; n = 4). AEs occurring in ≥10% of OST patients were headache, fatigue, and nausea. Drug-related serious AEs, AEs leading to study drug discontinuation, and Grade 3 or higher laboratory abnormalities were infrequent in both groups (<1%). No HCV reinfections occurred through post-treatment Week 12.

CONCLUSION:

Glecaprevir/pibrentasvir is highly efficacious and well tolerated in HCV-infected patients receiving OST.

Full-text article available online: https://www.sciencedirect.com/science/article/pii/S0955395919300192?via%3Dihub

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

KEYWORDS: Glecaprevir/pibrentasvir; Hepatitis C virus; Opioid substitution therapy; People who inject drugs

Treat All - Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore

Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore
Oluwaseun Falade-Nwulia, Risha Irvin, Alana Merkow , Mark Sulkowski, Alexander Niculescu, Yngvild Olsen, Kenneth Stoller , David L. Thomas, Carl Latkin, Shruti H. Mehta

Links
Download full-text article
Shared On Twitter: Henry E. Chang 

Highlights

•Most PWID with HCV have not been treated despite existence of effective treatments.
•Only 20% of PWID in Baltimore opioid treatment programs (OTPs) received HCV treatment.
•Recent drug use was identified as a barrier to HCV treatment.
•Peer support and HCV treatment at OTPs were identified as facilitators to HCV treatment.

Abstract
Background
Hepatitis C virus (HCV) infection is a major public health issue among people who inject drugs (PWID) with prevalence of 50–80% in the United States. Effective, simple, oral direct acting agents (DAA) of short duration with minimal side effects have been associated with cure rates > 95%. However, HCV treatment uptake among PWID remains low. We characterized the HCV care continuum, HCV treatment knowledge, as well as barriers and facilitators to HCV treatment uptake among PWID enrolled in two opioid treatment programs (OTPs) in Baltimore, Maryland, USA.

Methods
Between July and November 2016, 124 HCV infected PWID were recruited from two opioid treatment programs in Baltimore through convenience sampling. Participants completed a 50-item questionnaire to assess HCV treatment knowledge, attitudes, and practices. Progress through the HCV care continuum was assessed based on a series of questions assessing evaluation for HCV treatment, recommendation for HCV treatment by a provider, and HCV treatment initiation. HCV status was assessed based on participant self-report.

Results
The median age was 52 years (IQR 44–58), 56% were male, the majority were African American (69%), and 19% reported HIV coinfection. Participants had been tested for HCV at their primary care provider's PCP's office (34%), drug treatment center (20%), emergency room (11%), or prison (9%), and most (60%) had been diagnosed with HCV over 5 years prior. The majority reported that HCV was a major health concern for them (91%), were aware there were new treatments for HCV (89%), and that the new treatments cure most people (69%). More than half (60%) had seen a health professional who could treat HCV, 40% had HCV therapy recommended by their HCV specialist, and 20% had started or completed treatment. In univariable analysis, PWID were significantly more likely to have been treated if they were HIV co-infected (OR 3.4 (95% CI 1.3–9.2)) or had a partner or friend concerned about their HCV (OR 3.4 (95% CI 1.2–9.7)), and were significantly less likely to have been treated if they had used any illicit drugs in the preceding 6 months (OR 0.4 (95% CI 0.2–0.99). In multivariable analysis, having a friend or partner concerned about their HCV remained significantly associated with HCV treatment (OR 5.0 (95% CI 1.4–17.7)). When questioned about what would facilitate HCV treatment, the majority (85%) reported that a friend telling them that HCV treatment had helped them and having HCV treatment provided at their opioid treatment program would make them more likely to engage in HCV treatment.

Conclusion

Despite a high prevalence of HCV among opioid treatment program patients and the availability of effective treatments, uptake remains low. We identified several key barriers and facilitators that can affect HCV treatment uptake.

Download full-text article shared via Henry E. Chang 

HCV requires serious policies and affordable insurance coverage

Of Interest
Q&A: DAA restrictions impact patient care
January 14, 2019

Infectious Disease News spoke with Breskin about why DAAs restrictions were enacted, the current state of treatment denials and how DAA policies should be changed.

Beyond interferon side effects: What residual barriers exist to DAA hepatitis C treatment for people who inject drugs? 

The paper draws on participant interview data from a qualitative research study based on a participatory research design that included a peer researcher with direct experience of both hepatitis C DAA treatment and injecting drug use at all stages of the research process.

The role of insurance providers in supporting treatment and management of hepatitis C patients

Masoud Behzadifar, Hasan Abolghasem Gorji, Aziz Rezapour, Meysam Behzadifar and Nicola Luigi Bragazzi

BMC Health Services Research201919:25
https://doi.org/10.1186/s12913-019-3869-8

Excerpt from the article:
In order to cope with the high costs of the new DAA regimens, some insurers are restricting access to medications, establishing selective criteria for reimbursement. Gowda and collaborators performed a prospective cohort study among American HCV patients (Open Access Published online 2018 Jun 7). Authors found that absolute denials of DAA regimens by insurers have remained high and increased over time.

Received: 24 April 2018
Accepted: 4 January 2019

Published: 10 January 2019

Full-text article
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The role of insurance providers in supporting treatment and management of hepatitis C patients
Abstract
Today, one of the most important global public health challenges is represented by hepatitis C virus (HCV), which imposes relevant costs. Globally speaking, the median cost of HCV-related complications ranges from $280 for an uncomplicated hepatitis to $139,070 for a liver transplantation. There are effective therapies for HCV patients worldwide, which has increased the hope of improving the process of managing and curing these patients. The adherence of patients to the pharmacological treatment and the use of effective drugs in the management of HCV disease are of crucial importance for health policy- and decision-makers. Studies show that, globally, insurance coverage for patients with HCV is not adequate in that still many patients are not covered by insurance programs. This issue as well as the economic conditions of countries are very serious challenges for ensuring an effective treatment. The most important and greatest help currently available to ensure HCV treatment is to implement plans to reduce costs and support patients. Some studies have shown that the expansion of coverage by private payers seems able to generate positive spillover benefits to public insures. Insurers, in addition to maintaining and increasing their own interests, are trying to increase their social status as a sponsor of patients. In conclusion, HCV disease requires serious policies and affordable insurance coverage.

Read the full article: 

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-3869-8

On This Blog
Controversy over the cost of hepatitis C drugs
Link to research and news articles addressing insurance restrictions; private insurers/Medicaid - and -availability of generic versions of hepatitis C medications. 

Low hepatitis C prevalence in Belgium: implications for treatment reimbursement and scale up

Low hepatitis C prevalence in Belgium: implications for treatment reimbursement and scale up Amber Litzroth Email author View ORCID ID profile , Vanessa Suin, Chloé Wyndham-Thomas, Sophie Quoilin, Gaëtan Muyldermans, Thomas Vanwolleghem, Benoît Kabamba-Mukadi, Vera Verburgh, Marjorie Jacques, Steven Van Gucht and Veronik Hutse

BMC Public Health 201919:39
https://doi.org/10.1186/s12889-018-6347-z
© The Author(s). 2019
Received: 21 September 2018
Accepted: 19 December 2018

Published: 8 January 2019

Abstract

Background
Prevalence data of chronic hepatitis C virus (HCV) infection are needed to estimate the budgetary impact of reimbursement of direct-acting antivirals (DAAs). In Belgium, the restricted reimbursement criteria are mainly guided by regional seroprevalence estimates of 0.87% from 1993 to 1994. In this first Belgian nationwide HCV prevalence study, we set out to update the seroprevalence and prevalence of chronic HCV infection estimates in the Belgian general population in order to guide decisions on DAA reimbursement.

Methods
Residual sera were collected through clinical laboratories. We collected data on age, sex and district. HCV antibody status was determined with ELISA and confirmed with a line-immunoassay (LIA). In specimens with undetermined or positive LIA result, HCV viral load was measured. Specimens were classified seronegative, seropositive with resolved infection, indicative of chronic infection and with undetermined HCV status according to the test outcomes. Results were standardized for age, sex and population per district, and adjusted for clustered sampling.

Results
In total 3209 specimens, collected by 28 laboratories, were tested. HCV seropositivity in the Belgian general population was estimated to be 0.22% (95% CI: 0.09–0.54%), and prevalence of chronic HCV infection 0.12% (95% CI: 0.03–0.41). In individuals of 20 years and older, these estimates were 0.26% (95% CI: 0.10–0.64%) and 0.13% (95% CI: 0.04–0.43), respectively. Of the total estimated number of HCV seropositive individuals in Belgium, 66% were between 50 and 69 years old.

Conclusions

Prevalence of HCV seropositivity and chronic infection in the Belgian general population were low and comparable to many surrounding countries. These adjusted prevalences can help estimate the cost of reimbursement of DAAs and invite Belgian policy makers to accelerate the scaling up of reimbursement, giving all chronically infected HCV patients a more timely access to treatment.

Full-text available online:

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6347-z

Beyond interferon side effects: What residual barriers exist to DAA hepatitis C treatment for people who inject drugs?

Beyond interferon side effects: What residual barriers exist to DAA hepatitis C treatment for people who inject drugs? 
Annie Madden, Max Hopwood, Joanne Neale, Carla Treloar
Published: November 30, 2018 https://doi.org/10.1371/journal.pone.0207226

Abstract
Recent advances in the efficacy and tolerability of hepatitis C treatments and the introduction of a universal access scheme for the new Direct Acting Antiviral (DAA) therapies in March 2016, has resulted in a rapid increase in the uptake of hepatitis C treatment in Australia. Despite these positive developments, recent data suggest a plateauing of treatment numbers, indicating that more work may need to be done to identify and address ongoing barriers to hepatitis C treatment access and uptake. This paper aims to contribute to our understanding of the ongoing barriers to DAA therapies, with a focus on people who inject drugs. The paper draws on participant interview data from a qualitative research study based on a participatory research design that included a peer researcher with direct experience of both hepatitis C DAA treatment and injecting drug use at all stages of the research process. The study’s findings show that residual barriers to DAA treatment exist at personal, provider and system levels and include poor venous access, DAA treatments not considered ‘core-business’ by opioid substitution treatment (OST) providers, and patients having to manage multiple health and social priorities that interfere with keeping medical appointments such as childcare and poor access to transport services. Further, efforts to increase access to and uptake of DAA hepatitis C treatment over time will require a focus on reducing stigma and discrimination towards people who inject drugs as this remains as a major barrier to care for many people.

Links:
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Australian experience shows high DAA uptake and rapid fall in rates of HCV viraemia among people who inject drugs

Australian experience shows high DAA uptake and rapid fall in rates of HCV viraemia among people who inject drugs

Michael Carter

Published: 28 November 2018

Providing hepatitis C virus (HCV) therapy with direct-acting antivirals (DAAs) to people who inject drugs can achieve rapid reductions in community prevalence of viraemia, according to Australian research published in the Journal of Hepatology. Uptake of HCV treatment increased from 10% to 41% after unrestricted access to DAAs was rolled out in March 2016, and the proportion of viraemic patients fell from 43% to 25%.

The authors believe their findings have significance for the World Health Organization (WHO) target of eliminating HCV as a public health threat by 2030.

Read More:

http://www.aidsmap.com/page/3394458/

In a Critical State: Ongoing Barriers to Treatment for Hepatitis C Virus (HCV)

Editorial

In a Critical State: Ongoing Barriers to Treatment for Hepatitis C Virus (HCV)

Jorge Mera, MD, Brigg Reilley, MPH, Jessica Leston, David Stephens, RN

DOI: https://doi.org/10.1016/j.amjmed.2018.10.031

The American Journal of Medicine

Publication History

Published online: November 24, 2018

Abstract 

Recent advances in Hepatitis C Virus HCV treatment could be described as revolutionary: for uncomplicated patients, treatment is nearly 100% effective, oral-only, has a low pill burden, minimal side effects, and results in a cure.1 Comparisons we have heard from clinicians are that HCV is now easier to treat than either diabetes or hypertension. Unfortunately for many patients, their state of residence is the decisive factor for whether they will receive lifesaving treatment. As part of a tribal telehealth network for HCV, we support several rural clinics successfully treating HCV and see this dilemma all too frequently.

Consider a patient with chronic HCV infection who presents with a recent history of marijuana use and has been late picking up hypertension medication. The patient has cirrhosis and is at high risk of HCV related mortality. He is enrolled in state Medicaid and highly motivated for treatment. What is the treatment plan? It depends on the state. A resident of New Mexico can start treatment without delay. If instead the patient lives in Montana, a state that determines treatment eligibility based on advanced liver fibrosis, documented sobriety, and compliance with existing medications, the consultation is effectively moot; treatment will be denied. Montana is far from alone in its HCV treatment restrictions. Patients in South Dakota, Oregon, and several other states we serve face similar hurdles …

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https://www.amjmed.com/action/showFullTextImages?pii=S0002-9343%2818%2931072-6

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https://www.amjmed.com/article/S0002-9343(18)31072-6/pdf

Current Issue
November 2018
Volume 131, Issue 11 

HCV Re-infection in People with High-risk Behavior Low

AGA Reading Room 

11.15.2018 

HCV Re-infection in People with High-risk Behavior Low

Widespread treatment should be offered to people who inject drugs

by Pippa Wysong

Contributing Writer, MedPage Today 

The overall number of people re-infected with hepatitis C (HCV) after successful treatment with direct-acting agents (DAAs) was small in a large population-based study from Canada, providing more evidence to offer widespread treatment to high-risk populations.

But the key to eliminating HCV is to get treatment to HCV-infected people who have high-risk behaviors quickly to reduce the number of people living with infection. This in turn would reduce the passing on of the disease to others who have cleared the virus from treatment, said Naveed Janjua, PhD, senior scientist with the British Columbia Centre for Disease Control.

In fact, the study, published in the Journal of Hepatology, found evidence that people who inject drugs (PWID) who continued to use opiate agonist therapy after successful cure with direct-acting antiviral therapies (DAAs) had lower re-infection rates than PWID who had no opiate-agonist therapy or supports.
Read More: https://www.medpagetoday.com/reading-room/aga/lower-gi/76361

Epidemiology and Elimination of HCV-Related Liver Disease

In Case You Missed It

Received: 1 September 2018 / Accepted: 3 October 2018 / Published: 6 October 2018 

Viruses 2018, 10(10), 545; doi: 10.3390/v10100545

Review 

Epidemiology and Elimination of HCV-Related Liver Disease 
Pierre Pradat , Victor Virlogeux and Eric Trépo

Abstract:

Hepatitis C virus (HCV) infection, defined by active carriage of HCV RNA, affects nearly 1.0% of the worldwide population. The main risk factors include unsafe injection drug use and iatrogenic infections. Chronic HCV infection can promote liver damage, cirrhosis and hepatocellular carcinoma (HCC) in affected individuals. The advent of new second-generation, direct-acting antiviral (DAA) agents allow a virological cure in more than 90% of treated patients, and therefore prevent HCV-related complications. Recently, concerns have been raised regarding the safety of DAA-regimens in cirrhotic patients with respect to the occurrence and the recurrence of HCC. Here, we review the current available data on HCV epidemiology, the beneficial effects of therapy, and discuss the recent controversy with respect to the potential link with liver cancer. We also highlight the challenges that have to be overcome to achieve the ambitious World Health Organization objective of HCV eradication by 2030.

Read full-text article online

On This Blog

Sift through current Liver Cancer and Hepatitis C research articles. 

Liver Cancer After Treatment For Hepatitis C: 

Research demonstrates that while SVR markedly reduced liver-related complications and liver cancer, some long-term risk for liver cancer remained in those who were cured of Hepatitis C. But after direct-acting antiviral therapy does the risk of developing liver cancer increase? Research is saying no, check out an index of articles here..... 

Also see; HCV Newsletters & Blog Updates

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:

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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).

Continue reading...…

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.....

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

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:

 https://www.id.theclinics.com/article/S0891-5520(18)30022-9/fulltext?rss=yes

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

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
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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

For Viral Hepatitis Elimination One Size Does Not Fit All

Health Is Global

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.

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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)

Source - https://www.jwatch.org/na46054/2018/02/09/mortality-benefit-successful-anti-hcv-daa-therapy-patients

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.