Elimination of HCV as a public health concern among people who inject drugs by 2030 - What will it take to get there?

Reasons for Not Seeking Hepatitis C Treatment among People Who Inject Drugs

Despite increases in treatment uptake for hepatitis C viral infection (HCV) in Australia since the introduction of direct acting antiviral (DAA) therapy, a large proportion of HCV-infected people who inject drugs (PWID) have not sought treatment. Purpose/Objectives: To examine predictors of treatment uptake and reasons for not seeking treatment among PWID. Methods: PWID (n = 404) recruited through five needle and syringe programs in South East Queensland were interviewed about HCV testing, status and treatment, recent injecting drug use, mental health and reasons for not taking up treatment. Predictors of treatment uptake were examined using unadjusted and adjusted logistic regression analyses. Proportions were calculated for participants reporting each reason for not taking up treatment. Results: We recruited 404 PWID. Of those tested for HCV (94%), 55% were HCV antibody positive and 31% with active infection. Approximately 36% of eligible participants had begun or completed DAA treatment. In adjusted analyses, injecting drugs three or more times per day was associated with not taking up HCV treatment (p = 0.005). Common reasons for not seeking treatment ("applied a lot") included experiencing no HCV-related symptoms (25%), HCV treatment not being a priority (23%), fear of treatment side effects (18%), and no knowledge of DAA treatments (15%). Conclusions/Importance: HCV education efforts for PWID should target misperceptions and lack of awareness of DAA therapy, and highlight the likely benefits of treatment even when asymptomatic. The use of peer workers and increased investment in integrated treatment facilities will likely aid treatment uptake.

Increased case-finding and uptake of direct-acting antiviral treatment essential for micro-elimination of hepatitis C among people living with HIV: a national record linkage study

OBJECTIVES

Micro-elimination of hepatitis C virus (HCV) in people living with HIV (PLHIV) and co-infected with HCV has been proposed as a key contribution to the overall goal of HCV elimination. While other studies have examined micro-elimination in HIV-treated cohorts, few have considered HCV micro-elimination among those not treated for HIV or at a national level.

METHODS

Through data linkage of national and sentinel surveillance data, we examined the extent of HCV testing, diagnosis and treatment among a cohort of PLHIV in Scotland identified through the national database of HIV-diagnosed individuals, up to the end of 2017.

RESULTS

Of 5018 PLHIV, an estimated 797 (15%) had never been tested for HCV and 70 (9%) of these had undiagnosed chronic HCV. The odds of never having been tested for HCV were the highest in those not on HIV treatment [adjusted odds ratio (aOR) = 7.21, 95% confidence interval (CI): 5.15-10.10). Overall HCV antibody positivity was 11%, and it was at its highest among people who inject drugs (49%). Most of those with chronic HCV (91%) had attended an HCV treatment clinic but only half had been successfully treated (54% for those on HIV treatment, 12% for those not) by the end of 2017. The odds of never having been treated for HCV were the highest in those not on HIV treatment (aOR = 3.60, 95% CI: 1.59-8.15).

CONCLUSIONS

Our data demonstrate that micro-elimination of HCV in PLHIV is achievable but progress will require increased effort to engage and treat those co-infected, including those not being treated for their HIV.

The hepatitis C care cascade among people who inject drugs accessing harm reduction services in Catalonia: Major gaps for migrants

BACKGROUND

This study aimed to describe the HCV cascade of care among people who inject drugs (PWID) in Catalonia, as well as to compare the observed gaps in care between Spanish-born and migrant PWID.

METHODS

A cross-sectional study of PWID (N = 410) attending four harm reduction services (HRS) was performed in 2016-17 (HepCdetect II Study). Participants were tested for both HCV antibodies (rapid testing) and RNA (from dried blood spot samples). The HCV care cascade was estimated from HCV testing results combined with self-reported data on previous testing, diagnosis and treatment collected through a questionnaire. Logistic regressions were used to test for an association between migration status and the proportions observed in each step of the HCV care cascade adjusting for age, sex, years of injection, homelessness, and treatment for drug dependence.

RESULTS

Overall, 85.4% were men and 28.0% were migrants. Among Spanish-born (n = 295) and migrant (n = 115) PWID participants in the study, 96.6% vs. 88.6% had previously been HCV screened (AOR=3.11; 95% CI: 1.11-8.65), 79.3% vs. 80.9% were antibody positive, and 70.7% vs. 67.6% were HCV-RNA positive or cured with treatment; among the latter, 36.6% vs. 18.2% had started treatment (AOR=2.41; 95% CI: 1.09-5.34), and 20.6% vs. 9.1% had been cured by treatment, respectively. Unawareness of having hepatitis C was more common among migrants than Spanish-born PWID (46.0% and 31.5%, respectively; p<0.05).

CONCLUSION

This study estimates the HCV care cascade among Spanish-born and migrant PWID in Catalonia for the very first time, and highlights a higher attrition of migrant PWID in all HCV care cascade stages. The observed limited linkage to care and treatment by PWID that attend the HRS network warrants future implementation of decentralized diagnosis and antiviral treatment. Strategies focusing on migrants by increasing HCV screening coverage and treatment access will be especially relevant in our setting.

Innovative procedures for micro-elimination of HCV infection in persons who use drugs

People who use drugs are a key population in global HCV control. We evaluated the efficacy of an innovative model to eliminate HCV infection in a high-risk population of PWUD in a service for substance use disorder (SUD). Between January 2018 and December 2018, we conducted a prospective, interventional, before and after study, based on audits performed by Infectious Diseases physicians in a SUD facility in Piedimonte Matese, in southern Italy, to improve the knowledge about HCV infection; a shared protocol for screening and linkage to care of patients was implemented. The pre-intervention period was defined as January-December 2017 and the post-intervention period as January-December 2018. The subjects followed up at SUD facility in the pre-intervention and post-intervention periods were 318 and 275, respectively. Compared with the pre-intervention period, the number of anti-HCV-positive subjects tested for HCV RNA was higher in the post-intervention period (91% vs 27%, P < .0001), as was the number who started directly acting antivirals (DAAs). Of the 18 HCV RNA-positive subjects in the pre-intervention period, only 3 (16.6%) started DAA, a percentage decisively lower than that observed after the start of the programme, 63 (84%) of 75 subjects (P < .0001), and all obtained SVR. The data were similar for people who inject drugs (PWID) and non-PWID sub-populations. The use of our innovative model with close interaction between the Infectious Disease Unit and the SUD facility determined a significant increase in HCV RNA testing, linkage to care and the start of DAA in the PWUD population.

Hepatitis C virus infection in EU/EEA and United Kingdom prisons: opportunities and challenges for action

BACKGROUND

Hepatitis C virus (HCV) transmission in the European Union, European Economic Area and United Kingdom is driven by injecting drug use (IDU), which contributes to the high burden of chronic infection among people in prisons. This study aimed to describe the context, epidemiology and response targeting HCV in prisons across the region.

METHODS

We retrieved and collated HCV-related data from the World Health Organization's Health in Prisons European Database and the European Centre for Disease Prevention and Control's hepatitis C prevalence database. Prisons population data were obtained from the Council of Europe Annual Penal Statistics on prison populations (SPACE I).

RESULTS

There were 12 to 93,266 people in prisons, with rates of 31·5 to 234·9 per 100,000 population. Median age was between 31 and 40 years, with up to 72% foreign nationals. Average detention time ranged from one to 31 months. Ministries of Health had sole authority over prisons health, budget administration and funding in 27, 31 and 8% of 26 reporting countries, respectively. Seroprevalence of HCV antibodies ranged from 2·3% to 82·6% while viraemic infections ranged from 5·7% to 8·2%, where reported. Up to 25·8 and 44% reported current and ever IDU, respectively. Eight countries routinely offered HCV screening on an opt-out basis. Needle and syringe programmes were available in three countries. Among the nine countries with data, the annual number of those who had completed HCV treatment ranged between one and 1215 people in prisons.

CONCLUSIONS

HCV burden in prisons remains high, amidst suboptimal levels of interventions. Systematic monitoring at both local and regional levels is warranted, to advance progress towards the elimination of HCV in the region.

The Copenhagen test and treat hepatitis C in a mobile clinic study: a protocol for an intervention study to enhance the HCV cascade of care for people who inject drugs (T'N'T HepC)

INTRODUCTION

Injecting drug use is the primary driver of hepatitis C virus (HCV) infection in Europe. Despite the need for more engagement with care, people who inject drugs (PWID) are hard to reach with HCV testing and treatment. We initiated a study to evaluate the efficacy for testing and linkage to care among PWID consulting peer-based testing at a mobile clinic in Copenhagen, Denmark.

METHODS AND ANALYSIS

In this intervention study, we will recruit participants at a single community-based, peer-run mobile clinic. In a single visit, we will first offer participants a point-of-care HCV antibody test, and if they test positive, then they will receive an HCV RNA test. If they are HCV-RNA+, we will administer facilitated referrals to designated 'fast-track' clinics at a hospital or an addiction centre for treatment. The primary outcomes for this study are the number of tested and treated individuals. Secondary outcomes include individuals lost at each step in the care cascade.

ETHICS AND DISSEMINATION

The results of this study could provide a model for targeting PWID for HCV testing and treatment in Demark and other settings, which could help achieve WHO HCV elimination targets. The Health Research Ethics Committee of Denmark and the Danish Data Protection Agency confirmed (December 2018/January 2019) that this study did not require their approval. Study findings will be disseminated through peer-reviewed publications, conference presentations and social media.

Determinants of stigma among patients with hepatitis C virus infection

Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV treatment and elimination. The determinants of HCV-related stigma, including the impacts of stage of HCV treatment (ie spontaneously cleared; diagnosed, untreated; previously treated, not cured; currently being treated; and treated, cured) and coinfection with human immunodeficiency virus (HIV), remain unknown. To address these gaps, we conducted a cross-sectional study among patients with a history of HCV infection (n = 270) at outpatient clinics in Philadelphia from July 2018 to May 2019. We evaluated stigma using the validated HCV Stigma Scale, adapted from the Berger HIV Stigma Scale. Associations among HCV-related stigma and hypothesized demographic, behavioural, and clinical risk factors were evaluated by multivariable linear regression. Most participants (95.5%) experienced HCV-related stigma. Mean stigma scores did not differ significantly between HCV-monoinfected and HIV/HCV-coinfected participants (P = .574). However, we observed significant interactions between HIV status and multiple determinants; therefore, we stratified analyses by HIV status. Among HIV/HCV-coinfected participants, previous HCV treatment without cure, female gender, Hispanic/Latinx ethnicity and some college education were significantly associated with higher HCV-stigma scores. An annual income of $10 000-$40 000 was associated with significantly lower stigma scores. No significant associations were observed among HCV-monoinfected participants. We found that most participants experienced stigma associated with HCV diagnosis. While stigma scores were similar between HCV-monoinfected and HIV/HCV-coinfected participants, the determinants associated with HCV stigma differed by HIV status. Understanding how experiences of stigma differ between HCV-monoinfected and HIV/HCV-coinfected patients may aid in the development of targeted interventions to address the HCV epidemic.

Hepatitis C in 2020: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper

In 1989, a collaboration between the Centers for Disease Control (CDC) and a California biotechnology company identified the hepatitis C virus (HCV, formerly known as non-A, non-B hepatitis virus) as the causative agent in the epidemic of silent posttransfusion hepatitis resulting in cirrhosis. We now know that, the HCV genome is a 9.6 kb positive, single-stranded RNA. A single open reading frame encodes a 3011 amino acid residue polyprotein that undergoes proteolysis to yield 10 individual gene products, consisting of 3 structural proteins (core and envelope glycoproteins E1 and E2) and 7 nonstructural (NS) proteins (p7, NS2, NS3, NS4A, NS4B, NS5A, and NS5B), which participate in posttranslational proteolytic processing and replication of HCV genetic material. Less than 25 years later, a new class of medications, known as direct-acting antivirals (DAAs) which target these proteins, were introduced to treat HCV infection. These highly effective antiviral agents are now approved for use in children as young as 3 years of age and have demonstrated sustained virologic responses exceeding 90% in most genotypes. Although tremendous scientific progress has been made, the incidence of acute HCV infections has increased by 4-fold since 2005, compounded in the last decade by a surge in opioid and intravenous drug use. Unfortunately, awareness of this deadly hepatotropic virus among members of the lay public remains limited. Patient education, advocacy, and counseling must, therefore, complement the availability of curative treatments against HCV infection if this virus is to be eradicated.

SAR study of bisamides as cyclophilin a inhibitors for the development of host-targeting therapy for hepatitis C virus infection

The therapy of chronic hepatitis C virus infections has significantly improved with the development of direct-acting antivirals (DAAs), which contain NS3/4A protease, NS5A, and NS5B polymerase inhibitors. However, mutations in specific residues in these viral target genes are associated with resistance to the DAAs. Especially inhibitors of NS3/4A protease and NS5A, such as grazoprevir and velpatasvir, have a low barrier to resistant mutations. As a result, the mutations influence the virological outcomes after DAA treatment. CypA inhibitors, as host-targeted agents, act on host factors to inhibit HCV replication, exhibiting a high resistance barrier and pan-genotype activities against HCV. Therefore, they can be developed into alternative, more effective anti-HCV agents. However, CypA inhibitors are natural products and analogs. Based on previous studies, bisamide derivatives were designed and synthesized to develop a novel class of CypA inhibitors. Bisamide derivative 7c is a promising compound with potent anti-HCV activity at subtoxic concentrations. Surface plasmon resonance experiments revealed that 7c directly binds to CypA. All these studies indicated that the derivative 7c is a potent CypA inhibitor, which can be used as a host-targeted agent in combination with other antiviral agents for anti-HCV treatment.

2020 Taiwan consensus statement on the management of hepatitis C: Part (II) special populations

Hepatitis C virus (HCV) infection is a silent killer that leads to rapid progression of liver cirrhosis and hepatocellular carcinoma (HCC). High prevalence of HCV infection has been reported in Taiwan, especially in high-risk populations including people who inject drugs (PWID) and patients requiring dialysis. Besides, certain populations merit special considerations due to suboptimal outcome, potential drug-drug interaction, or possible side effect. Therefore, in the second part of this 2-part consensus, the Taiwan Association for the Study of the Liver (TASL) proposes the treatment recommendations for the special population in order to serve as guidance to optimizing the outcome in the direct-acting antiviral (DAA) era. Special populations include patients with acute or recent HCV infection, previous DAA failure, chronic kidney disease, decompensated cirrhosis, HCC, liver and other solid organ transplantations, receiving an HCV viremic organ, hepatitis B virus (HBV) and HCV dual infection, HCV and human immunodeficiency virus (HIV) coinfection, active tuberculosis infection, PWID, bleeding disorders and hemoglobinopathies, children and adolescents, and pregnancy. Moreover, future perspectives regarding the management of hepatitis C are also discussed and summarized in this consensus statement.

Validation of hepatitis C virus RNA detection using capillary blood by finger prick (GenXpert system)-Hepatitis C fingerprick study

To achieve the ambitious goals of the WHO to eliminate hepatitis C virus (HCV) infection as a public health threat by 2030, innovative approaches are needed to improve the uptake for screening and treatment in people who inject drugs (PWID). Important barriers to care are difficult venous access and the two-step approach in current point-of-care tests, using an HCV antibody screening test followed by a confirmatory HCV RNA test. In this study, we aimed to validate the new GenXpert instrument to diagnose HCV RNA by finger prick. This prospective study was conducted in a cohort of PWID in 6 alcohol/drug clinic sites and 1 outreach project in Belgium between January 2018 and March 2019. Plasma and capillary whole-blood samples were collected by venepuncture and finger prick, respectively. Sensitivity and specificity of the GenXpert system were compared to the gold standard Artus HCV RNA kit. Of 153 participants enrolled, 147 (96.1%) had results of both the GenXpert system and Artus HCV RNA kit available. HCV RNA was detected in 35 of 147 (23.8%) by the Artus HCV RNA kit and in 36 of 147 (24.8%) by the GenXpert. Median quantitative HCV RNA viral load on finger prick was 28 700 IU/mL (IQR 4070-65 875) vs 1 900 000IU/mL (IQR 416,466-2,265,510) on plasma. The GenXpert instrument had a sensitivity of 100% (95% CI 90%-100%) and a specificity of 99.1% (95.1%-99.9%). The overall diagnostic accuracy was 99.3% (96.3%-99.9%). This study validates the excellent performance of the GenXpert instrument to assess HCV RNA in capillary whole blood by finger prick in a PWID cohort.

Pre-treatment antiviral resistance in Australians with chronic hepatitis C: prevalence of NS3 and NS5A resistance data in the state of New South Wales

BACKGROUND

Direct-acting antivirals (DAAs) have revolutionized HCV treatment, but the impact of antiviral resistance at a population level is still not clear. The majority of patients who fail DAA therapy develop resistance-associated substitutions (RASs), which can impact re-treatment. There is potential for resistance prevalence to rise in the community with treatment scale up, due to transmission of resistant virus. Monitoring for increasing antiviral resistance requires a reliable baseline, yet there are few published data on the prevalence of HCV resistance in Australia. The aim of this study was to determine the prevalence of RASs among untreated Australians with HCV genotype-1a infection, to inform ongoing surveillance.

METHODS

A cross-sectional study was performed at a single large university hospital pathology laboratory in Australia. Archived blood samples referred for HCV genotype testing were analysed. All patients were naive to DAAs. The prevalence of RASs in the HCV NS3 and NS5A regions was determined using Sanger based population sequencing.

RESULTS

Of 379 samples tested, 34% contained DAA-resistant virus: 24% had resistance to NS3 protease inhibitors, 12% had NS5A inhibitor resistance and 4% of patients had resistance to both drug classes. Clinically relevant RASs conferring resistance against NS5A inhibitors ledipasvir, daclatasvir and elbasvir were detected in 5.8% of samples.

CONCLUSIONS

This is the largest study of HCV antiviral drug resistance in Australia, which differs from resistance prevalence in the USA. The results provide valuable data on the baseline prevalence of HCV resistance, which can be used in the future to monitor for increasing antiviral resistance.

Motivations, facilitators and barriers to accessing hepatitis C treatment among people who inject drugs in two South African cities

Background

Treatment of hepatitis C (HCV) among people who inject drugs (PWID) is a critical component of efforts to eliminate viral hepatitis. A recent study found high HCV prevalence among PWID in two cities, Pretoria (84%) and Cape Town (44%). Very few (< 5%) HCV-infected individuals attended follow-up appointments. This sub-study explores differences between stated desire for cure and appointment attendance in light of perceived facilitators and barriers to HCV treatment and care access among PWID.

Method

Two sets of semi-structured interviews were implemented in a group of HCV-infected participants opportunistically sampled and recruited at harm reduction service sites. Initial interviews, conducted before the planned hospital appointment date, asked participants (N = 17, 9 in Pretoria and 8 in Cape Town) about past experiences of healthcare provision, plans to attend their referral appointment and perceived barriers and facilitators to seeking hepatitis treatment. Second interviews (n = 9, 4 in Pretoria, 5 in Cape Town), conducted after the planned referral appointment date, asked about appointment attendance and treatment experience. Trained social scientists with experience with PWID conducted the interviews which were recorded in detailed written notes. Data was thematically analysed in NVivo 11.

Results

Despite routine experiences of being stigmatised by the healthcare system in the past, most participants (n = 16, 94%) indicated a desire to attend their appointments. Attendance motivators included the desire to be cured, fear of dying and the wish to assist the research project. Perceived barriers to appointment attendance included fear of again experiencing stigmatisation and concerns about waiting periods and drug withdrawal. Perceived facilitators included the knowledge they would be treated quickly, and with respect and access to opioid substitution therapy. In the end, very few participants (n = 5) went to their appointment. Actual barriers to attendance included lack of finances, lack of urgency and forgetting and fatalism about dying.

Conclusions

South Africa can learn from other countries implementing HCV treatment for PWID. Successful linkage to care will require accessible, sensitive services where waiting time is limited. Psychosocial support prior to initiating referrals that focuses on building and maintaining a sense of self-worth and emphasising that delayed treatment hampers health outcomes is needed.

Addressing Hepatitis C in the American Incarcerated Population: Strategies for Nationwide Elimination

PURPOSE OF REVIEW

The prevalence of Hepatitis C virus (HCV) in the US incarcerated population is disproportionately high, and when inmates with infection are released back into the general population, they play a substantial role in the spread of disease. This review provides support for targeting the jail/prison population to eliminate HCV in the general population. It will also summarize various screening/treatment models to curtail the burden of disease behind and beyond bars.

RECENT FINDINGS

Transitioning from risk-based testing to opt-out testing in prisons/jails would be cost-effective through greater identification of cases and treatment to prevent complications from cirrhosis. Other innovative strategies, such as the nominal pricing mechanism or the "Netflix" DAA subscription model, have the potential to be cost-effective and to increase access to treatment. Addressing HCV in the incarcerated population is a strategy to bring the US closer to successfully eradicating the epidemic. Such findings should incentivize policymakers to implement care models that target this population.

Progress Toward Hepatitis C Virus Elimination: Therapy and Implementation

The World Health Organization has called for the elimination of hepatitis C virus (HCV) as a public health threat by 2030. Highly effective direct-acting antiviral agents provide the therapeutic tools required for elimination. In the absence of a vaccine, HCV elimination will require enhanced primary prevention and an increase in the proportions of people diagnosed and treated. Given that globally only 20% of people with chronic HCV are diagnosed, and around 5% have initiated HCV treatment, the task ahead is enormous. But, global public health needs optimism, and countries currently on track for HCV elimination provide a pathway forward.

Harm Reduction Coverage and Hepatitis C Incidence: Findings From a Cohort of People Who Inject Drugs

INTRODUCTION

Needle and syringe programs and opioid agonist therapy are essential for harm reduction among people who inject drugs. Few studies assess their combined potential in preventing hepatitis C virus infection. No studies have assessed whether they perform similarly among individuals at risk of primary and recurrent infection. This study aimed to estimate the rates of hepatitis C virus acquisition according to harm reduction coverage among hepatitis C virus-naive and previously infected people who inject drugs in Montreal, Canada.

METHODS

This prospective cohort study involved regular interviews and hepatitis C antibody and RNA testing (data collection: 2010-2017, analysis: 2018). Opioid agonist therapy coverage was defined by current dose: high (≥60 mg/day methadone, ≥16 mg buprenorphine), low, or none. Complete needle and syringe program coverage was defined as exclusively reporting safe needle and syringe sources (past 6 or 3 months). Combined coverage was defined as full (high-dose agonist/complete needle/syringe coverage), minimal (low-dose agonist/incomplete needle/syringe coverage), and partial (remaining combinations). Cox regression models were fit.

RESULTS

A total of 106 events were observed over 1,183.1 person-years for primary and recurrent incidence rates of 10.6 (95% CI=8.0, 13.8) and 7.6 (95% CI=5.6, 9.9) per 100 years, respectively. High-dose opioid agonist therapy was associated with a 77% reduction in hepatitis C virus acquisition (hazard ratio=0.23, 95% CI=0.10, 0.50) compared with not receiving opioid agonist therapy. Needle and syringe coverage was not associated with infection rates. Estimates considering their combination reflected opioid agonist therapy coverage. Associations were similar among hepatitis C virus-naive and previously infected people who inject drugs.

CONCLUSIONS

High-dose opioid agonist therapy seems particularly important to reduce drug-related harms among hepatitis C virus-naive and previously infected people who inject drugs in Montreal.

Peer outreach point-of-care testing as a bridge to hepatitis C care for people who inject drugs in Toronto, Canada

BACKGROUND

People who inject drugs have high rates of hepatitis C (HCV) and yet many remain undiagnosed and untreated. HCV treatment guidelines and elimination strategies recommend task-shifting to expand where, and by whom, HCV testing and care is delivered.

METHODS

A randomized controlled trial design was used to evaluate if point-of-care (POC) HCV antibody testing by peer outreach workers outside of health and social service spaces would improve engagement in HCV care. People with a lifetime history of injection drug use without prior knowledge of HCV antibody status were randomized to receive HCV outreach plus either POC or referral to community-based HCV program for testing as usual. The study was co-designed by people with lived experience of HCV.

RESULTS

920 people were approached to participate over 14 weeks. After refusals, withdrawals and removal of duplicates, there were 380 study participants. Outreach took place primarily in public spaces (66%) such as parks, coffee shops and apartment lobbies. Participants reported very high rates of poverty, housing instability and recent injection drug use. Despite being at high risk for HCV, 61% had no history or knowledge of past HCV testing (n = 230). Of those who received a POC test 77/195 (39%) were positive for HCV antibodies. There was no change in rates of engagement in HCV care among those who received the POC (n = 6; 3%) compared to those who did not (n = 5; 3%).

CONCLUSION

Peer outreach workers were able to efficiently reach a marginalized group of individuals who had a high HCV antibody prevalence and low rates of prior HCV testing. This improved participants' knowledge of their HCV antibody status, but that knowledge in itself did not lead to any change in participant's subsequent engagement in HCV care. Future work is required to evaluate strategies such as incentives or peer navigators to improve linkage to HCV care after diagnosis.

HIV control programs reduce HIV incidence but not HCV incidence among people who inject drugs in HaiPhong, Vietnam

In Vietnam, harm reduction programs to control HIV among people who inject drugs (PWID) were implemented approximately 10 years ago. Since then, the HIV prevalence has declined in this population, however, the impact of these programs on the rate of new HIV and Hepatitis C (HCV) infections remains unknown as high mortality can exceed the rate of new infections. We evaluated HIV and HCV incidences in a cohort of active PWID in HaiPhong in 2014, who were recruited from a community-based respondent driven sampling (RDS) survey and followed for 1 year. Only HIV-negative or HCV-negative participants not on medication assisted treatment (MAT) were eligible. HIV/HCV serology was tested at enrollment and at 32- and 64-week follow-up visits. Among 603 RDS participants, 250 were enrolled in the cohort, including 199 HIV seronegative and 99 HCV seronegative PWID. No HIV seroconversion was reported during the 206 person-years (PY) of follow-up (HIV incidence of 0/100PY, one-sided 97.5%CI:0-1.8/100 PY). Eighteen HCV seroconversions were reported for an incidence of 19.4/100 PY (95%CI;11.5-30.7). In multivariate analysis, "Injecting more than twice daily" was associated with HCV seroconversion with an adjusted odds ratio of 5.8 (95%CI;1.8-18.1). In Hai Phong, in a context that demonstrates the effectiveness of HIV control programs, the HCV incidence remains high. New strategies such as mass access to HCV treatment should be evaluated in order to tackle HCV transmission among PWID.

From risk to care: the hepatitis C screening and diagnostic cascade in a primary health care clinic in Karachi, Pakistan-a cohort study

BACKGROUND

In the high-prevalence setting of Pakistan, screening, diagnosis and treatment services for chronic hepatitis C (CHC) patients are commonly offered in specialized facilities. We aimed to describe the cascade of care in a Médecins Sans Frontières primary health care clinic offering CHC care in an informal settlement in Karachi, Pakistan.

METHODS

This was a retrospective cohort analysis using routinely collected data. Three different screening algorithms were assessed among patients with one or more CHC risk factors.

RESULTS

Among the 87 348 patients attending the outpatient clinic, 5003 (6%) presented with one or more risk factors. Rapid diagnostic test (RDT) positivity was 38% overall. Approximately 60% of the CHC patients across all risk categories were in the early stage of the disease, with an aspartate aminotransferase:platelet ratio index score <1. The sequential delays in the cascade differed between the three groups, with the interval between screening and treatment initiation being the shortest in the cohort tested with GeneXpert onsite.

CONCLUSIONS

Delays between screening and treatment can be reduced by putting in place more patient-centric testing algorithms. New strategies, to better identify and treat the hidden at-risk populations, should be developed and implemented.

Untreated alcohol use disorder in people who inject drugs (PWID) in France: a major barrier to HCV treatment uptake (the ANRS-FANTASIO study)

BACKGROUND AND AIMS

Although people who inject drugs (PWID) are the core at-risk population in the hepatitis C virus (HCV) epidemic in industrialized countries, few initiate treatment. Alcohol use disorder (AUD), common within this population, has been identified as a barrier to HCV treatment uptake in the general population. We investigated whether the arrival of new and well-tolerated HCV treatments (direct-acting antivirals: DAA) has improved HCV treatment uptake in French PWID compared with former treatments (pegylated interferon-based treatments: Peg-IFN).

DESIGN

Using discrete-time Cox proportional hazards models based on exhaustive care delivery data, we tested for associations between AUD (defined by AUD-related long-term illness status, diagnosis coding during hospitalization and/or AUD pharmacological treatment) and first HCV treatment delivery, after adjusting for gender, age, complementary universal health cover, liver disease severity and type of opioid agonist therapy (OAT) received. Separate analyses were performed for 2012-13 (Peg-IFN era) and 2014-16 (DAA era).

SETTING

France.

PARTICIPANTS

All French people chronically HCV-infected who received OAT at least once during 2012-16 and were covered by the national health insurance (n = 24 831).

MEASUREMENTS

Incidence rate of HCV treatment uptake, hazard ratios associated with AUD and other covariates.

FINDINGS

Incidence rate (IR) of HCV treatment uptake per 100 person-years was 6.56, confidence interval (CI) = 6.30-6.84; and IR = 5.70, 95% CI = 5.51-5.89 for Peg-IFN-based treatment (2012-13) and DAA (2014-16), respectively. After multiple adjustment, people with AUD not receiving related medication had 30 and 14% lower Peg-IFN-based treatment and DAA uptake, respectively, than those without AUD [hazard ratio (HR) = 0.70, 95% CI = 0.62-0.80 and HR = 0.86, 95% CI = 0.78-0.94]. No difference was observed between those treated for AUD and those without AUD.

CONCLUSIONS

Despite the benefits of direct-acting antiviral treatment, untreated alcohol use disorder appears to remain a major barrier to hepatitis C virus treatment access for people who inject drugs in France.

Validation of a modified Berger HIV stigma scale for use among patients with hepatitis C virus (HCV) infection

BACKGROUND

Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV prevention, treatment, and elimination. To date, no validated instrument exists to measure patients' experiences of HCV stigma. This study aimed to revise the Berger (2001) HIV stigma scale and evaluate its psychometric properties among patients with HCV infection.

METHODS

The Berger HIV stigma scale was revised to ask about HCV and administered to patients with HCV (n = 270) in Philadelphia, Pennsylvania. Scale reliability was evaluated as internal consistency by calculating Cronbach's alpha. Exploratory factor analysis was performed to evaluate construct validity by comparing item clustering to the Berger HIV stigma scale subscales. Item response theory was employed to further evaluate individual items and to calibrate items for simulated computer adaptive testing sessions in order to identify potential shortened instruments.

RESULTS

The revised HCV Stigma Scale was found to have good reliability (α = 0.957). After excluding items for low loadings, the exploratory factor analysis indicated good construct validity with 85% of items loading on pre-defined factors. Analyses strongly suggested the predominance of an underlying unidimensional factor solution, which yielded a 33-item scale after items were removed for low loading and differential item functioning. Adaptive simulations indicated that the scale could be substantially shortened without detectable information loss.

CONCLUSIONS

The 33-item HCV Stigma Scale showed sufficient reliability and construct validity. We also conducted computer adaptive testing simulations and identified shortened six- and three-item scale alternatives that performed comparably to the original 40-item scale.

Economic Evaluation of Hepatitis C Treatment Extension to Acute Infection and Early-Stage Fibrosis Among Patients Who Inject Drugs in Developing Countries: A Case of China

We aimed to assess the cost-effectiveness of (1) treating acute hepatitis C virus (HCV) vs. deferring treatment until the chronic phase and (2) treating all chronic patients vs. only those with advanced fibrosis; among Chinese genotype 1b treatment-naïve patients who injected drugs (PWID), using a combination Daclatasvir (DCV) plus Asunaprevir (ASV) regimen and a Peg-interferon (PegIFN)-based regimen, respectively. A decision-analytical model including the risk of HCV reinfection simulated lifetime costs and quality-adjusted life-years (QALYs) of three treatment timings, under the DCV+ASV and PegIFN regimen, respectively: Treating acute infection (“Treat at acute”), treating chronic patients of all fibrosis stages (“Treat at F0 (no fibrosis)”), treating only advanced-stage fibrosis patients (“Treat at F3 (numerous septa without cirrhosis)”). Incremental cost-effectiveness ratios (ICERs) were used to compare scenarios. “Treat at acute” compared with “Treat at F0” was cost-saving (cost: DCV+ASV regimen—US$14,486.975 vs. US$16,224.250; PegIFN-based regimen—US$19,734.794 vs. US$22,101.584) and more effective (QALY: DCV+ASV regimen—14.573 vs. 14.566; PegIFN-based regimen—14.148 vs. 14.116). Compared with “Treat at F3”; “Treat at F0” exhibited an ICER of US$3780.20/QALY and US$15,145.98/QALY under the DCV+ASV regimen and PegIFN-based regimen; respectively. Treatment of acute HCV infection was highly cost-effective and cost-saving compared with deferring treatment to the chronic stage; for both DCV+ASV and PegIFN-based regimens. Early treatment for chronic patients with DCV+ASV regimen was highly cost-effective.

Syringe Service Program Utilization, Barriers, and Preferences for Design in Rural Appalachia: Differences between Men and Women Who Inject Drugs

Background People who inject drugs (PWID) in rural areas of the United States have had limited access to syringe service programs (SSP). Rural SSP have recently surged, but accompanying research is lacking about PWID utilization, barriers, and preferences for SSP design and how those preferences vary by gender. Methods: Interviewer-administered surveys elicited information about utilization, barriers, and preferences for SSP design from 234 PWID recruited using respondent-driven sampling in Appalachian, Kentucky. Gender differences among reported barriers to utilizing SSP and preferences for program design were explored using Mantel-Haenszel chi-square tests. Results: Overall, 49% of PWID had ever utilized an SSP. The most common reasons for not utilizing an SSP were lack of awareness (23%), fear of being seen or disclosing drug use (19%), and lack of need (19%). The most preferred SSP design was located within a health department (74%) and operating during afternoon hours (66%). Men were more likely than women to prefer SSP in health departments (80% vs. 65%, p = 0.01), while more women than men preferred staffing by health department personnel (62% vs. 46%, p = 0.02). Women were less likely to favor evening hours (55% vs. 70%, p = 0.02). Fewer women wanted SSP nurses (78% vs. 90%, p = 0.01), social workers (11% vs. 24%, p = 0.01), or people who use drugs (20% vs 34%, p = 0.02) to staff SSP. Conclusions: Despite recent scale-up, SSP in Appalachia remain under-utilized. PWID were open to a range of options for SSP design and staffing, though there were variations by gender. Implementation research that identifies best strategies for tailored SSP scale-up in rural settings should be considered.

An Investigation of the Side Effects, Patient Feedback, and Physiological Changes Associated with Direct-Acting Antiviral Therapy for Hepatitis C

Background: Hepatitis C virus (HCV) infection is one of the major causes of liver cirrhosis and hepatocellular carcinoma globally. The advent of direct-acting antivirals (DAAs) with high cure rates provides an opportunity to reduce the rising HCV disease burden. However, few studies have explored the side effects and physiological benefits of DAA therapy in rural areas. The aim of this study was to investigate the subjective reports of discomfort, patient feedback about the course of treatment, and physiological changes after DAA treatment in HCV patients. Methods: A descriptive, prospective, comparative cohort study was conducted from January to August 2019 in western coastal Yunlin County, Taiwan. Data regarding demographic characteristics, subjective discomfort levels, and physiological responses were collected through face to face interviews and from medical records by a cooperating hospital. Results: Six-hundred-and-twenty-three participants with an active HCV infection were identified; 555 (89.1%) had completed treatment, and sustained virologic response was achieved in 99.6% (n = 553). The mean age was 64.9 (standard deviation = 13.1) years, and 35% of patients experienced discomfort during DAA treatment, including fatigue, itching, and dizziness. After three months of treatment, physiological markers, including body weight (p < 0.001), waist circumference (p < 0.05), blood pressure (p < 0.001), alanine aminotransferase (p < 0.001), and aspartate aminotransferase (p < 0.001), had significantly improved. Almost all participants provided positive feedback about the treatment experience and reported manageable side effects. Conclusions: The findings showed that, in an endemic rural area, DAA treatment had a high cure rate and improved physiological markers with few discomforts. These results can be used to reduce the barriers HCV patients face in adopting new medications.

Utility of a one-step screening and diagnosis strategy for viremic HCV infection among people who inject drugs in Catalonia

BACKGROUND

In Catalonia (Spain), people who inject drugs (PWID) face numerous barriers to access to mainstream healthcare services for hepatitis C confirmatory diagnosis and treatment, so simplified testing strategies for viremic infection are urgently needed. Among PWID attending harm-reduction services in Catalonia, we aimed (i) to assess the utility of an in-house HCV-RNA detection assay on dried blood spots (DBS) as a one-step screening and confirmatory diagnosis strategy for hepatitis C, (ii) to estimate the prevalence of viremic HCV infection, and (iii) to identify factors associated with unawareness of viremic infection.

METHODS

A cross-sectional study of current PWID (N  = 410) was performed in four harm-reduction services. All participants underwent HCV antibody point-of-care testing and parallel DBS collection for centralized RNA testing. An epidemiological questionnaire was administered. Paired EDTA-plasma samples were additionally collected for HCV viral load testing in 300 participants.

RESULTS

HCV-RNA testing from DBS was feasible and showed 97.2% sensitivity and 100% specificity for viral loads >3000 IU/mL in real-life conditions. No significant differences in the performance when detecting viremic infections were observed between this one-step testing strategy vs. the conventional two-step algorithm involving venepuncture. Overall HCV seroprevalence was 79.8%, and prevalence of viremic infection was 58.5%. Importantly, 35.8% of viremic HCV participants were unaware of their status, and no specific socio-demographic or bio-behavioral factors independently associated with unawareness of viremic infection were identified. Among participants reporting a past or current HCV infection, 29.0% stated having received HCV antiviral treatment.

CONCLUSION

The high viremic HCV infection burden among PWID attending HRS, estimated for the first time in Catalonia, together with the low levels of awareness of viremic status and access to treatment, suggest that scaling up this one-step screening and diagnosis strategy to the network of harm-reduction services would help to achieve HCV elimination targets set by the World Health Organization.

A systematic review and meta-analysis of community and primary-care-based hepatitis C testing and treatment services that employ direct acting antiviral drug treatments

Background

Direct Acting Antiviral (DAAs) drugs have a much lower burden of treatment and monitoring requirements than regimens containing interferon and ribavirin, and a much higher efficacy in treating hepatitis C (HCV). These characteristics mean that initiating treatment and obtaining a virological cure (Sustained Viral response, SVR) on completion of treatment, in non-specialist environments should be feasible. We investigated the English-language literature evaluating community and primary care-based pathways using DAAs to treat HCV infection.

Methods

Databases (Cinahl; Embase; Medline; PsycINFO; PubMed) were searched for studies of treatment with DAAs in non-specialist settings to achieve SVR. Relevant studies were identified including those containing a comparison between a community and specialist services where available. A narrative synthesis and linked meta-analysis were performed on suitable studies with a strength of evidence assessment (GRADE).

Results

Seventeen studies fulfilled the inclusion criteria: five from Australia; two from Canada; two from UK and eight from USA. Seven studies demonstrated use of DAAs in primary care environments; four studies evaluated integrated systems linking specialists with primary care providers; three studies evaluated services in locations providing care to people who inject drugs; two studies evaluated delivery in pharmacies; and one evaluated delivery through telemedicine. Sixteen studies recorded treatment uptake. Patient numbers varied from around 60 participants with pathway studies to several thousand in two large database studies. Most studies recruited less than 500 patients. Five studies reported reduced SVR rates from an intention-to-treat analysis perspective because of loss to follow-up before the final confirmatory SVR test. GRADE assessments were made for uptake of HCV treatment (medium); completion of HCV treatment (low) and achievement of SVR at 12 weeks (medium).

Conclusion

Services sited in community settings are feasible and can deliver increased uptake of treatment. Such clinics are able to demonstrate similar SVR rates to published studies and real-world clinics in secondary care. Stronger study designs are needed to confirm the precision of effect size seen in current studies. Prospero: CRD42017069873.

Innovative strategies for the elimination of viral hepatitis at a national level: A country case series

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost-effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence-gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

Hep-CORE: a cross-sectional study of the viral hepatitis policy environment reported by patient groups in 25 European countries in 2016 and 2017

Introduction

The first World Health Organization (WHO) global health sector strategy on hepatitis B and C viruses (HBV and HCV) has called for the elimination of viral hepatitis as a major public health threat by 2030. This study assesses policies and programmes in support of elimination efforts as reported by patient groups in Europe.

Methods

In 2016 and 2017, hepatitis patient groups in 25 European countries participated in a cross‐sectional survey about their countries’ policy responses to HBV and HCV. The English‐language survey addressed overall national response; public awareness/engagement; disease monitoring; prevention; testing/diagnosis; clinical assessment; and treatment. We performed a descriptive analysis of data and compared 2016 and 2017 findings.

Results

In 2017, 72% and 52% of the 25 European study countries were reported to not have national HBV and HCV strategies respectively. The number of respondents indicating that their governments collaborated with civil society on viral hepatitis control increased from 13 in 2016 to 18 in 2017. In both 2016 and 2017, patient groups reported that 9 countries (36%) have disease registers for HBV and 11 (44%) have disease registers for HCV. The number of countries reported to have needle and syringe exchange programmes available in all parts of the country dropped from 10 (40%) in 2016 to 8 in 2017 (32%). In both 2016 and 2017, patient groups in 5 countries (20%) reported that HCV treatment is available in non‐hospital settings. From 2016 to 2017, the reported number of countries with no restrictions on access to direct‐acting antivirals for HCV increased from 3 (12%) to 7 (28%), and 5 fewer countries were reported to refuse treatment to people who are currently injecting drugs.

Conclusions

The patient‐led Hep‐CORE study offers a unique perspective on the readiness of study countries to undertake comprehensive viral hepatitis elimination efforts. Viral hepatitis monitoring should be expanded to address policy issues more comprehensively and to incorporate civil society perspectives, as is the case with global HIV monitoring. Policy components should also be explicitly added to the WHO framework for monitoring country‐level progress against viral hepatitis.

Research gaps in viral hepatitis

Introduction

The World Health Organization has aimed for global elimination of both hepatitis B virus (HBV) and hepatitis C virus (HCV) by 2030. Treatments available to cure HCV and control HBV, as well as vaccination to prevent HBV infection, have certainly allowed for such bold goals, yet the final steps to usher in elimination require further evidence.

Discussion

We broadly discuss the needs for three major public health approaches. First, an effective vaccine exists for HBV and mass‐vaccination campaigns have resulted in decreases in hepatitis B surface antigen seroprevalence and overall rates of liver‐related morality. Still, HBV vaccination coverage is poor in certain regions of the world, while the reasons for such low coverage require further study. A prophylactic vaccine is probably needed to eliminate HCV, but is not being readily developed. Second, identifying HBV/HCV infected individuals remains a priority to increase awareness of disease status, particularly for key populations. Research evaluating large‐scale implementation of novel, rapid and mobile point‐of‐care tests would be helpful to determine whether increased awareness is achievable in these settings. Third, antiviral therapy allows for strong HBV suppression and HCV cure, while its access depends on financial factors among many others. Although there is strong evidence to treat key populations and specific groups with progressed disease, as stated in current guidelines, the advantages of extending treatment eligibility to decrease onward spread of HBV/HCV infection and prevent further burden of disease are lacking “real world” evidence. Novel anti‐HBV treatments are being developed to target intrahepatocellular HBV replication, but are still in the early phases of clinical development. Each of the strategies mentioned above has specific implications for HIV infection.

Conclusions

There are certainly effective tools to combat the spread of viral hepatitis and treat infected individuals – yet how they are able to reach key populations, and the infrastructure required to do so, continue to represent the largest research gap when evaluating the progress towards elimination. Continuously adapted and informed research is required to establish the priorities in achieving elimination goals.

High rates of early HCV reinfection after DAA treatment in people with recent drug use attended at mobile harm reduction units

BACKGROUND AND AIMS

The World Health Organization recently called for the elimination of hepatitis C virus (HCV) and has identified people who inject drugs (PWID) as a key target population. Clinical trials analyzing currently available all-oral regimens have demonstrated a high degree of efficacy in this population, with a relatively low reinfection rate. There is an urgent need to confirm these data in a harm reduction and active consumption setting. The primary aim of this study was to evaluate the HCV reinfection rate in people with recent drug use followed at low-threshold mobile harm reduction units.

METHOD

We included people with recent drug use (smoked or injected heroin/cocaine in the previous 6 months) who received HCV treatment and were attended at two low-threshold mobile harm reduction units over 19 months. Sustained virologic response was assessed 12 weeks after therapy (SVR12). The incidence density of HCV reinfection was defined as the number of reinfections per 100-person years (PY) using person-time of observation and was stratified by drug consumption at initiation of HCV treatment. Cox proportional hazard regression analysis was used to assess factors associated with reinfection.

RESULTS

During the study period, 160 people who used drugs in the past 6 months completed HCV therapy. 122 (73.9%) and 88 (53.3%) reported injecting drug use in the 6 months and 30 days prior to HCV treatment, respectively. The overall SVR12 was 68% in the ITT analysis (reinfection = failure) and 90.7% in the modified intent-to-treat analysis (considering reinfections as response and removing people who were missing SVR data). The cohort at-risk for reinfection (n = 121) included 47 (39.2%) people who initiated HCV treatment with recently reported abstinence. Reinfection was identified in 10 persons (8.3%), and the median time to reinfection was 7.2 (IQR 4.2-18) months. Total follow-up time at-risk was 101.1-PY (median 0.6 years, IQR 0.3-1.3). The overall incidence of reinfection was 9.8 per 100-PY (95% CI 4.7,18.2). The incidence of reinfection was higher amongst those who had injected drugs in the previous 6 months (16.7 [95%CI 8.0; 30.7] per 100-PY) and in the previous 30 days (18.9 [95% CI 8.1; 37.2] per 100-PY). In the adjusted analysis, only injecting drugs use in the month prior to initiation of HCV therapy was associated with reinfection (aHR 8.7, 95%CI 1.0; 73.6; p 0.04).

CONCLUSION

High efficacy of HCV treatment, was found in people with recent drug use attended and followed at low-threshold mobile harm reduction units. The high rate of early HCV reinfections in this setting should promote surveillance for reinfection at 7-month intervals after ending the treatment or earlier.

Direct-acting antiviral treatment for hepatitis C, reinfection and mortality among people attending an inner-city community health centre in Victoria, Canada

BACKGROUND

Direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) has been shown to be effective among PWID, but more real-world data on treatment outcomes is needed. The aim of this analysis was to assess the efficacy of DAA therapy, and the rate of reinfection and mortality among people attending an inner-city community health centre in Victoria, Canada.

METHODS

In this retrospective study, patients treated with DAA therapy between November 2014 and Dec 31, 2017 were included. Retrospective chart review was performed to assess recent injecting drug use (IDU, previous six months) or receipt of opioid agonist treatment (OAT). The primary endpoint was Sustained Virologic Response (SVR12). Secondary endpoints included HCV reinfection and mortality.

RESULTS

Of 270 patients who initiated DAA treatment (31% female), 20% (n=54) had HIV/HCV coinfection, 32% (n=84) had cirrhosis, 67% (n=181) had genotype 1, 6% (n=15) had genotype 2, 26% (n=69) had genotype 3. 46% (n=125) of patients were receiving OAT and 49% (n=132) reported recent IDU. 98% (n=265) completed treatment; two people stopped due to mental health, two people died, and one was non-adherent. 92% (249 of 270) achieved SVR12. 16 patients with End of Treatment (EOT) response did not have a SVR12; 7 were lost to follow-up; 2 people refused bloodwork; 2 people died; 1 had reinfection; and 4 had viral relapse. There was no difference in SVR12 by OAT (OAT, 93% vs. no OAT, 91%, P=0.435), recent injecting drug use (yes, 92% vs. no, 92%, P=0.904), or HIV status (HIV, 92% vs. no HIV, 94%, P=0.498). Eight cases of HCV reinfection were observed over 253 person-years of follow up (3.2 cases per 100 person-years; 95% CI 1.6-6.3). Twenty people died (6.3 per 100 person-years; 95% CI 3.9-10.3), including two during therapy (drug overdose, n=2) and 18 following therapy completion (drug overdose, n=7).

CONCLUSION

This study demonstrates that DAA treatment is effective among a marginalized population receiving care in an inner-city community health centre. The high mortality in this study highlights the importance of integrating HCV care within a framework addressing drug-related harms, preventing overdose mortality, addressing social inequalities, and improving the health of PWID.

Point-of-care hepatitis C testing from needle and syringe programs: An Australian feasibility study

BACKGROUND

Achieving hepatitis C elimination requires novel approaches to engage people at highest risk of infection into care pathways. Point-of-care-tests may help to overcome some of the barriers preventing people who inject drugs (PWID) accessing testing and progressing to treatment for hepatitis C virus (HCV). We assessed the feasibility and acceptability of HCV point-of-care testing at needle and syringe exchange programs (NSPs) co-located in three community health clinics in Melbourne, Australia.

METHODS

NSP clients were offered an oral fluid point-of-care test for HCV antibody by NSP staff. Positive HCV antibody tests were followed by a point-of-care test for HCV RNA alongside standard-of-care laboratory testing for hepatitis C treatment work-up. Participants were offered same-day point-of-care results on site, via phone or text message, or upon return to the service. Participants were scheduled for follow-up review with the study nurse for assessment and linkage to treatment.

RESULTS

A total of 174 participants completed HCV antibody point-of-care test; 150 (86%) had a reactive result. Of these, 140 (93%) underwent a HCV RNA point-of-care test and 76 (54%) tested positive; few participants (5%) waited on site for results delivery, but the majority of RNA positive (63%) attended a follow-up visit for treatment work-up (median time to follow-up visit = 11 days; IQR = 7-20 days). The majority of participants reported a preference for point-of-care tests (66%) and supported NSP staff involvement in testing (90%).

CONCLUSION

Provision of HCV point-of-care tests, follow-up and linkage to treatment services through NSPs was feasible and acceptable to PWID. Despite few participants waiting to receive same-day results, there was effective linkage to care, suggesting value in further evaluation of this approach.

Endocarditis in the setting of IDU: multidisciplinary management

PURPOSE OF REVIEW

The purpose of this article is to provide a brief overview of the medical and surgical management of infective endocarditis secondary to IDU, with a focus on the underlying substance use disorder.

RECENT FINDINGS

Patients with infective endocarditis secondary to IDU are often young with unique comorbidities including mental illness, chronic hepatitis C, HIV infection, which are often compounded by limited social and familial supports. The focus of management has been treatment of endocarditis using IV antibiotics alongside surgery. Surgical outcomes compare favorably with those of infective endocarditis in the general population but long-term outcomes of IDUs are significantly worse. This is primarily due to the high rate of recidivism of drug use and the risk of prosthetic valve infective endocarditis. Contemporary management of addiction utilizes an integrative approach, combining both pharmacologic and nonpharmacologic strategies while remaining patient-centered. Given the complexity of care required, we advocate for a multidisciplinary team-based approach including psychiatry, infectious disease, cardiology, cardiac surgery and social services.

SUMMARY

Infective endocarditis secondary to IDU remains a medical and surgical challenge with dismal outcomes. Here we offer practical suggestions on the multidisciplinary management of this challenging and high-risk patient cohort.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

A Randomized Controlled Trial of Cash Incentives or Peer Support to Increase HCV Treatment for Persons With HIV Who Use Drugs: The CHAMPS Study

Background

Despite access to direct-acting antivirals, barriers to a hepatitis C virus (HCV) cure persist, especially among persons living with human immunodeficiency virus (HIV) (PLWH) who use drugs. Interventions such as peer mentors or cash incentives may improve the care continuum.

Methods

The CHAMPS (Chronic HepAtitis C Management to ImProve OutcomeS) study randomized 144 PLWH, recruited from an outpatient clinic, with substance use disorders into three treatment groups: usual care (UC) (n = 36), UC plus cash incentives (n = 54), and UC plus peer mentors (n = 54) to evaluate HCV treatment uptake and cure. All participants received 12-weeks of ledipasvir/sofosbuvir (LDV/SOF). Trained peer mentors had well-controlled HIV and HCV. Cash incentives were contingent on visit attendance (maximum $220). The primary endpoint was HCV treatment initiation; secondary endpoints included sustained virologic response (SVR) and HCV reinfection.

Results

The majority of participants were male (61%), Black (93%), and unemployed (85%). Depression and active drug and alcohol use were common. Overall, 110 of 144 (76%) participants initiated LDV/SOF. Although treatment initiation rates were higher in PLWH randomized to peers (83%, 45 of 54) or cash (76%, 41 of 54) compared to UC (67%, 24 of 36), these differences were not statistically significant (P = .11). Most PLWH who initiated treatment achieved SVR (100 of 110, 91%). LDV/SOF was well tolerated; peers and cash had no effect on drug and alcohol use during therapy. One individual from the cash cohort experienced HCV reinfection.

Conclusion

After removal of system barriers, one-third of PLWH in UC did not initiate HCV treatment. Among those who initiated, SVR rates were high. Research involving PLWH who use drugs should focus on overcoming barriers to treatment initiation.

Clinical trial information

The registration data for the trial are in the ClinicalTrials.gov database, number NCT02402218.

Cost Effectiveness of Early Treatment with Direct-Acting Antiviral Therapy in Adolescent Patients with Hepatitis C Virus Infection

OBJECTIVE

To evaluate the cost effectiveness of early treatment with direct-acting antiviral therapy in adolescent patients with chronic hepatitis C virus (HCV) infection compared with treatment deferral.

STUDY DESIGN

We constructed a Markov model to assess the cost effectiveness of treating a hypothetical cohort of 30 000 adolescent patients with chronic HCV at age 12 years compared with deferring treatment until adulthood from a societal perspective. Model inputs for transition probabilities, HCV treatment and medical care costs, and quality-adjusted life-year (QALY) utilities were derived from the literature and wholesale acquisition estimates. Deterministic sensitivity analyses varied parameters for non-HCV medical care and treatment cost, reinfection rates, treatment uptake, disease progression, liver transplant survival, and treatment with recently approved pangenotypic direct-acting antiviral agents. Discounted costs and total QALYs per person were quantified after 30 years. Cost effectiveness was evaluated as the incremental change in total medical costs per QALY gained.

RESULTS

The incremental cost effectiveness of early treatment initiation compared with deferred treatment was approximately $27 000 per QALY gained after 30 years and considered cost effective. In a scenario analysis, hypothetical treatment initiation with currently available pangenotypic agents would be even more cost effective, ranging from $10 000 to $21 000 per QALY gained. Cost-effectiveness estimates were sensitive to variations in decompensated cirrhosis progression in adolescence, adult reinfection, and treatment uptake in adults.

CONCLUSIONS

Early treatment in adolescent patients with chronic HCV infection with currently available direct-acting antivirals seems to be cost effective compared with deferred treatment. Future efforts to control the HCV epidemic should include increasing the number of children treated.

Direct-Acting Antiviral Treatment Failure Among Hepatitis C and HIV-Coinfected Patients in Clinical Care

Background

There are limited data on the real-world effectiveness of direct-acting antiviral (DAA) treatment in patients coinfected with hepatitis C virus (HCV) and HIV—a population with complex challenges including ongoing substance use, cirrhosis, and other comorbidities. We assessed how patient characteristics and the appropriateness of HCV regimen selection according to guidelines affect treatment outcomes in coinfected patients.

Methods

We included all patients who initiated DAA treatment between November 2013 and July 2017 in the Canadian Co-Infection Cohort. Sustained virologic response (SVR) was defined as an undetectable HCV RNA measured between 10 and 18 weeks post-treatment. We defined treatment failure as virologic failure, relapse, or death without achieving SVR. Bayesian logistic regression was used to estimate the posterior odds ratios (ORs) associated with patient demographic, clinical, and treatment-related risk factors for treatment failure.

Results

Two hundred ninety-five patients initiated DAAs; 31% were treatment-experienced, 29% cirrhotic, and 80% HCV genotype 1. Overall, 92% achieved SVR (263 of 286, 9 unknown), with the highest rates in females (97%) and lowest in cirrhotics (88%) and high-frequency injection drug users (89%). Many patients (38%) were prescribed regimens that were outside current clinical guidelines. This did not appreciably increase the risk of treatment failure—particularly in patients with genotype 1 (prior odds ratio [OR], 1.5; 95% credible interval [CrI], 0.38–6.0; posterior OR, 1.0; 95% CrI, 0.40–2.5).

Conclusions

DAAs were more effective than anticipated in a diverse, real-world coinfected cohort, despite the use of off-label, less efficacious regimens. High-frequency injection drug use and cirrhosis were associated with an increased risk of failure.

Strategies to Reduce Hepatitis C Virus Reinfection in People Who Inject Drugs

Reinfection after direct-acting antiviral therapy may pose a challenge to hepatitis C virus elimination efforts. Reinfection risk is cited as a reason for not offering treatment to people who inject drugs. As treatment scale-up expands among populations with risks for reacquisition, acknowledgment that reinfection can and will occur is essential. Efforts to prevent and manage reinfection should be incorporated into individual- and population-level strategies. The risk of reinfection after successful treatment emphasises the need for education, harm reduction, and posttreatment surveillance. Reinfection must not be considered an impediment to treatment, if hepatitis C virus elimination is to be achieved.

Global, regional, and country-level estimates of hepatitis C infection among people who have recently injected drugs

BACKGROUND AND AIMS

People who have recently injected drugs are a priority population in efforts to achieve hepatitis C virus (HCV) elimination. This study estimated the prevalence and number of people with recent injecting drug use living with HCV, and the proportion of people with recent injecting drug use among all people living with HCV infection at global, regional and country-levels.

METHODS

Data from a global systematic review of injecting drug use and HCV antibody prevalence among people with recent (previous year) injecting drug use were used to estimate the prevalence and number of people with recent injecting drug use living with HCV. These data were combined with a systematic review of global HCV prevalence to estimate the proportion of people with recent injecting drug use among all people living with HCV.

RESULTS

There are an estimated 6.1 million [95% uncertainty interval (UI) = 3.4-9.2] people with recent injecting drug use aged 15-64 years living with HCV globally (39.2% viraemic prevalence; UI = 31.6-47.0), with the greatest numbers in East and Southeast Asia (1.5 million, UI = 1.0-2.1), eastern Europe (1.5 million, UI = 0.7-2.4) and North America (1.0 million, UI = 0.4-1.7). People with recent injecting drug use comprise an estimated 8.5% (UI = 4.6-13.1) of all HCV infections globally, with the greatest proportions in North America (30.5%, UI = 11.7-56.7), Latin America (22.0%, UI = 15.3-30.4) and eastern Europe (17.9%, UI = 8.2-30.9).

CONCLUSIONS

Although, globally, 39.2% of people with recent injecting drug use are living with hepatitis C virus (HCV) and 8.5% of all HCV infections occur globally among people with recent injecting drug use, there is wide variation among countries and regions.

Glecaprevir/pibrentasvir for the treatment of chronic hepatitis C virus infection

In recent years, management of chronic hepatitis C virus (HCV) infection has been revolutionized by the availability of oral direct-acting antivirals (DAAs), which have significantly better efficacy and safety profiles than interferon-containing regimens. Simple, short-duration DAA therapies will facilitate expansion of HCV treatment to nonspecialist providers, which will be vital to achieve the WHO target of eliminating chronic HCV as a major public health threat by 2030. Coformulated glecaprevir/pibrentasvir is the only 8-week, pan-genotypic, 2-DAA regimen recommended by international guidelines as a first-line regimen in treatment-naive, noncirrhotic HCV genotype 1-6 patients. This review provides a comprehensive summary of the pharmacodynamic and pharmacokinetic parameters, efficacy, safety and place in the HCV treatment paradigm for glecaprevir/pibrentasvir.

Understanding the Determinants of BnAb Induction in Acute HCV Infection

Despite recent advances in curative therapy, hepatitis C virus (HCV) still remains a global threat. In order to achieve global elimination, a prophylactic vaccine should be considered high priority. Previous immunogens used to induce broad neutralising antibodies (BnAbs) have been met with limited success. To improve immunogen design, factors associated with the early development of BnAbs in natural infection must first be understood. In this study, 43 subjects identified with acute HCV were analysed longitudinally using a panel of heterogeneous HCV pseudoparticles (HCVpp), to understand the emergence of BnAbs. Compared to those infected with a single genotype, early BnAb development was associated with subjects co-infected with at least 2 HCV subtypes during acute infection. In those that were mono-infected, BnAbs were seen to emerge with increasing viral persistence. If subjects acquired a secondary infection, nAb breadth was seen to boost upon viral re-exposure. Importantly, this data highlights the potential for multivalent and prime-boost vaccine strategies to induce BnAbs against HCV in humans. However, the data also indicate that the infecting genotype may influence the development of BnAbs. Therefore, the choice of antigen will need to be carefully considered in future vaccine trials.

Update on global epidemiology of viral hepatitis and preventive strategies

Viral hepatitis is one of the major public health concerns around the world but until recently it has drawn little attention or funding from global health policymakers. Every year 1.4 million people die from viral hepatitis-related cirrhosis and liver cancer. However, the majority of the infected population are unaware of their condition. This population have significant obstacles to overcome such as lack of awareness, vulnerability, increased migration, disease stigma, discrimination, as well as poor health resources, conflict in policy development and program implementation. Despite implementing infection control measures over the last few decades eradication or significant disease reduction remains elusive. This study aims to present the current global prevalence status and examines potential elimination strategies. The information for this research were obtained through a systematic review, published scientific literatures, the official websites of various government organisations, international public health organisations and internationally recognised regulatory bodies over a period of 40 years between 1978 and 2018.

Real-world outcomes of unrestricted direct-acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience

In March 2016, the Australian government offered unrestricted access to direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow-up. 14.2% were lost to follow-up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04-2.18, P = .03), prison-based treatment (OR 2.02, 95% CI 1.08-3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97-0.99, P = .05). Of the 1534 subjects completing treatment and follow-up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07-0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12-0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve-month period in conjunction with a shift from hospital to community-based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real-world cohort due to LTFU. A declining treatment initiation rate and shift to community-based treatment highlight the need to explore additional strategies to identify, treat and follow-up remaining patients in order to achieve elimination targets.

Hepatitis C virus reinfection after successful treatment with direct-acting antiviral therapy in a large population-based cohort

BACKGROUND & AIMS

Direct-acting antiviral therapies (DAA) are an important tool for hepatitis C virus (HCV) elimination. However, reinfection among people who inject drugs (PWID) may hamper elimination targets. Therefore, we estimated HCV reinfection rates among DAA-treated individuals, including PWID.

METHODS

We analyzed data from the British Columbia Hepatitis Testers Cohort which included ∼1.7 million individuals screened for HCV in British Columbia, Canada. We followed HCV-infected individuals treated with DAAs who achieved a sustained virologic response (SVR) and had ≥1 subsequent HCV RNA measurement to April 22nd, 2018. Reinfection was defined as a positive RNA measurement after SVR. PWID were identified using a validated algorithm and classified based on recent (<3 years) or former (≥3 years before SVR) use. Crude reinfection rates per 100 person-years (PYs) were calculated. Poisson regression was used to model adjusted incidence rate ratios (IRRs) and 95% CIs.

RESULTS

Of 4,114 individuals who met the inclusion criteria, most were male (n = 2,692, 65%), born before 1965 (n = 3,411, 83%) and were either recent (n = 875, 21%) or former PWID (n = 1,793, 44%). Opioid-agonist therapy (OAT) was received by 19% of PWID. We identified 40 reinfections during 2,767 PYs. Reinfection rates were higher among recent (3.1/100 PYs; IRR 6.7; 95% CI 1.9-23.5) and former PWID (1.4/100 PYs; IRR 3.7; 95% CI 1.1-12.9) than non-PWID (0.3/100 PYs). Among recent PWID, reinfection rates were higher among individuals born after 1975 (10.2/100 PYs) and those co-infected with HIV (5.7/100 PYs). Only one PWID receiving daily OAT developed reinfection.

CONCLUSIONS

Population-level reinfection rates remain elevated after DAA therapy among PWID because of ongoing exposure risk. Engagement of PWID in harm-reduction and support services is needed to prevent reinfections.

LAY SUMMARY

Direct-acting antivirals are an effective tool for the treatment of hepatitis C virus, enabling the elimination of the virus. However, some patients who have been successfully treated with direct-acting antivirals are at risk of reinfection. Our findings showed that the risk of reinfection was highest among people with recent injection drug use. Among people who inject drugs, daily use of opioid-agonist therapy was associated with a lower risk of reinfection.

Acceptability and preferences of point-of-care finger-stick whole-blood and venepuncture hepatitis C virus testing among people who inject drugs in Australia

BACKGROUND

Uptake of hepatitis C virus (HCV) testing remains inadequate globally. Simplified point-of-care tests should enhance HCV diagnosis and elimination. We aimed to assess the acceptability of finger-stick and venepuncture HCV RNA testing among people who inject drugs (PWID).

METHODS

Participants were enrolled in an observational cohort study with recruitment at 13 sites between June 2016 and February 2018. Capillary whole-blood collected by finger-stick and plasma collected by venepuncture were performed for Xpert^® HCV viral load testing. Participants completed a questionnaire on acceptability of, and preferences for, blood collection methods.

RESULTS

Among 565 participants (mean age, 44 years; 69% male), 64% reported injecting drugs in the last month, and 63% were receiving opioid substitution treatment. Eighty three percent reported that finger-stick testing was very acceptable. Overall, 65% of participants preferred finger-stick over venepuncture testing, with 61% of these preferring to receive results in 60 min. The most common reason for preferring finger-stick over venepuncture testing was it was quick (62%) followed by venous access difficulties (21%). The main reasons for preferring venepuncture over finger-stick testing were that it was quick (61%) and accurate (29%). Females were more likely to prefer finger-stick testing than males (adjusted OR 1.96; 95% CI 1.30, 2.99; p = 0.002). Among people with recent (previous month) injecting drug use, Aboriginal and/or Torres Strait Islander people were less likely than non-Aboriginal people to prefer finger-stick testing (adjusted OR 0.57; 95% CI 0.34, 0.9; p = 0.033).

CONCLUSIONS

Finger-stick whole-blood collection is acceptable to people who inject drugs, with males and Aboriginal and/or Torres Strait Islander people with recent injecting drug use less likely to prefer finger-stick testing. Further research is needed to evaluate interventions integrating simplified point-of-care HCV testing to engage people in care in a single-visit, thereby facilitating HCV treatment scale-up.

Direct-acting antiviral therapy for hepatitis C infection among people receiving opioid agonist treatment or heroin assisted treatment

BACKGROUND

Treating chronic hepatitis C virus (HCV) infection among PWID (people who inject drugs) is crucial to achieve the WHO goal of HCV elimination, as this population is highly affected and carries a high risk of transmission. The aim of our study was to provide real-life data on HCV treatment among PWID either in opioid agonist treatment (OAT) or in heroin-assisted treatment (HAT) in a low-threshold access primary care-based addiction medicine institution.

METHODS

We conducted a retrospective chart analysis of patients treated with direct-acting antivirals (DAA) between 10/2014 and 08/2017 in the Arud outpatient clinics in Zurich, Switzerland. We reported patient and treatment characteristics and substance use. The outcomes were sustained virological response (SVR) by intention-to-treat (ITT) and modified ITT (mITT) analyses, excluding patients with missing SVR data.

RESULTS

We included 64 patients in our analysis. Forty-two (66%) were in OAT, and 22 (34%) were in HAT. Twenty-six patients (41%) reported harmful alcohol use, and 9 patients (14%) reported injecting drug use during DAA treatment. Every patient completed the treatment. Fifty-nine out of 64 achieved SVR resulting in an ITT SVR rate of 92.2%. Two patients had virological failure. Three patients were lost to follow-up between the end of treatment and SVR12 visit. Excluding these 3 patients, our study showed an mITT SVR rate of 96.7%.

CONCLUSION

PWID can be treated with DAA treatment integrated in OAT and HAT with an excellent SVR rate. OAT and HAT programs should offer integrated HCV treatment to their patients.

Hepatitis C virus genotype 3: clinical features, current and emerging viral inhibitors, future challenges

Hepatitis C virus (HCV) represents a global burden on healthcare that affects over 150 million people worldwide. In the past, HCV genotype 3 was considered difficult to treat relative to other genotypes. Genotype 3 has been associated with a higher rate of complications, including fatty liver disease, fibrosis, hepatocellular carcinoma and mortality. However, with the advent of first- and second-generation direct-acting antivirals, genotype 3 can be treated effectively. Additionally, these new drugs are well tolerated by patients and have significantly fewer side effects compared to ribavirin and interferon-based regimens. However, while great strides have been made in overcoming biological barriers, our next challenge lies in overcoming economic and financial obstacles if we are to eradicate HCV genotype 3. Herein, we review the clinical features associated with HCV genotype 3, current and emerging treatment regimens, and challenges associated with treatment.