Evolving epidemiology of hepatitis C virus in the United States

Characterizing the temporal evolution of the hepatitis C virus epidemic in Pakistan

Pakistan has the second largest number of HCV infections in the world. We assessed past, present and future levels and trends of the HCV epidemic in Pakistan. An age-structured mathematical model was developed and analysed to describe transmission dynamics over 1980-2050. The model was fitted to a nationally representative survey and a comprehensive database of systematically gathered HCV Ab prevalence data. HCV Ab and chronic infection prevalences peaked at 5.3% and 3.9% in 2000 but were projected to decline to 4.3% and 3.2% by 2017, 3.4% and 2.6% by 2030 and 2.6% and 1.9% by 2050, respectively. The number of chronically infected individuals was estimated at 6 663 906 in 2017 and was projected to peak at 6 665 900 in 2018 and decline to 6 372 100 in 2030 and 5 131 500 in 2050. Annual number of new infections peaked at 346 740 in 1992 but was projected to decline to 198 320 in 2017, 151 090 in 2030 and 98 120 in 2050. Incidence rate per 100 000 person-year peaked at 343 in 1988 but was projected to decline to 99 in 2017, 62 in 2030 and 36 in 2050. Prevalence and incidence varied by age, and the majority of new infections occurred in the 20-39 age group. Prevalence and incidence of HCV in Pakistan have been slowly declining for two decades-Pakistan is enduring a large epidemic that will persist for decades if not controlled. Nearly, 10% of global infections are in Pakistan, with about 200 000 additional infections every year. Rapid and mass scale-up of prevention and treatment programmes are critically needed.

Improving adherence to hepatitis C screening guidelines

BACKGROUND

Hepatitis C (HCV) is a viral liver disease that can result in cirrhosis, hepatocellular carcinoma, liver transplantation or death. The Centers for Disease Control (CDC) estimates that 2.7-3.9 million Americans are living with HCV, yet the majority are unaware. Starting in 2013, both CDC and US Preventative Services Task Force guidelines agreed in recommending HCV screening for all those born between 1945 and 1965 yet many clinics have been slow to adopt screening.

OBJECTIVE

We designed a quality improvement project seeking to improve HCV screening rates among patients seen for new or annual visits to ≥90% over a 3-year period in an academic primary care clinic.

METHODS

Screening rates were assessed through repeated review of charts (50 per cycle or 300 charts total, roughly 35% of eligible visits) as a series of interventions were executed. Sustainability was assessed by repeating an additional 50-chart analysis 1 year after completion of the study interventions. At the conclusion of the study, a post hoc analysis of socioeconomic factors was undertaken to determine whether gender, income or ethnicity might affect screening rates.

RESULTS

Over 6 cycles of interventions, screening rates improved from 24% to ≥90%. Screening rates remained at 88% 1 year after completion of the interventions. The most effective interventions used reminders built into our electronic medical record and informed providers of their personal HCV screening rates relative to the clinic as a whole. Our post hoc analysis found that lower socioeconomic standing and white race were associated with reduced likelihood of screening.

CONCLUSIONS

Provider adoption of new HCV screening guidelines can be markedly and sustainably increased with electronic medical record prompts as well as directed feedback informing providers of their personal screening rates compared with colleagues.

Maternal hepatitis C (HCV) infection and Anti-D immunoglobulin therapy: study testing antibodies, RNA and Genotype of HCV in Baghdad

Introduction: Hepatitis C virus (HCV) infection is a serious health problem. It is a major contributor to end-stage liver disease. Worldwide, 1-8% of all pregnant women were infected. Women with viral hepatitis may be at an increased risk of pregnancy complications. There are several obstetrics intervention acts as risk factors, which are specific to women pertaining the HCV infection; anti-D immunoglobulin (Ig) therapy may be one of them. Our objectives were to estimate the prevalence of HCV antibodies (anti-HCV), RNA, and genotype distribution among women with anti-D Ig therapy. Materials and methods: A cross sectional study was conducted. A sample of 154 Rhesus negative (Rh - ve) pregnant women regardless of the anti-D Ig therapy was collected. Anti-HCV were tested using third generation enzyme immunoassay (EIA-3) and immunoblot assay (Lia Tek-111), subsequently. In addition, 89 serum samples were subjected to molecular analysis using RT-PCR and DNA enzyme immunoassay (DEIA) method for the detection of HCV-RNA and genotypes. Results: Anti-HCV, and HCV-RNA seroprevalence were significantly higher (17.1, 35.5%) among women with anti-D Ig than their counter group (6.4, 13.16%), p = .038, .018, respectively. Significant direct positive dose response correlation (r = 0.78, p = .005) had been seen between number of anti-D Ig therapy and anti-HCV seropositive rate. Anti-D Ig therapy act as a risk factor (odds ratio (OR) = 3.01, 95%CI: 1.01-8.9) especially from the third dose onward. Women with anti-D Ig therapy were at higher risk (3.6 times more) of positive HCV-RNA (OR =3.6, 95%CI =1.19-10.837). Genotype HCV-1b showed higher prevalent (52.9%) among the recipients of anti-D Ig therapy while genotype HCV-3a (6.6%) was the lowest. Conclusions: Our study showed that Anti-D immunoglobulin therapy acts as a risk factor for acquiring HCV infection. Screening for HCV should be recommended for all recipients of anti-D Ig. Not only HCV antibodies but HCV-RNA detection being recommended for the diagnosis of HCV infection. A brief rational: Pregnant women with HCV infection are at risk of adverse obstetric outcome. Anti-D Ig therapy may be a risk factor for HCV infection. Hence, we conducted a cross sectional study with the objectives to estimate the prevalence of HCV antibodies (anti-HCV), RNA, and genotype distribution among women with anti-D Ig therapy. We found that anti-HCV and HCV-RNA seroprevalence were significantly higher in women with anti-D Ig. In addition, women with anti-D Ig therapy were 3.6 times more at risk of positive HCV-RNA with genotype HCV-1b showed higher prevalence. Therefore, anti-D Ig therapy is a risk factor for acquiring HCV infection and we recommend screening for HCV for all recipients of anti-D Ig. In addition, the diagnosis of HCV infection, should be made with HCV antibodies and HCV-RNA detection.

Hepatitis C in Pregnancy

The prevalence of hepatitis C in pregnancy is as high as 3.6% in large cohorts. The prevalence of hepatitis C acquired by vertical transmission is 0.2% to 0.4% in the United States and Europe. Although screening is not recommended in the absence of certain risk factors, the importance of understanding hepatitis C in pregnancy lies in its association with adverse maternal and neonatal outcomes. There is potential for those infants infected by vertical transmission to develop chronic hepatitis C, cirrhosis or hepatocellular carcinoma. The risk of vertical transmission is increased when mothers are co-infected with Human Immunodeficiency Virus (HIV) or possess a high viral load. There is no clear data supporting that mode of delivery increases or reduces risk. Breastfeeding is not associated with increased risk of transmission. Premature rupture of membranes, invasive procedures (such as amniocentesis), intrapartum events, or fetal scalp monitoring may increase risk of transmission. In pregnant patients, hepatitis C is diagnosed with a positive ELISA-3 and detectable Hepatitis C Virus (HCV) RNA viral load. Infants born to HCV-infected mothers should be tested for either HCV RNA on at least two separate occasions. Although prevention is not possible, there may be a role for newer direct acting anti-viral medications in the future.

A Population-Based Surveillance Study on the Epidemiology of Hepatitis C in Estonia

Background and objective: The hepatitis C virus (HCV)-infected patients serve as a reservoir for transmission of the disease to others and are at risk of developing chronic hepatitis C, cirrhosis, and hepatocellular carcinoma. Although the epidemiological data of high rate HCV infection have been obtained in many countries, such data are insufficient in Estonia. Therefore, the aim of the study was to analyze country-specific data on HCV patients. Materials and methods: Data about age, gender, diagnosis, possible risk factors, coinfections, HCV genotypes, liver fibrosis stages and extrahepatic manifestations were collected from 518 patients. Results: The most common risk factors for hepatitis C were injection drug use and tattooing in the 30–39 and 40–49 year age groups, and blood transfusion in the 50–59 and 60–69 year age groups. The other risk factors established were profession-related factors and sexual contact. The prevailing viral genotype among the HCV infected patients was genotype 1 (69% of the patients) followed by genotype 3 (25%). Genotypes 1 and 3 correlated with blood transfusions before 1994, drug injections and tattooing. Conclusions: Our study provides the best representation of genotype distribution across Estonia. As a result of the study, valuable data has been collected on hepatitis C patients in Estonia.

Individual-level key associations and modes of exposure for hepatitis C virus infection in the Middle East and North Africa: a systematic synthesis

PURPOSE

To identify, map, and synthesize the individual-level key associations and modes of exposure for hepatitis C virus (HCV) infection in the Middle East and North Africa (MENA), the most affected region by HCV.

METHODS

Source of data was the MENA HCV Epidemiology Synthesis Project database, populated through systematic literature searches. Risk factors determined to be statistically significant after adjustment for confounders were extracted and categorized into key associations or modes of exposure.

RESULTS

In total, 329 risk factors were identified from 109 articles in 14 of 24 MENA countries. Among key associations, age was most frequently reported (n = 39; 34.2%), followed by other infections/diseases (n = 20; 17.5%), and incarceration (n = 17; 14.9%). Among modes of exposure, health care-related exposures were most frequently reported (n = 127; 59.5%), followed by injecting drug use exposures (n = 45; 20.9%), community-related exposures (n = 34; 15.8%), and sexual-related exposures (n = 8; 3.7%). Blood transfusion, hemodialysis, surgical and other medical procedures, dental work, and medical injections were identified as key health care-related exposures.

CONCLUSIONS

Health care appears to be the primary driver of prevalent (and possibly incident) infections in MENA, followed by injecting drug use. HCV screening should target the identified modes of exposure. Commitment to prevention should be an integral component of HCV response to achieve HCV elimination by 2030, with focus on strengthening infection control in health care facilities, improving injection safety and blood screening, and expanding harm reduction services for people who inject drugs.

Incidence of Hepatitis C Virus and Other Bloodborne Virus Infections Among Nonurban Residents of Fairfield and New Haven Counties, Connecticut Who Inject Drugs

Opioid overdose and substance abuse treatment entry data suggest that injection drug use is increasing in nonurban locations. We sought to explore the prevalence and incidence of viral infections among people who inject drugs (PWID) residing in Fairfield and New Haven counties but outside of the six largest cities. A longitudinal cohort of PWID was assembled and incidence of HIV-1, hepatitis B virus, and hepatitis C virus infections was determined by annual antibody screening. Data on participants' socioeconomic situation and risk behaviors were collected. We identified 11 new hepatitis C virus infections and calculated incidence at 9.03 cases per 100 person-years. Only one new HIV infection and one new hepatitis B virus infection were detected. Factors associated with seroconversion were assessed. Given the high incidence of HCV and lack of HBV vaccination coverage, prevention and treatment resources need to be targeted to this population.

Impact of Moderate Alcohol Discontinuation on Insulin Action and Secretion in Latinos With and Without Hepatitis C

BACKGROUND

Insulin resistance (IR) is associated with hepatitis C virus (HCV), and Latinos are both at risk of IR and are disproportionately affected by HCV. Moderate alcohol consumption improves insulin sensitivity and may modify HCV-associated IR. We investigated the impact of moderate alcohol discontinuation on insulin sensitivity and secretion in Latinos using direct measurements.

METHODS

Twenty-five nondiabetic, noncirrhotic Latino adults without (n = 17) or with (n = 8) HCV underwent 3-day metabolic assessment before and after prescription of 6 weeks of moderate alcohol discontinuation. Peripheral IR was measured via steady-state plasma glucose (SSPG) and hepatic IR using endogenous glucose production during a 2-step 240-minute insulin suppression test. Insulin secretion was measured using graded glucose infusion test.

RESULTS

Baseline mean age was 46 ± 11 years, 63% male, 29% had HCV, and mean body mass index was 27 ± 4 kg/m² . Compared to non-HCV, HCV patients had a higher median SSPG (132 vs. 98.8 mg/dl, p = 1.0), hepatic IR (13.5 vs. 11.3, p = 0.24), and insulin secretion rate (ISR-AUC, 1,290 vs. 1,250 pmol/min, p = 0.98). After confirmed alcohol discontinuation, hepatic IR was the only parameter that changed significantly (increased, mean change 2.6 ± 4.8, p = 0.02). Higher baseline alanine aminotransferase (ALT) was also associated with a greater change in hepatic IR (average 4.0 points/ALT doubling, p = 0.004), and HCV was associated with a lesser change (average -7.3 points, p = 0.002), independent of ALT.

CONCLUSIONS

Short-term moderate alcohol discontinuation adversely impacted hepatic IR in Latinos which was influenced by level of ALT at baseline independent of etiology. Although reduction in ALT through weight loss and HCV eradication remains a priority in improving IR, the observed nonharmful effect of moderate alcohol use represents a potentially confounding variable that warrants further study.

Prevalence of Hepatitis C Screening, Testing, and Care Experience Among Young Adults Who Use Prescription Opioids Nonmedically

PURPOSE

Examine the prevalence of hepatitis C virus (HCV) screening, confirmatory testing, and care experiences among young adult nonmedical prescription opioid (NMPO) users.

METHODS

We examined self-reported HCV screening history in a sample of 18- to 29-year-olds reporting past-month NMPO use, and we used modified Poisson regression to identify associated sociodemographic and drug use patterns.

RESULTS

Among 196 participants, 154 (78.6%) reported prior HCV screening, among whom 18 (11.7%) reported positive results. Of these, 13 (72.2%) reported receiving a confirmatory test; 12 (66.7%) were referred for specialty HCV care. Screening was associated with injection drug use (adjusted prevalence ratio [APR] = 1.19; 95% confidence interval [CI] = 1.05-1.33) and history of hospitalization for psychiatric illness (APR = 1.23; 95% CI = 1.09-1.39). Younger participants (18-23 years) were less likely to have been screened (APR = .69; 95% CI = .57-.85).

CONCLUSION

Among young adult NMPO users, post-HCV screening support and referral to care were inadequate.

A dirty little secret: stigma, shame and hepatitis C in the health setting

While recent medical innovation shows great promise in treating hepatitis C (HCV), it remains a condition associated with profound stigma. HCV is a bloodborne virus (BBV) most commonly transmitted in high-income countries by injecting drug use, and it is the stigmatising association between the two which is deeply problematic for those with HCV. A qualitative study undertaken in 2002 found that disclosure in health settings places those with HCV in positions of pronounced vulnerability. Disclosure is a primal scene, an interface, where the stigma of HCV, replete with connotations of disease and deviance, potentially transforms those affected into shamed subjects. Standard precautions protect health workers and minimise the transmission of contagion, measures which, in theory, also mitigate the requirement of those with BBVs to unnecessarily disclose their blood status. However, questions on pre-employment health checks, concerns that health treatments might adversely affect the liver and an ethical need to pre-emptively inform healthcare professionals undertaking exposure prone procedures are occasions when those with HCV confront the decision to disclose their blood status. This paper employs Goffman's model of actual and virtual social identities, along with Douglas' notion of dirt and pollution, to examine the dilemmas around disclosure those with HCV negotiate within the health setting. Discriminatory responses by healthcare professionals elucidate the stigmatising potential HCV carries. The subsequent reticence by those with HCV to disclose their blood status risks less than optimum healthcare. Recent studies indicate that stigma occurring in health settings remains a perennial concern for those with HCV.

Population-level intervention and information collection in dynamic healthcare policy

We develop a general framework for optimal health policy design in a dynamic setting. We consider a hypothetical medical intervention for a cohort of patients where one parameter varies across cohorts with imperfectly observable linear dynamics. We seek to identify the optimal time to change the current health intervention policy and the optimal time to collect decision-relevant information. We formulate this problem as a discrete-time, infinite-horizon Markov decision process and we establish structural properties in terms of first and second-order monotonicity. We demonstrate that it is generally optimal to delay information acquisition until an effect on decisions is sufficiently likely. We apply this framework to the evaluation of hepatitis C virus (HCV) screening in the general population determining which birth cohorts to screen for HCV and when to collect information about HCV prevalence.

Patterns in Liver-Related Health Outcomes with Hepatitis C Virus Treatments and Health Equity Implications for Decision Makers: A Cohort Analysis of Medicaid Patients

Introduction: Hepatitis C virus (HCV) infection is a blood-borne communicable disease that, in perhaps 20% of cases, results in a chronic disease. However, traditional peginterferon/ribavirin therapies pose many adverse side effects that are difficult to tolerate, and many patients do not complete the therapy. However, healthcare access to these newer, efficacious treatments are reduced, due to inadequate or lack of coverage of direct acting antiviral (DAA) medication. The objective of this study was to evaluate the impact of HCV treatment regimens on outcomes of care for HCV-infected Medicaid beneficiaries without cirrhosis/liver disease scarring. Methods: A cohort analysis was performed to evaluate the changes in cirrhosis, hepatocellular carcinoma (liver cancer), and liver transplantation with use of HCV treatments in Medicaid beneficiaries with HCV, and was followed over a period of 10 years. The cohort of Medicaid beneficiaries and relevant variables were generated from published literature. Results: Finally, considering the impact on health expenditures due to improved access to new treatments in Medicaid beneficiaries, DAAs resulted in the lowest decompensated cirrhosis and hepatocellular carcinoma-related healthcare cost per person over the 10-year time frame the cohort was followed. Conclusions: The risk of liver-related disease is higher in patients with cirrhosis, as reaching treatment success results in continued disease progression, not normal health status; thus, liver cancer healthcare costs are higher in patients with cirrhosis, compared to those without cirrhosis.

Drugs of Abuse

Drug abuse and its consequences remain a significant public health issue. An increasing number of individuals are present in the emergency room with life-threatening drug intoxication. It is imperative that emergency room physicians are cognizant of the signs, symptoms, and treatment to improve the chances of early recognition and treatment. As a result, the proportion of lives saved will increase significantly. In this article, we present some of the most prevalent life-threatening drugs that lead to emergency room admission. The signs, symptoms, and treatment modalities are discussed.

High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary care clinic

BACKGROUND

Though direct acting antivirals (DAAs) promise high cure rates, many providers and payers remain concerned about successful treatment for people who use drugs (PWUD), even among those engaged in opioid agonist treatment (OAT). The efficacy of DAAs among PWUD in real-world settings is unclear.

METHODS

We conducted a cohort study of patients initiating HCV treatment between January 2014 and August 2015 (n=89) at a primary care clinic in the Bronx, NY. Onsite HCV treatment with DAAs was performed by an HCV specialist, with support from a care coordinator funded by the NYC Department of Health. We identified four categories of drug use and drug treatment: (1) no active drug use/not receiving OAT (defined as non-PWUD); (2) no active drug use/receiving OAT; (3) active drug use/not receiving OAT; and (4) active drug use/receiving OAT. The primary outcome was SVR at 12 weeks post-treatment.

RESULTS

Overall SVR rates were 95% (n=41/43) for non-PWUD and 96% (n=44/46) for patients actively using drugs and/or receiving OAT [p=0.95]. There were no differences in SVR rates by drug use or drug treatment category. Compared to non-PWUD, those with no active drug use/receiving OAT had 100% SVR (n=15/15; p=1.0), those actively using drugs/not receiving OAT had 90% SVR (n=9/10; p=0.47), and those actively using drugs/receiving OAT had 95% SVR (20/21; p=1.0).

CONCLUSION

Regardless of active drug use or OAT, patients who received DAA therapy at an urban primary care clinic achieved high HCV cure rates. We found no clinical evidence to justify restricting access to HCV treatment for patients actively using drugs and/or receiving OAT.

Improving Screening Methods for Hepatitis C Among People Who Inject Drugs: Findings from the HepTLC Initiative, 2012-2014

OBJECTIVE

People who inject drugs (PWID) are at increased risk for hepatitis C virus (HCV) infection. We examined HCV testing outcomes among PWID through CDC's Hepatitis Testing and Linkage to Care initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites during 2012-2014. Ten grantees in nine geographically diverse cities conducted HCV testing among PWID.

METHODS

Among those testing positive for HCV antibody (anti-HCV), we calculated the proportion who were offered a confirmatory HCV ribonucleic acid (RNA) test, positively diagnosed, and referred to a specialist for care. We stratified anti-HCV-positive people who completed each step by same-day testing (i.e., an HCV RNA test administered on the same date as an anti-HCV test) vs. person not receiving same-day testing to evaluate whether the need for follow-up testing affected diagnosis of chronic infection and linkage to care.

RESULTS

A total of 15,274 people received an anti-HCV test at 84 testing sites targeting PWID. Of those, 11,159 (73%) reported having injected drugs in their lifetime, 7,789 (51%) reported injecting drugs in the past 12 months, and 3,495 (23%) tested anti-HCV positive. A total of 1,630 people received testing for HCV RNA, of whom 1,244 (76%) were HCV RNA positive. When not receiving both tests on the same day, 601 of 2,465 (24%) anti-HCV-positive people received an HCV RNA test.

CONCLUSION

Strategies to diagnose PWID for HCV infection are needed to reduce associated morbidity and mortality. Agencies can substantially increase the number of PWID who are diagnosed and informed of their HCV infection by administering both anti-HCV and HCV RNA tests during a single testing event.

Epidemiology of Hepatocellular Carcinoma in the Asia-Pacific Region

Hepatocellular carcinoma (HCC) is the predominant primary liver cancer in many countries and is the third most common cause of cancer-related death in the Asia-Pacific region. The incidence of HCC is higher in men and in those over 40 years old. In the Asia-Pacific region, chronic hepatitis B virus and hepatitis C virus infections are the main etiological agents; in particular, chronic hepatitis B infection (CHB) is still the major cause in all Asia-Pacific countries except for Japan. Over the past two decades, the incidence of HCC has remained stable in countries in the region except for Singapore and Hong Kong, where the incidence for both sexes is currently decreasing. Chronic hepatitis C infection (CHC) is an important cause of HCC in Japan, representing 70% of HCCs. Over the past several decades, the prevalence of CHC has been increasing in many Asia-Pacific countries, including Australia, New Zealand, and India. Despite advancements in treatment, HCC is still an important health problem because of the associated substantial mortality. An effective surveillance program could offer early diagnosis and hence better treatment options. Antiviral treatment for both CHB and CHC is effective in reducing the incidence of HCC.

Comparative treatment effectiveness of direct acting antiviral regimens for hepatitis C: Data from the Veterans administration

BACKGROUND AND AIMS

Data addressing real world effectiveness of direct acting antiviral agents in hepatitis C infected patients are now emerging. This study compared the sustained virologic response rates achieved 12 weeks post-treatment in patients treated with three such agents by the Veterans Health Administration.

METHODS

A retrospective cohort study was conducted using patients who terminated treatment by July 1, 2015. Data were retrieved from the Veterans Health Administration electronic medical records system. Patients were included if sufficient viral load laboratory data were available to determine sustained virologic response. Applying an intention to treat approach and logistic regression analysis, the sustained virologic response rates achieved were compared across drug regimens.

RESULTS

A total of 11 464 patients met study selection criteria. Without controlling for other risk factors, sustained virologic response at least 12 weeks post treatment was achieved in 92% of ledipasvir/ sofosbuvir, 86% of ombitasvir/paritaprevir/ritonavir/dasabuvir, and 83% of simeprevir/sofosbuvir patients. After adjusting for patient characteristics, simeprevir/sofosbuvir (93.3%) and ledipasvir/sofosbuvir (96.2%) patients were statistically more likely than ombitasvir/paritaprevir/ritonavir/dasabuvir (91.8%) patients to demonstrate sustained virologic response. Human immunodeficiency virus, hepatitis B infection, diabetes, obesity, previous treatment history and augmentation therapy using ribavirin did not impact sustained virologic response rates. Sustained virologic response rates were lower for patients under age 65, with cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, indications of fibrosis, or a non-genotype 1 infection. Women and Caucasian patients were more likely to achieve a sustained virologic response.

CONCLUSIONS

All three direct acting antiviral regimens appear highly effective in achieving sustained virologic response.

Contrasting HCV and HIV seroepidemiology in 11 years of blood donors screening in Brazil

BACKGROUND

Blood donors are, in principle, healthy individuals who may be revealed as infectious for blood-borne agents by the laboratory screening process, depicting the asymptomatic burden of the disease. Therefore, monitoring hepatitis C virus (HCV)-infected donor and human immunodeficiency virus (HIV)-infected donor and associating to their demographical and behavioural characteristics may shed light on the dynamics and contemporary changes in these viruses' epidemiology.

METHODS

Donors presenting repeatedly reactive HCV or HIV serology/nucleic acid testing (NAT) screening results were submitted to confirmatory testing. Confirmed positive donors were invited to return to the blood bank for notification and counselling when a follow-up sample was obtained and an interview performed to eventually disclose potential risks. HCV- or HIV-infected donors identified over 11 years of screening (2004-2015) were evaluated for demographic and behavioural parameters.

RESULTS

In the period, 139 160 donations were screened, and 36 (0.025%) were found positive for HIV, stemming from 29 male and 7 female donors. Among those, eight subjects were repeat donors. A total of 95 donations were found repeatedly reactive for HCV (0.068%), obtained from 60 men and 35 women. Noticeably, in despite of a higher HCV prevalence in the donor population, the incidence of HIV among repeat donors was 10 times that of HCV (18 × 1.6/100 000 persons-year, respectively). On average, HIV-seroreactive men were found to be younger (mean = 34 years old) than women (mean = 40 years old). A total of 10 donors acknowledged sexual behaviours not previously informed, including 2 who were aware of their HIV-positive status and another 2 who admitted to be seeking HIV testing. No window period donation was verified.

DISCUSSION

The majority of the HIV-infected donors are young males who deny risk factors in the interview and also ignore the confidence self-exclusion opportunity. As they may reiterate this behaviour in serial donations, use of the most sensitive laboratory testing is justified in this setting.

Risk factors for hepatitis C seropositivity among young people who inject drugs in New York City: Implications for prevention

Background

Hepatitis C virus (HCV) infection remains a significant problem in the United States, with people who inject drugs (PWID) disproportionately afflicted. Over the last decade rates of heroin use have more than doubled, with young persons (18–25 years) demonstrating the largest increase.

Methods

We conducted a cross-sectional study in New York City from 2005 to 2012 among young people who injected illicit drugs, and were age 18 to 35 or had injected drugs for ≤5 years, to examine potentially modifiable factors associated with HCV among young adults who began injecting during the era of syringe services.

Results

Among 714 participants, the median age was 24 years; the median duration of drug injection was 5 years; 31% were women; 75% identified as white; 69% reported being homeless; and 48% [95% CI 44–52] had HCV antibodies. Factors associated with HCV included older age (adjusted odds ratio [AOR], 1.99 [1.52–2.63]; p<0.001), longer duration of injection drug use (AOR, 1.68 [1.39–2.02]; p<0.001),more frequent injection (AOR, 1.26 [1.09–1.45]; p = 0.001), using a used syringe with more individuals (AOR, 1.26 [1.10–1.46]; p = 0.001), less confidence in remaining uninfected (AOR, 1.32 [1.07–1.63]; p<0.001), injecting primarily in public or outdoors spaces (AOR, 1.90 [1.33–2.72]; p<0.001), and arrest for carrying syringes (AOR, 3.17 [1.95–5.17]; p<0.001).

Conclusions

Despite the availability of harm reduction services, the seroprevalence of HCV in young PWID in New York City remained high and constant during 2005–2012. Age and several injection behaviors conferred independent risk. Individuals were somewhat aware of their own risk. Public and outdoor injection and arrest for possession of a syringe are risk factors for HCV that can be modified through structural interventions.

Hepatitis C among blood donors: cascade of care and predictors of loss to follow-up

OBJECTIVE

To investigate the HCV cascade of care and to identify the factors associated with loss or absence to follow-up of patients identified as infected with hepatitis C through blood donation.

METHODS

Blood donors from 1994 to 2012, identified with positive anti- HCV by enzyme immunoassay and immunoblot tests were invited to participate in the study, through letters or phone calls. Patients who agreed to participate were interviewed and their blood samples were collected for further testing. The following variables were investigated: demographic data, data on comorbidities and history concerning monitoring of hepatitis C. Multiple regression analysis by Poisson regression model was used to investigate the factors associated with non-referral for consultation or loss of follow-up.

RESULTS

Of the 2,952 HCV-infected blood donors, 22.8% agreed to participate: 394 (58.2%) male, median age 48 years old and 364 (53.8%) Caucasian. Of the 676 participants, 39.7% did not receive proper follow-up or treatment after diagnosis: 45 patients referred not to be aware they were infected, 61 did not seek medical attention and 163 started a follow-up program, but were non-adherent. The main reasons for inadequate follow-up were not understanding the need for medical care (71%) and health care access difficulties (14%). The variables showing a significant association with inadequate follow-up after multiple regression analysis were male gender (PR = 1.40; 95%CI 1.15–1.71), age under or equal to 50 years (PR = 1.36; 95%CI 1.12–1.65) and non-Caucasians (PR = 1.53; 95%CI 1.27–1.84).

CONCLUSIONS

About 40.0% of patients did not receive appropriate follow-up. These data reinforce the need to establish strong links between primary care and reference centers and the need to improve access to specialists and treatments.

Burden of hepatocellular carcinoma among hispanics in South Texas: a systematic review

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the fastest rising causes of cancer-related mortality in the United States (U.S.). Despite improved HCC screening and surveillance guidelines, significant race/ethnicity-specific disparities in hepatocellular carcinoma remain, disproportionately affecting at risk racial minorities in the U.S. The current review aims to provide an updated analysis on race/ethnicity-specific disparities in HCC epidemiology with a focus on predisposing risk factors.

CONCLUSION

Among different race/ethnicities in the U.S., Hispanics experienced the greatest burden of HCC, particularly those residing in South Texas. It is important to understand that the underlying etiologies for these disparities are complex and multi-factorial. Some of these risk factors for developing chronic liver disease include non-alcoholic fatty liver disease/non-alcoholic steatohepatitis and alcohol use. In addition, population genetics, acculturation of ethnic minorities, and access to healthcare may be further contributing to the observed disparities in HCC. By increasing awareness, improved modalities for screening and surveillance for HCC are important in guiding future research for targeted preventive and therapeutic interventions.

Hepatitis C: Review of the Epidemiology, Clinical Care, and Continued Challenges in the Direct Acting Antiviral Era

PURPOSE OF REVIEW

This review highlights key studies and recently published data, policies, and recommendations related to hepatitis C virus (HCV) epidemiology, transmission, and treatment.

RECENT FINDINGS

HCV is a leading cause of liver-related deaths, cirrhosis, and hepatocellular carcinoma. Since 2011 and accelerating since 2013, new, safe, tolerable, and curative therapies have considerably altered clinical and public health frameworks related to the prevention, control and clinical management of HCV. Nevertheless, there are several populations in the United States that are important to consider because of disparities in HCV prevalence and transmission risk. Adults born during 1945-1965 have an estimated anti-HCV antibody prevalence of ~3%, which is six times higher than among other adults, are often unaware of their infections, and are at increased risk of having HCV-associated morbidity and mortality from decades of chronic infection. Since the early 2000s, increasing incidence of acute HCV infections among young, white, non-urban people who inject drugs have been reported. Despite promising therapeutic advances, significant challenges remain for reducing HCV-associated morbidity and mortality.

SUMMARY

The high burden of HCV and significant health consequences associated with chronic infection make HCV a critical public health priority. Advances in HCV treatment have created new opportunities for reducing HCV-associated morbidity and mortality. These treatments are safe, well-tolerated, and highly effective; however, benefits cannot be realized without a significant increase in the number of persons tested for HCV so that all chronically infected individuals can be aware of their diagnosis and linked to appropriate clinical care.

Hurdles to the Development of Effective HBV Immunotherapies and HCV Vaccines

Chronic infections with HBV and HCV continue to be major public health problems, with hundreds of millions of people infected worldwide; this is despite the availability of both an effective prophylactic HBV vaccine for more than 3 decades and potent direct antivirals for HBV and, more recently, HCV infection. Consequently, development of HBV immunotherapies and prophylactic HCV vaccines remains extremely urgent, but limited funding and significant gaps in our understanding of the correlates of immune protection pose serious hurdles for the development of novel immune-based interventions. Here we discuss immunological questions related to HBV and HCV, some shared and some pertinent to only 1 of the viruses, that should be addressed for the rational design of HBV immunotherapies and HCV vaccines.

Sofosbuvir Monotherapy for Asymptomatic and Noncirrhotic Hepatitis C Infection in a Renal Retransplantation Recipient: A Case Report

Renal transplant recipients infected with hepatitis C virus (HCV) have a high risk of progressing to cirrhosis, end-stage liver diseases, and hepatocellular carcinoma. It is also considered as an independent risk for graft loss and is correlated with proteinuria, transplant glomerulopathy, HCV-associated glomerulonephritis, and chronic rejection. Previous therapy involving interferon alfa and ribavirin led to treatment complications, including toxicity, anemia, sepsis, and drug-drug interactions with calcineurin inhibitors, as well as reduced tolerability and efficacy. New direct-acting antiviral drugs simplify and shorten the treatment along with increasing tolerability and efficacy. Nevertheless, limited data and no specific regimen with direct-acting antiviral drugs have been described in the literature for renal transplant recipients with chronic HCV. We describe here the case of a 52-year-old Chinese man who diagnosed with chronic renal failure in 1997 and underwent renal transplantation the same year. In 2012, he was diagnosed with renal graft failure and again underwent hemodialysis. The patient then underwent his second renal transplantation and was administered an immunosuppressive cyclosporine-based regimen in 2015. During hemodialysis, he acquired asymptomatic genotype 1b HCV infection. Serologic test results reflecting liver cirrhosis were all negative, and ultrasound showed no abnormalities in the liver. The patient later required oral sofosbuvir monotherapy for 12 weeks after the second kidney transplantation. Curing HCV in renal transplant recipients is necessary. Although our treatment did not successfully result in a sustained virologic response, it suggests that genotype 1b HCV may have a poor response to a sofosbuvir monotherapy regimen. Specific and effective regimens for renal transplant recipients with HCV infection need to be confirmed in the future.

Hepatitis C virus infection: opportunities for an earlier detection in primary care

BACKGROUND/AIM

In the era of direct-acting antiviral medications, which can cure the hepatitis C virus (HCV) infection, the actual epidemiology of this condition in the general population is still unclear. We therefore aimed to estimate the prevalence rate of HCV and assess the determinants for incident cases of HCV in primary care in Italy.

METHODS

We identified outpatients aged at least 15 years registered in the Italian Health Search IMS Health Longitudinal Patient Database from 1 January 2002 to 30 June 2013. The annual trend of HCV prevalence was estimated. The candidate determinants for the risk of incident HCV infection included geographical area of residence, sex, age, infections by the HIV, hepatitis B virus (HBV), or other forms of hepatitis, and abuse of illicit substances or drugs.

RESULTS

The eligible cohort included 826 300 patients (53.5% women, mean age 48.1±19.1 years). The prevalence rate of HCV increased over the 11-year study period, ranging from 0.24 to 0.50%, with a small increase in men versus women. Patients aged more than 24 years had a higher risk than those aged 14-24 years, with up to a five-fold increase among patients aged 65-74 years. Being resident of Southern/Islands Italy, concurrent diagnosis HBV or HIV, and drug or illicit substance abuse were significant determinants for HCV infection.

CONCLUSION

Our study shows that the prevalence of HCV in Italy has doubled over the last decade. Patients with certain demographics and clinical characteristics are more prone to be infected by HCV. In this scenario, general practitioners may play a crucial role in screening, early identification, and therapy of high-risk patients.

Retention in buprenorphine treatment is associated with improved HCV care outcomes

Persons who inject drugs, most of whom are opioid dependent, comprise the majority of the HCV infected in the United States. As the national opioid epidemic unfolds, increasing numbers of people are entering the medical system to access treatment for opioid use disorder, specifically with buprenorphine. Yet little is known about HCV care in patients accessing buprenorphine-based opioid treatment. We sought to determine the HCV prevalence, cascade of care, and the association between patient characteristics and completion of HCV cascade of care milestones for patients initiating buprenorphine treatment. We reviewed electronic health records of all patients who initiated buprenorphine treatment at a primary-care clinic in the Bronx, NY between January 2009 and January 2014. Of the 390 patients who initiated buprenorphine treatment, 123 were confirmed to have chronic HCV infection. The only patient characteristic associated with achieving HCV care milestones was retention in opioid treatment. Patients retained (vs. not retained) in buprenorphine treatment were more likely to be referred for HCV specialty care (63.1% vs. 34.0%, p<0.01), achieve an HCV-specific evaluation (40.8% vs. 21.3%, p<0.05), be offered HCV treatment (22.4% vs. 8.5%, p<0.05), and initiate HCV treatment (9.2% vs. 6.4%, p=0.6). Given the current opioid epidemic in the US and the growing number of people receiving buprenorphine treatment, there is an unprecedented opportunity to access and treat persons with HCV, reducing HCV transmission, morbidity and mortality. Retention in opioid treatment may improve linkage and retention in HCV care; innovative models of care that integrate opioid drug treatment with HCV treatment are essential.

"Hep C, where art thou": What are the remaining (fundable) questions in hepatitis C virus research?

Hepatitis C virus (HCV) has dominated the field of hepatology for the past 25 years, and its cure in the majority of treated patients is one of the greatest achievements in all of medicine. However, the latter has led to the belief by some that HCV research should be shelved for other, more pressing areas. The mission for HCV eradication is far from accomplished. As a historical reference, we should consider that disease elimination has required vaccination with all previously controlled infections including smallpox and polio and that simple, effective treatment is not sufficient in most infections to lead to substantial control. Syphilis is the best example, for which a single dose of penicillin (which literally costs pennies and that we have had since 1945) is curative in early stages. Not only have we not eradicated syphilis, rates of infection have increased in many places within the United States in recent years. Most HCV-infected subjects are unaware of their infection, remaining at risk for transmission to others and disease progression, including cirrhosis and hepatocellular carcinoma. In the era of highly effective direct-acting antivirals (DAAs), many questions pertaining to HCV remain, but they are more complex and difficult to answer. Here, I provide my perspective on some of these salient issues: the residual risk for disease progression after sustained virologic response, the optimal approach to current DAA failures, the impact of targeting people who inject drugs with DAAs, vaccine prospects, and application of neutralizing HCV glycoprotein antibodies. (Hepatology 2017;65:341-349).

A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA

Supervised injection facilities (SIFs) have been shown to reduce infection, prevent overdose deaths, and increase treatment uptake. The United States is in the midst of an opioid epidemic, yet no sanctioned SIF currently operates in the United States. We estimate the economic costs and benefits of establishing a potential SIF in San Francisco using mathematical models that combine local public health data with previous research on the effects of existing SIFs. We consider potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT) uptake. We find that each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system.

Sociodemographic characteristics, knowledge and prevalence of viral hepatitis infection among Vietnamese Americans at community screenings

Few studies have investigated the prevalence of hepatitis B virus (HBV) and C virus (HCV) infection among Vietnamese Americans (VAs). The purpose of this paper is to assess the prevalence of HBV and HCV infection, identify the sociodemographic characteristics of the HBV infected population and the level of HBV knowledge among VAs in the Baltimore-Washington metropolitan areas with data from a health fair in 2011. A total of 617 VAs received serological testing for HBV and HCV, and 329 completed a survey of HBV knowledge assessment. About 9% were infected with HBV and 5% with HCV. Vietnamese Americans younger than 30 years had the highest HBV prevalence (13.1%) followed by those age 41-50 years (12.1%). The prevalence of HCV infection was particularly higher among those older than 70 years old (13.9%). Misunderstanding HBV as a food-borne disease is prevalent among VAs. Efforts to develop public health screening and education programs targeting this population are warranted.

Apolipoprotein B100 is required for hepatitis C infectivity and Mipomersen inhibits hepatitis C

AIM

To characterize the role of apolipoprotein B100 (apoB100) in hepatitis C viral (HCV) infection.

METHODS

In this study, we utilize a gene editing tool, transcription activator-like effector nucleases (TALENs), to generate human hepatoma cells with a stable genetic deletion of APOB to assess of apoB in HCV. Using infectious cell culture-competent HCV, viral pseudoparticles, replicon models, and lipidomic analysis we determined the contribution of apoB to each step of the viral lifecycle. We further studied the effect of mipomersen, an FDA-approved antisense inhibitor of apoB100, on HCV using in vitro cell-culture competent HCV and determined its impact on viral infectivity with the TCID50 method.

RESULTS

We found that apoB100 is indispensable for HCV infection. Using the JFH-1 fully infectious cell-culture competent virus in Huh 7 hepatoma cells with TALEN-mediated gene deletion of apoB (APOB KO), we found a significant reduction in HCV RNA and protein levels following infection. Pseudoparticle and replicon models demonstrated that apoB did not play a role in HCV entry or replication. However, the virus produced by APOB KO cells had significantly diminished infectivity as measured by the TCID-50 method compared to wild-type virus. Lipidomic analysis demonstrated that these virions have a fundamentally altered lipidome, with complete depletion of cholesterol esters. We further demonstrate that inhibition of apoB using mipomersen, an FDA-approved anti-sense oligonucleotide, results in a potent anti-HCV effect and significantly reduces the infectivity of the virus.

CONCLUSION

ApoB is required for the generation of fully infectious HCV virions, and inhibition of apoB with mipomersen blocks HCV. Targeting lipid metabolic pathways to impair viral infectivity represents a novel host targeted strategy to inhibit HCV.

The Impact of Delayed Hepatitis C Viral Load Suppression on Patient Risk: Historical Evidence from the Veterans Administration

Background:

The high cost of new hepatitis C (HCV) treatments has resulted in “watchful waiting” strategies being developed to safely delay treatment, which will in turn delay viral load suppression (VLS).

Objective:

To document if delayed VLS adversely impacted patient risk for adverse events and death.

Methods:

187,860 patients were selected from the Veterans Administration’s (VA) clinical registry (CCR), a longitudinal compilation of electronic medical records (EMR) data for 1999–2010. Inclusion criteria required at least 6 months of CCR/EMR data prior to their HCV diagnosis and sufficient data post-diagnosis to calculate one or more FIB-4 scores. Primary outcome measures were time-to-death and time-to-a composite of liver-related clinical events. Cox proportional hazards models were estimated separately using three critical FIB-4 levels to define early and late viral response.

Results:

Achieving an undetectable viral load before the patient’s FIB-4 level exceed pre-specified critical values (1.00, 1.45 and 3.25) effectively reduced the risk of an adverse clinical events by 33–35% and death by 21–26%. However, achieving VLS after FIB-4 exceeds 3.25 significantly reduced the benefit of viral response.

Conclusions:

Delaying VLS until FIB-4 >3.25 reduces the benefits of VLS in reducing patient risk.

A Smartphone Application Supporting Recovery from Heroin Addiction: Perspectives of Patients and Providers in China, Taiwan, and the USA

Smartphone-based interventions are increasingly used to support self-monitoring, self-management, and treatment and medication compliance in order to improve overall functioning and well-being. In attempting to develop a smartphone application (S-Health) that assists heroin-dependent patients in recovery, a series of focus groups (72 patients, 22 providers) were conducted in China, Taiwan, and the USA to obtain their perspectives on its acceptance and potential adoption. Data were analyzed according to the Diffusion of Innovation (DOI) theory of characteristics important to the adoption of innovation. Important to Relative Advantage, USA participants cited S-Health's potential ability to overcome logistical barriers, while those in China and Taiwan valued its potential to supplement currently limited services. In terms of Compatibility, participants across sites reported recovery needs and goals that such an application could be helpful in supporting; however, its utility during strong craving was questioned in China and Taiwan. Important factors relevant to Complexity included concerns about smartphone access and familiarity, individualization of content, and particularly in China and Taiwan, participants wanted assurance of privacy and security. The study results suggest a general acceptance, but also indicate cultural variations in access to therapeutic and other social support systems, legal repercussions of substance use, societal perceptions of addiction, and the role of family and other social support in recovery. Taking these factors into consideration is likely to increase diffusion as well as effectiveness of these smartphone-based interventions.

2015 Philip S. Portoghese Medicinal Chemistry Lectureship. Curing Hepatitis C Virus Infection with Direct-Acting Antiviral Agents: The Arc of a Medicinal Chemistry Triumph

The development of direct-acting antiviral agents that can cure a chronic hepatitis C virus (HCV) infection after 8-12 weeks of daily, well-tolerated therapy has revolutionized the treatment of this insidious disease. In this article, three of Bristol-Myers Squibb's HCV programs are summarized, each of which produced a clinical candidate: the NS3 protease inhibitor asunaprevir (64), marketed as Sunvepra, the NS5A replication complex inhibitor daclatasvir (117), marketed as Daklinza, and the allosteric NS5B polymerase inhibitor beclabuvir (142), which is in late stage clinical studies. A clinical study with 64 and 117 established for the first time that a chronic HCV infection could be cured by treatment with direct-acting antiviral agents alone in the absence of interferon. The development of small molecule HCV therapeutics, designed by medicinal chemists, has been hailed as "the arc of a medical triumph" but may equally well be described as "the arc of a medicinal chemistry triumph".

Chronic hepatitis C virus (HCV) burden in Rhode Island: modelling treatment scale-up and elimination

We utilized a disease progression model to predict the number of viraemic infections, cirrhotic cases, and liver-related deaths in the state of Rhode Island (RI) under four treatment scenarios: (1) current HCV treatment paradigm (about 215 patients treated annually, Medicaid reimbursement criteria fibrosis stage ⩾F3); (2) immediate scale-up of treatment (to 430 annually) and less restrictive Medicaid reimbursement criteria (fibrosis stage ⩾F2); (3) immediate treatment scale-up and no fibrosis stage-specific Medicaid reimbursement criteria (⩾F0); (4) an 'elimination' scenario (i.e. a continued treatment scale-up needed to achieve >90% reduction in viraemic cases by 2030). Under current treatment models, the number of cirrhotic cases and liver-related deaths will plateau and peak by 2030, respectively. Treatment scale-up with ⩾F2 and ⩾F0 fibrosis stage treatment criteria could reduce the number of cirrhotic cases by 21·7% and 10·0%, and the number of liver-related deaths by 19·3% and 7·4%, respectively by 2030. To achieve a >90% reduction in viraemic cases by 2030, over 2000 persons will need to be treated annually by 2020. This strategy could reduce cirrhosis cases and liver-related deaths by 78·9% and 72·4%, respectively by 2030. Increased HCV treatment uptake is needed to substantially reduce the burden of HCV by 2030 in Rhode Island.

Hepatitis C Infection Among Hispanics in California

Hispanics in California are more likely to be infected with hepatitis C, and those infected have had their infection detected later. A total of 1,567 Hispanic and Caucasian individuals were tested for antibodies to hepatitis C from 2000 through 2013. Interviewers administered the Risk Behavior Assessment. Hepatitis C-infected Hispanics were incarcerated longer than hepatitis C-infected Caucasians, and they used marijuana less and illicit methadone more. They were more likely to use crack, heroin, speedballs, and to have been in methadone treatment. Hispanics need hepatitis C testing linked to methadone treatment and written information in Spanish and English.

Role of IL28-B Polymorphism (rs12979860) on Sustained Virological Response to Pegylated Interferon/Ribavirin in Iranian Patients With Chronic Hepatitis C

Background

The current medical treatment for hepatitis C virus (HCV) infection is pegylated interferon plus ribavirin, but just 50% of genotype 1 HCV patients and about 80% of HCV genotype 3 patients are treated completely. Recently, the rs12979860 C/T polymorphism, which is located 3 kb upstream of the IL28b gene that codes IFNλ3, shows a powerful association in response to the treatment in HCV patients.

Objectives

The aim of this study was to evaluate the relationship between IL28b single nucleotide polymorphism (SNP) and treatment outcomes among chronic HCV patients in Iran.

Patients and Methods

In this cross-sectional study, 108 blood samples were collected from chronic patients in Iran; 50 unrelated healthy subject samples were also collected. Genomic DNA was extracted, and rs12979860 SNP was done by PCR-RFLP. Finally, products were detected on 12% polyacrylamide gel electrophoresis.

Results

The analysis of data for C/T SNP showed that the CC genotype is more common in the control group than in the group of patients. In contrast, the frequency of TT as a mutant genotype is more frequent in patients than in uninfected people. In addition, results showed a statistically significant relationship between CC, CT, and TT genotypes in sensitive and resistant groups (P value: < 0.001, Or: 0.003, CI: 0-0.047). This relationship was also examined in terms of allele frequency, to determine whether the possibility of resistance to treatment in patients with T allele is more than in patients who carry C allele (P value: < 0.001).

Conclusions

These results showed a significant effect between rs12979860 SNP and sustained virological response (SVR) rate in Iranian patients with chronic HCV. To decrease the cost of long treatments and to prevent severe side effects, determining this polymorphism at the beginning of treatment can be very helpful for patients and physicians.

Risk Factors Associated with HCV Among Opioid-Dependent Patients in a Multisite Study

We examined risk factors associated with hepatitis C virus (HCV) infection among opioid-dependent patients enrolled into medication-assisted therapy (buprenorphine or methadone) to determine factors affecting chronic infection. Patients (N = 1039) were randomized as part of a larger, multisite clinical trial sponsored by the National Drug Abuse Treatment Clinical Trials Network assessing liver function. HCV status was first assessed with an antibody screen; if positive, then current infection was determined with an antigen screen testing for detectable virus. Patients were classified as HCV negative, HCV positive but have cleared the virus, or as having chronic HCV. Logistic regression analysis was used to examine demographic and behavioral correlates of the three groups. Thirty-four percent of patients were classified with chronic infection and 14% had evidence of prior infection with apparent clearing of the virus. Chronic infection was associated with recent injection drug use and cocaine use. Chronic HCV infection was also associated with being older and Hispanic. Age, ethnicity, and current drug use increase the likelihood of being chronically infected with HCV. Strategies targeting high risk subgroups can aid in preventing further disease escalation.

Kushenin induces the apoptosis of HCV-infected cells by blocking the PI3K-Akt-mTOR pathway via inhibiting NS5A

With the increased burden induced by HCV, there is an urgent need to develop better-tolerated agents with good safety. In this study, we evaluated the anti-HCV capability of kushenin, as well as the possible mechanism to Huh7.5-HCV cells. The results demonstrated that kushenin significantly inhibited the HCV-RNA level. Similarly, the expression of HCV-specific protein NS5A was also decreased. Molecular docking results displayed that kushenin bonded well to the active pockets of HCV NS5A, further confirming the effects of kushenin on HCV replication. Coimmunoprecipitation assay determined that kushenin suppressed the interaction between PI3K and NS5A in HCV-replicon cells. Furthermore, kushenin exerted an obviously induced function on HCV-replicon cells apoptosis by inhibiting PI3K-Akt-mTOR pathway, which could be ameliorated by the specific activator IGF-1 addition. Taken together, kushenin possesses the ability to inhibit HCV replication, and contributes to the increased apoptosis of HCV-infected cells by blocking the PI3K-Akt-mTOR pathway via inhibiting NS5A. Our results provide important evidence for a better understanding of the pathogenesis of HCV infection, and suggest that kushenin has the potential to treat HCV disease.

Coverage for hepatitis C drugs in Medicare Part D

OBJECTIVES

The recent arrival of new hepatitis C virus (HCV) drugs has brought fiscal pressures onto Medicare Part D; spending on HCV drugs in Part D jumped from $283 million in 2013 to $4.5 billion in 2014. We examined the current benefit designs for HCV drugs in Part D plans and analyzed patients' financial burden for those drugs.

STUDY DESIGN

A cross-sectional analysis of CMS' July 2015 Part D Plan Formulary File and the Wolters Kluwer Health Medi-Span Electronic Drug File v.2.

METHODS

We analyzed the type and amount of cost sharing for HCV drugs and the extent to which plans apply utilization management tools. We then estimated total out-of-pocket spending for beneficiaries to complete a course of treatment.

RESULTS

All Part D plans covered at least 1 recently introduced HCV drug, as of July 2015. Nearly all plans charged relatively high coinsurance and required prior authorization for new HCV drugs. For enrollees with no subsidy, the mean out-of-pocket spending needed to complete a course of treatment is substantial, ranging from $6297 to $10,889. For enrollees with a low-income subsidy, out-of-pocket spending varies between $10.80 and $1191.

CONCLUSIONS

Under the current Part D benefits, HCV drug users with no subsidy face sizable financial burdens, even with catastrophic coverage and the recent in-gap discount for brand name drugs. As baby boomers-the group most likely to have HCV-join Medicare, efforts should be made to ensure patient access to these needed drugs.

Antibody Response to Hypervariable Region 1 Interferes with Broadly Neutralizing Antibodies to Hepatitis C Virus

Hypervariable region 1 (HVR1) (amino acids [aa] 384 to 410) on the E2 glycoprotein of hepatitis C virus contributes to persistent infection by evolving escape mutations that attenuate binding of inhibitory antibodies and by blocking access of broadly neutralizing antibodies to their epitopes. A third proposed mechanism of immune antagonism is that poorly neutralizing antibodies binding to HVR1 interfere with binding of other superior neutralizing antibodies. Epitope mapping of human monoclonal antibodies (HMAbs) that bind to an adjacent, conserved domain on E2 encompassing aa 412 to 423 revealed two subsets, designated HC33 HMAbs. While both subsets have contact residues within aa 412 to 423, alanine-scanning mutagenesis suggested that one subset, which includes HC33.8, has an additional contact residue within HVR1. To test for interference of anti-HVR1 antibodies with binding of antibodies to aa 412 to 423 and other E2 determinants recognized by broadly neutralizing HMAbs, two murine MAbs against HVR1 (H77.16) and aa 412 to 423 (H77.39) were studied. As expected, H77.39 inhibited the binding of all HC33 HMAbs. Unexpectedly, H77.16 also inhibited the binding of both subsets of HC33 HMAbs. This inhibition also was observed against other broadly neutralizing HMAbs to epitopes outside aa 412 to 423. Combination antibody neutralization studies by the median-effect analysis method with H77.16 and broadly reactive HMAbs revealed antagonism between these antibodies. Structural studies demonstrated conformational flexibility in this antigenic region, which supports the possibility of anti-HVR1 antibodies hindering the binding of broadly neutralizing MAbs. These findings support the hypothesis that anti-HVR1 antibodies can interfere with a protective humoral response against HCV infection.

IMPORTANCE

HVR1 contributes to persistent infection by evolving mutations that escape from neutralizing antibodies to HVR1 and by shielding broadly neutralizing antibodies from their epitopes. This study provides insight into a new immune antagonism mechanism by which the binding of antibodies to HVR1 blocks the binding and activity of broadly neutralizing antibodies to HCV. Immunization strategies that avoid the induction of HVR1 antibodies should increase the inhibitory activity of broadly neutralizing anti-HCV antibodies elicited by candidate vaccines.

Hepatitis C virus in Mexican Americans: a population-based study reveals relatively high prevalence and negative association with diabetes

This study aimed to estimate the prevalence and risk factors for hepatitis C virus (HCV) infection in Mexican Americans living in South Texas. We tested plasma for the presence of HCV antibody from the Cameron County Hispanic Cohort (CCHC), a randomized, population-based cohort in an economically disadvantaged Mexican American community on the United States/Mexico border with high rates of chronic disease. A weighted prevalence of HCV antibody of 2·3% [n = 1131, 95% confidence interval (CI) 1·2-3·4] was found. Participants with diabetes had low rates of HCV antibody (0·4%, 95% CI 0·0-0·9) and logistic regression revealed a statistically significant negative association between HCV and diabetes (OR 0·20, 95% CI 0·05-0·77) after adjusting for sociodemographic and clinical factors. This conflicts with reported positive associations of diabetes and HCV infection. No classic risk factors were identified, but important differences between genders emerged in analysis. This population-based study of HCV in Mexican Americans suggests that national studies do not adequately describe the epidemiology of HCV in this border community and that unique risk factors may be involved.