Restrictions for reimbursement of interferon-free direct-acting antiviral drugs for HCV infection in Europe

The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review

Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.

Uptake of hepatitis C virus treatment in HIV/hepatitis C virus-coinfected patients across Europe in the era of direct-acting antivirals

BACKGROUND AND AIMS

To investigate the uptake of hepatitis C virus (HCV) therapy among HIV/HCV-coinfected patients in the pan-European EuroSIDA study between 2011 and 2016.

METHODS

All HCV-RNA+ patients were included. Baseline was defined as latest of anti-HCV+, January 2011 or enrolment in EuroSIDA. The incidence of starting first interferon-free direct-acting antiviral (DAA) therapy was calculated. Factors associated with starting interferon-free DAA were determined by Poisson regression.

RESULTS

Among 4308 HCV-RNA+ patients (1255, 970, 663, 633, 787 from South, West, North, Central East and East Europe, respectively) with 11 863 person-years of follow-up, 1113 (25.8%) started any HCV therapy. Among patients with at least F3 fibrosis, more than 50% in all regions remained untreated. The incidence (per 1000 person-years of follow-up, 95% confidence interval) of starting DAA increased from 7.8 (5.9-9.8) in 2014 to 135.2 (122.0-148.5) in 2015 and 128.9 (113.5-144.3) in 2016. The increase was highest in North and West and intermediate in South, but remained modest in Central East and Eastern Europe. After adjustment, women, individuals from Central East or East, genotype 3, antiretroviral therapy naïve and those with detectable HIV-RNA were less likely to start DAA. Older persons, those with HCV-RNA more than 500 000 IU/ml and those with more advanced liver fibrosis were more likely to start DAA.

CONCLUSION

Uptake of DAA therapy among HIV/HCV-coinfected patients increased considerably in Western Europe between 2014 and 2016, but was modest in Central East and East. In all regions more than 50% with at least F3 fibrosis remained untreated. Women were less likely to start DAA.

Beyond cure: patient reported outcomes of hepatitis C treatment among people who inject drugs in Australia

Background

Recent advances in the treatment of hepatitis C virus (HCV) infection provide the possibility of eliminating HCV as a public health threat. This focus on HCV elimination through treatment, however, is also driving a concomitant focus on ‘achieving cure’ as the primary outcome of treatment. The aim of this paper is to explore what people who inject drugs consider to be important in relation to outcomes of HCV treatment, and whether there are outcomes ‘beyond cure’ that might be important to understand as part of improving engagement in treatment.

Methods

A peer researcher with experience of both HCV treatment and injecting drug use conducted interviews with 24 people in the following groups in Melbourne, Australia: (1) people who had refused or deferred HCV treatment; (2) people who were actively thinking about, planning and/or about to commence HCV treatment; (3) people currently undertaking HCV treatment and (4) people who had recently completed HCV treatment.

Results

The findings show that people who inject drugs are seeking outcomes ‘beyond cure’ including improved physical and mental health, positive changes in identity and social relationships and managing future health and risk. Participants indicated that these other outcomes had not been addressed within their experience of HCV treatment.

Conclusion

While cure is an obvious outcome of HCV treatment, patients are seeking change in other areas of their lives. This study also provides valuable insights for the development of patient-reported measures in this context, which would be an important step towards more patient-centred approaches to HCV treatment.

Chronic Hepatitis C Association with Diabetes Mellitus and Cardiovascular Risk in the Era of DAA Therapy

Patients with chronic hepatitis C have both higher prevalence of diabetes mellitus type 2 (T2DM) and increased cardiovascular risk compared to never infected people. Sustained viral response (SVR) achievement led to decreasing incidence and prevalence of T2DM during the interferon era of HCV treatment. Currently, direct-acting antiviral drugs (DAA) are the gold standard for treating HCV infection, while yielding SVR in nearly all patients. In chronic HCV patients with T2DM (prediabetes most likely too), DAA therapy is associated with both better fasting glucose and glycated hemoglobin (HbA1C) controls; thus reducing pharmacotherapy in a certain part of patients is possible. Papers mentioned in the review confirmed DAA role in both total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) increase. This alteration was accompanied by an increase in high-density lipoprotein cholesterol (HDL-C) and a decrease in triglycerides (TG) verified by most of the studies. However, the clinical significance of lipoprotein alterations caused by DAA therapy has not been explained yet. Moreover, DAA treatment of chronic hepatitis C improves hypertension control and atherosclerotic plaques. It is very likely that DAA therapeutic regimens will decrease both T2DM prevalence and cardiovascular risk in chronic hepatitis C patients; further research, however, is needed.

A policy analysis exploring hepatitis C risk, prevention, testing, treatment and reinfection within Australia's prisons

Background

Hepatitis C (HCV) is a global public health concern. There is a global prevalence of 15% among the world’s prisoner population, suggesting the need for priority HCV treatment among this population group. New highly efficacious therapies with low side effects, known as directing-acting antivirals, became available under Australia’s universal healthcare scheme on 1 March 2016. This creates an opportune time to trial treatment as prevention as an elimination strategy for HCV in prison settings. This paper examines whether policies in Australian jurisdictions support treatment scale-up to achieve elimination among this priority population.

Methods

A comprehensive search was conducted using Google and other web-based search functions to locate all publicly available policies in each Australian state and territory related to HCV health and HCV-related prison health. Ministers (corrections and health) were contacted from each jurisdiction to identify any additional policies. Inductive and deductive analyses were conducted for each jurisdiction, with documents being assessed against a set of four a priori criteria. Documents included in the analysis were current at 1 September 2017, or 18 months following treatment availability.

Results

A total of 18 documents were located, including both health (n = 12) and corrections/prison health (n = 6) documents relevant to HCV. Jurisdictions ranged in their commitments for delivering HCV harm reduction strategies and treatment availability within the prison setting.

Conclusion

Few jurisdictions have updated or published HCV-related health or prisoner health policies following availability of directing-acting antivirals. Current policies do not provide effective support for implementing treatment scale-up that could be possible under universal access to HCV treatment among this priority population.

Uptake of and Expenditure on Direct-Acting Antiviral Agents for Hepatitis C Treatment in Australia

BACKGROUND

Direct-acting antiviral agents (DAAs) have revolutionised treatment for the hepatitis C virus (HCV). Currently, treatment costs between 20,000 and 80,000 Australian dollars ($A) per patient. The Australian Federal Government provided $A1 billion over 5 years to subsidise these drugs.

OBJECTIVE

The aim of this paper was to evaluate the uptake and financial impact of DAA prescribing in Australia.

METHODS

We undertook a retrospective analysis of Medicare prescription and expenditure data for March 2016 to August 2017. Prescription numbers and expenditure data were extracted from the Medicare Statistical Reports website. Numbers of prescriptions were converted to per capita rates. HCV prevalence measures were used to provide context to prescription rates. All costs were reported in $A, year 2017 values.

RESULTS

Nationally, 211,184 DAA prescriptions were reimbursed. Whilst $A3.6 billion was expended through the Pharmaceutical Benefits Scheme, confidential pricing agreements precluded calculation of the precise cost. In 18 months, estimated expenditure greatly exceeded the $A1 billion in funding for 5 years. Nationally, the rate of prescriptions was 872/100,000 individuals. Prescription rates were highest in the Australian Capital Territory (1087/100,000) and lowest in Western Australia (625/100,000) despite HCV prevalence being comparable to the national rate in both regions.

CONCLUSIONS

Uptake of DAAs has been enthusiastic in the first 18 months of this funding agreement. However, the lack of transparency due to the confidential special pricing agreements means actual government expenditure is unknown. Post-marketing review by the Pharmaceutical Benefits Advisory Committee may enable renegotiation of DAA prices with the sponsors.

'It's been a long haul, a big haul, but we've made it': hepatitis C virus treatment in post-transplant patients with virus recurrence: An interpretative phenomenological analysis

The lived experience of both interferon-based and new interferon-free treatments in patients with hepatitis C virus remains understudied. To explore their journey through hepatitis C virus treatment, we interviewed seven post-transplant patients with recurrent hepatitis C virus. Three themes were identified using interpretative phenomenological analysis. Participants reported an ongoing sense of ontological uncertainty characterized by lack of control over their condition and treatment. Furthermore, an apposition of scepticism and hope accompanying each stage of hepatitis C virus treatment was described. A staged approach to psychological intervention tailored to the needs of the patient and their associated 'stage' of hepatitis C virus treatment was recommended.

Uptake of direct-acting antiviral treatment for chronic hepatitis C in Australia

A government-funded interferon-free direct-acting antiviral (DAA) treatment programme for chronic hepatitis C virus (HCV) infection has been available in Australia since March 2016. This study assessed the levels and patterns of DAA treatment uptake during March-December 2016 in Australia and described the key features in the development of the programme. All prescriptions in Australia are submitted to the Pharmaceutical Benefits Scheme by dispensing pharmacies. Data on dispensed DAA prescriptions for a longitudinal cohort of individuals, representing a 10% random sample of the Pharmaceutical Benefits Scheme database, were used for estimating DAA treatment uptake and subgroup analyses. The estimated number of 32 400 individuals initiated DAA treatment in 2016, equating to 14% of people with chronic HCV infection in Australia. Most commonly prescribed DAA regimens included sofosbuvir/ledipasvir (56%, n = 18 020), sofosbuvir + daclatasvir (39%, n = 12 600) and sofosbuvir + other agents (4%, n = 1220). Among individuals initiated DAA treatment, 66% (n = 21 430) were men, 43% (n = 13 870) were ≤50 years old and 36% (n = 11 670) had cirrhosis. DAA prescriptions were 62% (n = 20 080) by specialists, 19% (n = 6000) by general practitioners (GP) and 20% (n = 6320) by other physicians. Proportion of individuals prescribed DAA by GPs increased from 8% to 31% and proportion of individuals ≤50 years old increased from 28% to 61% between March and December. In conclusion, rapid treatment scale-up was observed in the first 10 months of unrestricted DAA programme in Australia. The proportion of prescriptions by GPs increased over time, important for broadened access. A trend towards younger age treatment suggested the broadening of DAA-treated population, potentially including individuals at higher risk of HCV transmission.

Eliminating HIV/HCV co-infection in gay and bisexual men: is it achievable through scaling up treatment?

INTRODUCTION

Broad availability of direct-acting antiviral therapy for hepatitis C virus (HCV) raises the possibility that HCV prevalence and incidence can be reduced through scaling-up treatment, leading to the elimination of HCV. High rates of linkage to HIV care among HIV-infected gay and bisexual men may facilitate high uptake of HCV treatment, possibly making HCV elimination more achievable in this group. Areas covered: This review covers HCV elimination in HIV-infected gay and bisexual men, including epidemiology, spontaneous clearance and long term sequelae in the absence of direct-acting antiviral therapy; direct-acting antiviral therapy uptake and effectiveness in this group; HCV reinfection following successful treatment; and areas for further research. Expert commentary: Early data from the direct-acting antiviral era suggest that treatment uptake is increasing among HIV infected GBM, and SVR rates are very promising. However, in order to sustain current treatment rates, additional interventions at the behavioral, physician, and structural levels may be required to increase HCV diagnosis, including prompt detection of HCV reinfection. Timely consideration of these issues is required to maximize the population-level impact of HCV direct-acting antiviral therapy. Potential HCV transmissions from HIV-uninfected GBM, across international borders, and from those who are not GBM also warrant consideration.

Heterogeneity in hepatitis C treatment prescribing and uptake in Australia: a geospatial analysis of a year of unrestricted treatment access

Background and aim

Direct-acting antiviral (DAA) treatments became available for all people living with hepatitis C virus (HCV) in Australia in March 2016. We assess variations in treatment rates and prescribing patterns across Australia's 338 Statistical Area 3 (SA3) geographical units.

Methods

Geocoded DAA treatment initiation data were analysed for the period 1 March 2016 to 30 June 2017. Regression models tested associations between the population demographics and healthcare service coverage of geographical areas and (a) their treatment rates; and (b) the proportion of prescriptions written by specialists compared to non-specialists.

Results

Across the 320 areas (95%) recording treatments, a median 76 (interquartile range [IQR] 35-207, range 4-3834) per 100,000 were initiated, corresponding to an estimated median 7.9% (IQR 2.9-23.6%, range 0-100%) treatment uptake. Major cities, areas of socioeconomic advantage and areas with lower proportions of the population born overseas had the highest per capita treatment rates. Non-specialists prescribed 46% (20,323/44,382) of treatment initiations. Prescriptions were written by non-specialists only in 163 areas (51%), while in other areas a median 40.0% (IQR 21.8-62.5%) of prescriptions were written by non-specialists. Non-specialist prescribing was higher in regional areas, as well as areas that had greater proportions of Indigenous Australians.

Conclusions

High national-level treatment uptake of 20% in Australia masks underlying health system limitations; more than half of geographical areas may have treated less than 8% of people living with HCV. Areas of socioeconomic disadvantage and areas with a higher proportion of the population born overseas may need targeting with interventions to improve treatment uptake.

Is hepatitis C virus elimination possible among people living with HIV and what will it take to achieve it?

INTRODUCTION

The World Health Organization targets for hepatitis C virus (HCV) elimination include a 90% reduction in new infections by 2030. Our objective is to review the modelling evidence and cost data surrounding feasibility of HCV elimination among people living with HIV (PLWH), and identify likely components for elimination. We also discuss the real-world experience of HCV direct acting antiviral (DAA) scale-up and elimination efforts in the Netherlands.

METHODS

We review modelling evidence of what intervention scale-up is required to achieve WHO HCV elimination targets among HIV-infected (HIV+) people who inject drugs (PWID) and men who have sex with men (MSM), review cost-effectiveness of HCV therapy among PLWH and discuss economic implications of elimination. We additionally use the real-world experience of DAA scale-up in the Netherlands to illustrate the promise and potential challenges of HCV elimination strategies in MSM. Finally, we summarize key components of the HCV elimination response among PWLH.

RESULTS AND DISCUSSION

Modelling indicates HCV elimination among HIV+ MSM and PWID is potentially achievable but requires combination treatment and either harm reduction or behavioural risk reductions. Preliminary modelling indicates elimination among HIV+ PWID will require elimination efforts among PWID more broadly. Treatment for PLWH and high-risk populations (PWID and MSM) is cost-effective in high-income countries, but costs of DAAs remain a barrier to scale-up worldwide despite the potential low production price ($50 per 12 week course). In the Netherlands, universal DAA availability led to rapid uptake among HIV+ MSM in 2015/16, and a 50% reduction in acute HCV incidence among HIV+ MSM from 2014 to 2016 was observed. In addition to HCV treatment, elimination among PLWH globally also likely requires regular HCV testing, development of low-cost accurate HCV diagnostics, reduced costs of DAA therapy, broad treatment access without restrictions, close monitoring for HCV reinfection and retreatment, and harm reduction and/or behavioural interventions.

CONCLUSIONS

Achieving WHO HCV Elimination targets is potentially achievable among HIV-infected populations. Among HIV+ PWID, it likely requires HCV treatment scale-up combined with harm reduction for both HIV+ and HIV- populations. Among HIV+ MSM, elimination likely requires both HCV treatment and behaviour risk reduction among the HIV+ MSM population, the latter of which to date has not been observed. Lower HCV diagnostic and treatment costs will be key to ensuring scale-up of HCV testing and treatment without restriction, enabling elimination.

Hepcare Europe - bridging the gap in the treatment of hepatitis C: study protocol

BACKGROUND

Hepatitis C (HCV) infection is highly prevalent among people who inject drugs (PWID). Many PWID are unaware of their infection and few have received HCV treatment. Recent developments in treatment offer cure rates >90%. However, the potential of these treatments will only be realised if HCV identification among PWID with linkage to treatment is optimised. This paper describes the Hepcare Europe project, a collaboration between five institutions across four member states (Ireland, UK, Spain, Romania), to develop, implement and evaluate interventions to improve the identification, evaluation and treatment of HCV among PWID.

METHODS

A service innovation project and a mixed-methods, pre-post intervention study, Hepcare will design and deliver interventions in Dublin, London, Seville and Bucharest to enhance PWID engagement and retention in the cascade of HCV care.

RESULTS

The feasibility, acceptability, potential efficacy and cost-effectiveness of these interventions to improve care processes and outcomes among PWID will be evaluated.

CONCLUSION

Hepcare has the potential to make an important impact on patient care for marginalised populations who might otherwise go undiagnosed and untreated. Lessons learned from the study can be incorporated into national and European guidelines and strategies for HCV.

Hepatitis C: The beginning of the end-key elements for successful European and national strategies to eliminate HCV in Europe

Hepatitis C virus (HCV) infection is a major public health problem in the European Union (EU). An estimated 5.6 million Europeans are chronically infected with a wide range of variation in prevalence across European Union countries. Although HCV continues to spread as a largely "silent pandemic," its elimination is made possible through the availability of the new antiviral drugs and the implementation of prevention practices. On 17 February 2016, the Hepatitis B & C Public Policy Association held the first EU HCV Policy Summit in Brussels. This summit was an historic event as it was the first high-level conference focusing on the elimination of HCV at the European Union level. The meeting brought together the main stakeholders in the field of HCV: clinicians, patient advocacy groups, representatives of key institutions and regional bodies from across European Union; it served as a platform for one of the most significant disease elimination campaigns in Europe and culminated in the presentation of the HCV Elimination Manifesto, calling for the elimination of HCV in Europe by 2030. The launch of the Elimination Manifesto provides a starting point for action in order to make HCV and its elimination in Europe an explicit public health priority, to ensure that patients, civil society groups and other relevant stakeholders will be directly involved in developing and implementing HCV elimination strategies, to pay particular attention to the links between hepatitis C and social marginalization and to introduce a European Hepatitis Awareness Week.