Predictors of treatment in patients with chronic hepatitis C infection - role of patient versus nonpatient factors

A Longitudinal Analysis of Mortality Related to Chronic Viral Hepatitis and Hepatocellular Carcinoma in the United States

(1) Background: Hepatocellular carcinoma (HCC) contributes to the significant burden of cancer mortality in the United States (US). Despite highly efficacious antivirals, chronic viral hepatitis (CVH) remains an important cause of HCC. With advancements in therapeutic modalities, along with the aging of the population, we aimed to assess the contribution of CVH in HCC-related mortality in the US between 1999-2020. (2) Methods: We queried all deaths related to CVH and HCC in the multiple-causes-of-death files from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) database between 1999-2020. Using the direct method of standardization, we adjusted all mortality information for age and compared the age-adjusted mortality rates (AAMRs) across demographic populations and by percentile rankings of social vulnerability. Temporal shifts in mortality were quantified using log-linear regression models. (3) Results: A total of 35,030 deaths were identified between 1999-2020. The overall crude mortality increased from 0.27 in 1999 to 8.32 in 2016, followed by a slight reduction to 7.04 in 2020. The cumulative AAMR during the study period was 4.43 (95% CI, 4.39-4.48). Males (AAMR 7.70) had higher mortality rates compared to females (AAMR 1.44). Mortality was higher among Hispanic populations (AAMR 6.72) compared to non-Hispanic populations (AAMR 4.18). Higher mortality was observed in US counties categorized as the most socially vulnerable (AAMR 5.20) compared to counties that are the least socially vulnerable (AAMR 2.53), with social vulnerability accounting for 2.67 excess deaths per 1,000,000 person-years. (4) Conclusions: Our epidemiological analysis revealed an overall increase in CVH-related HCC mortality between 1999-2008, followed by a stagnation period until 2020. CVH-related HCC mortality disproportionately affected males, Hispanic populations, and Black/African American populations, Western US regions, and socially vulnerable counties. These insights can help aid in the development of strategies to target vulnerable patients, focus on preventive efforts, and allocate resources to decrease HCC-related mortality.

Patients with severe mental illness and hepatitis C virus infection benefit from new pangenotypic direct-acting antivirals: Results of a literature review

INTRODUCTION

Hepatitis C virus (HCV) infection is a global health problem that can results in cirrhosis, hepatocellular carcinoma and even death. HCV infection is 3-20-fold more prevalent among patients with versus without severe mental illness (SMI), such as major depressive disorder, personality disorder, bipolar disorder and schizophrenia. Treatment options for HCV were formerly based on pegylated interferon alpha, which is associated with neuropsychiatric adverse events, and this contributed to the exclusion of patients with SMI from HCV treatment, elimination programmes, and clinical trials. Moreover, the assumption of poor adherence, scant access to healthcare and the stigma and vulnerability of this population emerged as barriers and contributed to the low rates of treatment and efficacy.

METHODS

This paper reviews the literature published between December 2010 and December 2020 exploring the epidemiology of HCV in patients with SMI, and vice versa, the effect of HCV infection, barriers to the management of illness in these patients, and benefits of new therapeutic options with pangenotypic direct antiviral agents (DAAs).

RESULTS

The approval of DAAs has changed the paradigm of HCV infection treatment. DAAs have proven to be an equally efficacious and safe option that improves quality of life (QoL) in patients SMI.

CONCLUSIONS

Knowledge of the consequences of the HCV infection and the benefits of treatment with new pangenotypic DAAs among psychiatrists can increase screening, referral and treatment of HCV infection in patients with SMI.

Disparities in the quality of care for chronic hepatitis C among Medicare beneficiaries

Purpose

Chronic hepatitis C virus (HCV) infection is an important public health concern. Limited information exists on disparities in the quality of HCV care. We examine disparities in genotype or quantitative HCV ribonucleic acid testing before and after starting HCV treatment, and screening for hepatocellular carcinoma (HCC) in HCV patients with cirrhosis.

Methods

This national study included Medicare beneficiaries with HCV between 2014 and 2017. We used bivariate probit to estimate the probability of receiving recommended tests before and after HCV treatment by patient race/ethnicity, urban/rural residence, and socioeconomic status. We used multivariate logistic regression to estimate adjusted odds ratios (aOR) of HCC screening among beneficiaries with cirrhosis by patient factors.

Findings

Of 41,800 Medicare patients with HCV treatment, 93.47% and 84.99% received pre- and post-treatment testing. Patients in racial minority groups had lower probabilities of pre- and post-treatment testing than whites. Rural residents were less likely to receive a post-treatment test (Coef. = -0.06, 95% CI: -0.11, -0.01). Among HCV patients with cirrhosis, 40% (24,021) received at least one semi-annual HCC screening during the study period. The odds of HCC screening were 14% lower in rural than in urban patients (aOR = 0.86, 95% CI: 0.80, 0.92), lower in African Americans (aOR = 0.93, 95% CI: 0.90, 0.96), but higher among Hispanics than in whites (aOR = 1.09, 95% CI: 1.04, 1.15). There was no significant association between ZIP-level income or education and HCC screening.

Conclusions

Disparities in the quality of HCV care existed by patient race/ethnicity, urban/rural residence, and socioeconomic status. Continued efforts are needed to improve the quality of care for all HCV patients—especially rural patients and racial/ethnic minorities.

Patients at a drug detoxification center share perspectives on how to increase hepatitis C treatment uptake: A qualitative study

BACKGROUND

The US opioid crisis is associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID), and yet the uptake of HCV curative therapy among PWID is low.

PURPOSE

To explore potential solutions to overcome barriers to HCV treatment uptake among individuals at a drug detoxification center.

METHODS

Qualitative study with in-depth interviews and thematic analysis of coded data.

RESULTS

Patients (N = 24) had the following characteristics: mean age 37 years; 67 % White, 13 % Black, 8 % Latinx, 4 % Native Hawaiian/Pacific Islander, 8 % other; 71 % with a history of injecting drugs. Most patients with a positive HCV test had not pursued treatment due to few perceived immediate consequences from a positive test and possible complications arising in a distant poorly imagined future. Active substance use was a major barrier to HCV treatment uptake because of disruptions to routine activities. In addition, re-infection after treatment was perceived as inevitable. Patients had suggestions to improve HCV treatment uptake: high-intensity wraparound care characterized by frequent interactions with supportive services; same-day/walk-in options; low-barrier access to substance use treatment; assistance with navigating the health care system; attention to immediate needs, such as housing; and the opportunity to select an approach that best fits individual circumstances.

CONCLUSIONS

Active substance use was a major barrier to treatment initiation. To improve uptake, affected individuals recommended that HCV treatment be integrated within substance use treatment programs. Such a model should incorporate patient education within low-barrier, high-intensity wraparound care, tailored to patients' needs and priorities.

Mental Disorders and Interferon Nontreatment in Hepatitis C Virus Infection-a Population Based Cohort Study

OBJECTIVE

This study investigates the association between mental disorders and interferon nontreatment in patients with chronic hepatitis C virus (HCV) infection in a large national sample.

METHODS

Using the National Health Insurance Research Database of Taiwan, we conducted a nationwide population-based study. Each case was matched to five controls by age, sex, urbanization, and income. Conditional logistic regression was used to assess odds of HCV nontreatment in different mental disorders.

RESULTS

From 1999 to 2013, we identified 92,970 subjects with HCV infection and 15,495 HCV cases (16.7%) had received IFN therapy. Other than chronic obstructive pulmonary disease, the medical diseases and mental disorders were significantly different between IFN and non-IFN treated HCV patients. After adjusting for medical diseases, depressive disorder and anxiety disorder was positively associated with receiving IFN therapy. Patients with schizophrenia, bipolar disorders and alcohol use disorders were significantly less likely to receive interferon. Antidepressant exposure (cumulative daily exposure or cumulative daily dose) was associated with lower odds of IFN treatment.

CONCLUSION

Our nationwide cohort study demonstrated that INF nontreatment rate was lower in certain mental disorders. Antidepressant exposure might lower the chance of receiving IFN treatment. Our results may help to identify and to overcome the obstacles for HCV treatment and further apply to DAAs regimen.

Impact of geographic origin on access to therapy and therapy outcomes in the Swiss Hepatitis C Cohort Study

Late diagnosis and treatment may increase morbidity and mortality among persons with hepatitis C virus (HCV) infection. We included all participants of the Swiss Hepatitis C Cohort Study (SCCS). We used unadjusted and adjusted logistic and Cox regressions to determine the association between the geographic origin of the participants and the following outcomes: antiviral treatment status; sustained virologic response; cirrhosis at enrolment; incident cirrhosis; loss to follow-up (LTFU); and mortality. The analyses were adjusted for sex, baseline age, education, source of income, alcohol consumption, injection drug use (IDU), HCV genotype, HIV or HBV coinfection, duration of HCV infection, time since enrolment, cirrhosis, (type of) HCV treatment, and centre at enrolment. Among 5,356 persons, 1,752 (32.7%) were foreign-born. IDU was more common among Swiss- (64.1%) than foreign-born (36.6%) persons. Cirrhosis at enrolment was more frequent among foreign- than Swiss-born persons, reflecting the high frequency of cirrhosis among Italian-born persons who acquired HCV between 1950 and 1970 in Italian healthcare settings. Although antiviral treatment coverage was similar, the sustained viral response rate was increased and the mortality was lower among foreign-vs. Swiss-born persons, with the lowest mortality in persons from Asia/Oceania. LTFU was more frequent in persons from Germany, Eastern and Southern Europe, and the Americas. In conclusion, in Switzerland, a country with universal healthcare, geographic origin had no influence on hepatitis C treatment access, and the better treatment outcomes among foreign-born persons were likely explained by their lower prevalence of IDU and alcohol consumption than among Swiss-born persons.

The distribution and socioeconomic burden of Hepatitis C virus in South Australia: a cross-sectional study 2010-2016

BACKGROUND

Hepatitis C virus infection (HCV) is a communicable disease of increasing global importance with 1.75 million new infections and 400,000 related deaths annually. Until recently, treatment options have had low uptake and most infected people remain untreated. New Direct Acting Antiviral medications can clear the virus in around 95% of cases, with few side-effects. These medications are restricted in most countries but freely accessible in Australia, yet most people still remain untreated. This study applies a cross-sectional research design to investigate the socio-spatial distribution of HCV in South Australia, to identify vulnerable populations, and examine epidemiological factors to potentially inform future targeted strategies for improved treatment uptake.

METHOD

HCV surveillance data were sourced from South Australia's Communicable Diseases Control Branch and socio-economic population data from the Australian Bureau of Statistics from January 2010 to December 2016 inclusive. HCV cases were spatially mapped at postcode level. Multivariate logistic regression identified independent predictors of demographic risks for HCV notification and notification source.

RESULTS

HCV notifications (n = 3356) were seven times more likely to be from people residing in the poorest areas with high rates of non-employment (75%; n = 1876) and injecting drug use (74%; n = 1862) reported. Notifications among Aboriginal and Torres Strait Islander people were around six times that of non-Indigenous people. HCV notifications negatively correlated (Spearman's rho - 0.426; p < 0.001) with socio-economic status (residential postcode socio-economic resources Index). History of imprisonment independently predicted HCV diagnoses in lesser economically-resourced areas (RR1.5; p < 0.001). Independent predictors of diagnosis elsewhere than in general practices were non-employment (RR 4.6; p = 0.028), being male (RR 2.5; p < 0.001), and younger than mean age at diagnosis (RR 2.1; p = 0.006).

CONCLUSIONS

Most people diagnosed with HCV were from marginalised sub-populations. Given general practitioners are pivotal to providing effective HCV treatment for many people in Australia a most concerning finding was that non-employed people were statistically less likely to be diagnosed by general practitioners. These findings highlight a need for further action aimed at improving healthcare access and treatment uptake to help reduce the burden of HCV for marginalised people, and progress the vision of eliminating HCV as a major public health threat.

Effect of Interferon-Free Regimens on Disparities in Hepatitis C Treatment of US Veterans

OBJECTIVES

To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder.

METHODS

Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years.

RESULTS

With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget.

CONCLUSIONS

The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.

Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population

OBJECTIVES

The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation.

METHODS

We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation.

RESULTS

Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007).

CONCLUSIONS

Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

Establishing the cascade of care for hepatitis C in England-benchmarking to monitor impact of direct acting antivirals

Little is known about engagement and retention in care of people diagnosed with chronic hepatitis C (HCV) in England. Establishing a cascade of care informs targeted interventions for improving case finding, referral, treatment uptake and retention in care. Using data from the sentinel surveillance of blood-borne virus (SSBBV) testing between 2005 and 2014, we investigate the continuum of care of those tested for HCV in England. Persons ≥1 year old with an anti-HCV test and subsequent RNA tests between 2005 and 2014 reported to SSBBV were collated. We describe the cascade of care, as the patient pathway from a diagnostic test, referral into care, treatment and patient outcomes. Between 2005 and 2014, 2 390 507 samples were tested for anti-HCV, corresponding to 1 766 515 persons. A total of 53 038 persons (35 190 men and 17 165 women) with anti-HCV positive were newly reported to SSBBV. An RNA test was conducted on 77.0% persons who were anti-HCV positive, 72.3% of whom were viraemic (RNA positive) during this time period, 21.4% had evidence of treatment and 3130 49.5% had evidence of a sustained virological response (SVR). In multivariable models, confirmation of viraemia by RNA test varied by age and region/test setting; evidence of treatment varied by age, year of test and region/test setting; and SVR varied by age, year of test and region/setting of test. In conclusion, our findings provide HCV cascade of care estimates prior to the introduction of direct acting antivirals. These findings provide important baseline cascade estimates to benchmark progress towards elimination of HCV as a major public health threat.

Barriers to care for chronic hepatitis C in the direct-acting antiviral era: a single-centre experience

Background

Cure rates for chronic hepatitis C have improved dramatically with direct-acting antivirals (DAAs), but treatment barriers remain. We aimed to compare treatment initiation rates and barriers across both interferon-based and DAA-based eras.

Methods

We conducted a retrospective cohort study of all patients with chronic hepatitis C seen at an academic hepatology clinic from 1999 to 2016. Patients were identified to have chronic hepatitis C by the International Classification of Diseases, Ninth Revision codes, and the diagnosis was validated by chart review. Patients were excluded if they did not have at least one visit in hepatology clinic, were under 18 years old or had prior treatment with DAA therapy. Patients were placed in the DAA group if they were seen after 1 January 2014 and had not yet achieved virological cure with prior treatment. All others were considered in the interferon group.

Results

3202 patients were included (interferon era: n=2688; DAA era: n=514). Despite higher rates of decompensated cirrhosis and medical comorbidities in the DAA era, treatment and sustained virological response rates increased significantly when compared with the interferon era (76.7% vs 22.3%, P<0.001; 88.8% vs 55%, P<0.001, respectively). Lack of follow-up remained a significant reason for non-treatment in both groups (DAA era=24% and interferon era=45%). An additional 8% of patients in the DAA era were not treated due to insurance or issues with cost. In the DAA era, African-Americans, compared with Caucasians, had significantly lower odds of being treated (OR=0.37, P=0.02).

Conclusions

Despite higher rates of medical comorbidities in the DAA era, considerable treatment challenges remain including cost, loss to follow-up and ethnic disparities.

Regional differences in treatment rates for patients with chronic hepatitis C infection: Systematic review and meta-analysis

BACKGROUND & AIMS

Treatment rates with interferon-based therapies for chronic hepatitis C have been low. Our aim was to perform a systematic review of available data to estimate the rates and barriers for antiviral therapy for chronic hepatitis C.

METHODS

We conducted a systematic review and meta-analysis searching MEDLINE, SCOPUS through March 2016 and abstracts from recent major liver meetings for primary literature with available hepatitis C treatment rates. Random-effects models were used to estimate effect sizes and meta-regression to test for potential sources of heterogeneity.

RESULTS

We included 39 studies with 476,443 chronic hepatitis C patients. The overall treatment rate was 25.5% (CI: 21.1-30.5%) and by region 34% for Europe, 28.3% for Asia/Pacific, and 18.7% for North America (p = 0.008). On multivariable meta-regression, practice setting (tertiary vs. population-based, p = 0.04), region (Europe vs. North America p = 0.004), and data source (clinical chart review vs. administrative database, p = 0.025) remained significant predictors of heterogeneity. The overall treatment eligibility rate was 52.5%, and 60% of these received therapy. Of the patients who refused treatment, 16.2% cited side effects, 13.8% cited cost as reasons for treatment refusal, and 30% lacked access to specialist care.

CONCLUSIONS

Only one-quarter of chronic hepatitis C patients received antiviral therapy in the pre-direct acting antiviral era. Treatment rates should improve in the new interferon-free era but, cost, co-morbidities, and lack of specialist care will likely remain and need to be addressed. Linkage to care should even be of higher priority now that well-tolerated cure is available.

Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System

CONTEXT

Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur.

OBJECTIVE

We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing.

DESIGN

This study was cross-sectional in design.

SETTING

This study was conducted at the Veterans Health Administration (VA).

PARTICIPANTS

Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients.

MAIN OUTCOME MEASURE

This study measured receipt of testosterone and guideline-concordant testosterone prescribing.

RESULTS

Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97).

CONCLUSIONS

Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.

Ethnic disparities in progression to advanced liver disease and overall survival in patients with chronic hepatitis C: impact of a sustained virological response

BACKGROUND

Chronic hepatitis C (CHC) can lead to cirrhosis and hepatocellular carcinoma (HCC). A sustained virological response (SVR) is associated with improved outcomes, however, its impact on different ethnic groups is unknown.

AIM

To evaluate ethnic differences in the natural history of CHC and the impact of SVR.

METHODS

We conducted a cohort study of 8039 consecutive adult CHC patients seen at two medical centres in California between January 1997 and June 2016. Individual chart review confirmed CHC diagnosis.

RESULTS

Asian and Hispanic but not African American patients had significantly higher cirrhosis and HCC incidence than Caucasians. On multivariate analysis, Hispanic ethnicity was independently associated with increased cirrhosis (adjusted HR 1.37, CI, confidence interval 1.10-1.71, P=.006) and HCC risk (adjusted HR 1.47, CI 1.13-1.92, P=.004) compared to Caucasian. Asian ethnicity had a significant association with cirrhosis (adjusted HR 1.28, CI 1.02-1.61, P=.034) and HCC risk (adjusted HR 1.29, CI 0.94-1.77, P=.025). In patients who achieved SVR, Hispanic ethnicity was no longer independently associated with cirrhosis (adjusted HR 1.76, CI 0.66-4.71, P=.26) or HCC (adjusted HR 1.05, CI 0.27-4.08, P=.94); nor was Asian ethnicity (adjusted HR 0.62, CI 0.21-1.82, P=.38 for cirrhosis; 2.01, CI 0.63-6.36, P=.24 for HCC). Similar findings were observed with overall survival among the ethnicities by SVR status.

CONCLUSION

Hispanic and Asian ethnicity was independently associated with increased cirrhosis and HCC risk. Achieving an SVR eliminates the ethnic disparity in liver disease progression and overall survival between Hispanic and Asian vs Caucasian CHC patients.

The Validity of HCC Diagnosis Codes in Chronic Hepatitis B Patients in the Veterans Health Administration

BACKGROUND

Administrative databases that include diagnostic codes are valuable sources of information for research purposes.

AIM

To validate diagnostic codes for hepatocellular carcinoma (HCC) in chronic hepatitis B patients.

METHODS

We conducted a retrospective study of patients with chronic HBV seen in the national Veterans Administration (VA). HCC cases were identified by the presence of ICD-9 code 155.0. We randomly selected 200 HBV controls without this code as controls. We manually reviewed the electronic medical record (EMR) of all cases and controls to determine HCC status. We calculated the positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity for the HCC code. We conducted an implicit review of the false-positive cases to determine possible reasons for the miscoding.

RESULTS

Of the 8350 patients with HBV, 416 had an ICD-9 code for HCC. Of these 416, 332 patients had confirmed HCC and 61 did not; HCC status was indeterminate for 23 patients. Of the 200 controls, none had HCC confirmed in the EMR. The PPV ranged from 85.3 to 80.0% and specificity ranged from 99.2 to 99.0% based on classification of indeterminate cases as true versus false positives, respectively. The NPV, sensitivity, and specificity were 100%. Two-thirds of false-positive cases were diagnosed with HCC prematurely as a workup of liver mass and latter imaging and/or biopsy were not diagnostic for HCC.

CONCLUSION

The diagnostic code of HCC in chronic HBV patients in the VHA data is predictive of the presence of HCC in medical records and can be used for epidemiological and clinical research.

Hepatitis C virus and its cutaneous manifestations: treatment in the direct-acting antiviral era

New all-oral direct-acting antivirals (DAA) have changed the hepatitis C virus (HCV) treatment landscape. Given that dermatologists frequently encounter HCV-infected patients, knowledge of the current treatment options and their utility in treating HCV-associated dermatologic disorders is important. In addition to highlighting the new treatment options, we review four classically HCV-associated dermatologic disorders - mixed cryoglobulinaemia (MC), lichen planus (LP), porphyria cutanea tarda (PCT) and necrolytic acral erythema (NAE) - and examine the role for all-oral direct-acting antiviral (DAA) regimens in their treatment. A literature search of English-language publications was conducted of the PubMed and EMBASE databases using search terms including 'hepatitis C', 'direct acting antivirals', 'cutaneous', 'mixed cryoglobulinemia', 'necrolytic acral erythema', 'lichen planus', 'porphyria cutanea tarda', 'rash', as well as specific drug names, related terms and abbreviations. Currently, limited data exist on the use of DAAs in HCV-infected patients with cutaneous side-effects, although treatment of the underlying HCV is now recommended for nearly all patients, with the new drugs offering much-improved dosage schedules and side-effect profiles. The most data exist for MC, in which several studies suggest that DAAs and achievement of sustained virologic response (SVR) improve cutaneous symptoms. Studies of both older and newer regimens are limited by their small size, retrospective nature, lack of appropriate controls and wide variability in study protocols. Given the strong association, screening for HCV should be considered in patients with MC, LP, PCT and NAE.

HCV Integrated Care: A Randomized Trial to Increase Treatment Initiation and SVR with Direct Acting Antivirals

BACKGROUND AND AIMS

Psychiatric or substance use disorders are barriers to successful HCV antiviral treatment. In a randomized, controlled trial (RCT), the effects of HCV Integrated Care (IC) for increasing treatment rates and sustained viral response (SVR) were studied with direct acting antivirals (DAA).

METHODS

In 2012-13, VA patients, whose screening was positive for depression, PTSD, or substance use (N = 79), were randomized to IC or Usual Care (UC). IC consisted of brief psychological interventions and case management. The primary endpoint was SVR among patients followed for an average of 16.6 months.

RESULTS

42% of the study participants were previously homeless and 79% had HCV genotype 1. Twice as many IC participants (45%) initiated treatment compared with UC participants (23%) (χ² = 4.59, p = 0.032). Among those treated, SVR rates did not significantly differ (IC: 12/18 = 67%; UC: 5/9 = 55%; p = 0.23). Among all randomized participants, IC participants trended toward better SVR rates (30.0% versus 12.8% in UC; p = 0.07).

CONCLUSIONS

Although first-generation DAAs are no longer used, this smaller RCT helps confirm the results of a larger multisite RCT showing that Integrated Care results in higher treatment initiation and SVR rates among HCV-infected persons with comorbid psychological disorders. Integrated mental health services can facilitate treatment among the most challenging HCV patients, many of whom have not been successfully treated. This trial is registered with ClinicalTrials.gov number NCT00722423.

Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus

BACKGROUND

Direct acting antiviral agents (DAA) are highly effective yet expensive. Disparities by race and/or gender often exist in the use of costly medical advances as they become available.

METHODS

We examined a cohort of hepatitis C virus (HCV) patients who received care at the Veterans Administration facilities nationwide. We evaluated the effect of race and gender on DAA receipt after adjusting for socioeconomic status, liver disease severity, comorbidity, and propensity for healthcare use. To determine if disparities had changed over time, we conducted a similar analysis of HCV patients who were seen in the previous standard of care treatment era.

RESULTS

Of the 145 596 patients seen in the current DAA era, 17 791 (10.2%) received treatment during the first 16 months of DAA approval. Black patients had 21% lower odds of receiving DAA than whites (odds ratio [OR] = 0.79; 95% confidence interval [CI], .75, .84). Overall, women were as likely to receive treatment as men (OR = 0.99; 95% CI, .90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (OR = 0.71, 95% CI, .54-.93). Similar to the DAA cohort, black patients had significantly lower odds of receiving treatment than whites (OR = 0.74, 95% CI, .69-.79) in the previous treatment era. The racial difference between the 2 eras did not reach statistical significance.

CONCLUSIONS

There were unexplained differences among HCV population subgroups in the receipt of new DAA treatment. Targeted interventions are needed for black patients and younger women.

Retrospective Analysis of the Medication Utilization and Clinical Outcomes of Patients Treated with Various Regimens for Hepatitis C Infection

BACKGROUND

The hepatitis C virus (HCV) is the most common chronic blood-borne infection and the leading cause of liver transplantation in the United States. There are approximately 3.2 million people currently infected with HCV in the United States. In late 2013, the introduction of sofosbuvir and simeprevir represented a critical advancement in the treatment of HCV by improving sustained virologic response (SVR) rates.

PURPOSE

The purpose of this study was to evaluate medication utilization and clinical outcomes of patients with HCV who were treated with any Food and Drug Administration-approved combination of ribavirin, peginterferon products, simeprevir, and sofosbuvir.

METHODS

Prescription records and clinical assessment forms of patients who started HCV therapy and were eligible for SVR between January 1, 2014, and December 31, 2014, were retrospectively reviewed. Data collection included patient demographics, genotype, SVR, patient-reported adverse events, discontinuations, and adherence markers.

RESULTS

A total of 367 eligible patients were identified who had initiated treatment during the study period. Genotype 1 was the most common genotype, and an overall SVR rate of 86.9% was observed. Results were similar to those seen in phase III clinical trials. In addition, adverse events of these medications were more tolerable, and discontinuation rates were lower than with previous therapies.

Conceptual framework for outcomes research studies of hepatitis C: an analytical review

Hepatitis C virus infection is one of the main causes of chronic liver disease worldwide. Until recently, the standard antiviral regimen for hepatitis C was a combination of an interferon derivative and ribavirin, but a plethora of new antiviral drugs is becoming available. While these new drugs have shown great efficacy in clinical trials, observational studies are needed to determine their effectiveness in clinical practice. Previous observational studies have shown that multiple factors, besides the drug regimen, affect patient outcomes in clinical practice. Here, we provide an analytical review of published outcomes studies of the management of hepatitis C virus infection. A conceptual framework defines the relationships between four categories of variables: health care system structure, patient characteristics, process-of-care, and patient outcomes. This framework can provide a starting point for outcomes studies addressing the use and effectiveness of new antiviral drug treatments.

Effect of treatment willingness on specialist assessment and treatment uptake for hepatitis C virus infection among people who use drugs: the ETHOS study

Among people who inject drugs (PWID) with chronic HCV, the association between HCV treatment willingness and intent, and HCV specialist assessment and treatment were evaluated. The Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) is a prospective observational cohort. Recruitment was through six opioid substitution treatment clinics, two community health centres and one Aboriginal community controlled health organisation in Australia. Analyses were performed using logistic regression. Among 415 participants (mean age 41 years, 71% male), 67% were 'definitely willing' to receive HCV treatment and 70% reported plans to initiate therapy 12 months postenrolment. Those definitely willing to receive HCV treatment were more likely to undergo specialist assessment (64% vs 32%, P < 0.001) and initiate therapy (36% vs 9%, P < 0.001), compared to those with lower treatment willingness. Those with early HCV treatment plans were more likely to undergo specialist assessment (65% vs 27%, P < 0.001) and initiate therapy (36% vs 5%, P < 0.001), compared to those without early plans. In adjusted analyses, HCV treatment willingness independently predicted specialist assessment (aOR 3.06, 95% CI 1.90, 4.94) and treatment uptake (aOR 4.33, 95% CI 2.14, 8.76). In adjusted analysis, having early HCV treatment plans independently predicted specialist assessment (aOR 4.38, 95% CI 2.63, 7.29) and treatment uptake (aOR 9.79, 95% CI 3.70, 25.93). HCV treatment willingness was high and predicted specialist assessment and treatment. Strategies for enhanced HCV care should be developed with an initial focus on people willing to receive treatment and to increase treatment willingness among those less willing.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In high income countries, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). In many low and middle income countries large HCV epidemics have also emerged among PWID populations. The burden of HCV-related liver disease among PWID is increasing, but treatment uptake remains extremely low. There are a number of barriers to care which should be considered and systematically addressed, but should not exclude PWID from HCV treatment. The rapid development of interferon-free direct-acting antiviral (DAA) therapy for HCV infection has brought considerable optimism to the HCV sector, with the realistic hope that therapeutic intervention will soon provide near optimal efficacy with well-tolerated, short duration, all oral regimens. Further, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provide a framework for HCV assessment and care. Further research is needed to evaluate strategies to enhance testing, linkage to care, treatment, adherence, viral cure, and prevent HCV reinfection among PWID, particularly as new interferon-free DAA treatments for HCV infection become available.

Treatment rate and factors related to interferon-based treatment initiation for chronic hepatitis C in South Korea

Under-recognition and under-treatment of chronic hepatitis C virus (HCV) infection is an important determinant of the disease outcome. The aim of this study was to investigate the treatment rate and factor of initiation of interferon-based antiviral treatment for chronic hepatitis C patients in a prospective, multicenter Korean HCV cohort. Treatment-naïve 759 patients with chronic HCV infection were prospectively followed from January 2007-2013 at six university hospitals during a median (interquartile range) follow-up of 769 (76-1,427) days. The subjects consisted of patients with chronic hepatitis C (n = 553, 72.9%), liver cirrhosis (n = 127, 16.7%), and hepatocellular carcinoma (n = 79, 10.4%), and were treated usually using pegylated interferon alpha and ribavirin. Treatment initiation rate and its related factors were analysed. The initiation rate of antiviral treatment was 37.3% (n = 273), and the cumulative probability of treatment initiation over 5 years was 39.4%. Multivariate analysis showed that age <58 years (hazard ratio [HR] = 1.588, 95% CI = 1.151-2.193), job employment (HR = 1.737, 95% CI = 1.279-2.363), absence of HCC (chronic hepatitis, HR = 2.534, 95% CI = 1.003-6.400; liver cirrhosis, HR = 2.873, 95% CI = 1.101-7.494), alanine transaminase (ALT) >40 IU/L (HR = 1.682, 95% CI = 1.228-2.303), and genotype 2 (HR = 1.364, 95% CI = 1.034-1.798) were independent factors related to treatment initiation. Interferon-based antiviral treatment was initiated in more than one third of chronic HCV infected patients visiting university hospitals, who were young, employed, HCV genotype 2, and with abnormal ALT without HCC, in Korea.

Correlates of Initiation of Treatment for Chronic Hepatitis C Infection in United States Veterans, 2004-2009

We describe the rates and predictors of initiation of treatment for chronic hepatitis C (HCV) infection in a large cohort of HCV positive Veterans seen in U.S. Department of Veterans Affairs (VA) facilities between January 1, 2004 and December 31, 2009. In addition, we identify the relationship between homelessness among these Veterans and treatment initiation. Univariate and multivariable Cox Proportional Hazards regression models with time-varying covariates were used to identify predictors of initiation of treatment with pegylated interferon alpha plus ribavirin. Of the 101,444 HCV treatment-naïve Veterans during the study period, rates of initiation of treatment among homeless and non-homeless Veterans with HCV were low and clinically similar (6.2% vs. 7.4%, p<0.0001). For all U.S. Veterans, being diagnosed with genotype 2 or 3, black or other/unknown race, having Medicare or other insurance increased the risk of treatment. Veterans with age ≥50 years, drug abuse, diabetes, and hemoglobin < 10 g/dL showed lower rates of treatment. Initiation of treatment for HCV in homeless Veterans is low; similar factors predicted initiation of treatment. Additionally, exposure to treatment with medications for diabetes predicted lower rates of treatment. As newer therapies become available for HCV, these results may inform further studies and guide strategies to increase treatment rates in all U.S. Veterans and those who experience homelessness.

Contextual analysis of determinants of late diagnosis of hepatitis C virus infection in medicare patients

Patient- and county-level characteristics associated with advanced liver disease (ALD) at hepatitis C virus (HCV) diagnosis were examined in three Medicare cohorts: (1) elderly born before 1945; (2) disabled born 1945-1965; and (3) disabled born after 1965. We used Medicare claims (2006-2009) linked to the Area Health Resource Files. ALD was measured over the period of 6 months before to 3 months after diagnosis. Using weighted multivariate modified Poisson regression to address generalizability of findings to all Medicare patients, we modeled the association between contextual characteristics and presence of ALD at HCV diagnosis. We identified 1,746, 3,351, and 592 patients with ALD prevalence of 28.0%, 23.0%, and 15.0% for birth cohorts 1, 2, and 3. Prevalence of drug abuse increased among younger birth cohorts (4.2%, 22.6%, and 35.6%, respectively). Human immunodeficiency virus coinfection (prevalence ratio [PR] = 0.63; 95% confidence interval [CI]: 0.50-0.80; P = 0.001), dual Medicare/Medicaid eligibility (PR = 0.89; 95% CI: 0.80-0.98; P = 0.017), residence in counties with higher median household income (PR = 0.82; 95% CI: 0.71-0.95; P = 0.008), higher density of primary care providers (PR = 0.84; 95% CI: 0.73-0.98; P = 0.022), and more rural health clinics (PR = 0.90; 0.81-1.01; P = 0.081) were associated with lower ALD risk. End-stage renal disease (PR = 1.41; 95% CI: 1.21-1.63; P = 0.001), alcohol abuse (PR = 2.57; 95% CI: 2.33-2.84; P = 0.001), hepatitis B virus (PR = 1.32; 95% CI: 1.09-1.59; P = 0.004), and Midwest residence (PR = 1.22; 95% CI: 1.05-1.41; P = 0.010) were associated with higher ALD risk. Living in rural counties with high screening capacity was protective in the elderly, but associated with higher ALD risk among the disabled born 1945-1965.

CONCLUSIONS

ALD prevalence patterns were complex and were modified by race, elderly/disability status, and the extent of health care access and screening capacity in the county of residence. These study results help inform treatment strategies for HCV in the context of coordinated models of care.

Capitalizing on knowledge of hepatitis C virus neutralizing epitopes for rational vaccine design

Hepatitis C virus infects nearly 3% of the world's population and is often referred as a silent epidemic. It is a leading cause of liver cirrhosis and hepatocellular carcinoma in endemic countries. Although antiviral drugs are now available, they are not readily accessible to marginalized social groups and developing nations that are disproportionally impacted by HCV. To stop the HCV pandemic, a vaccine is needed. Recent advances in HCV research have provided new opportunities for studying HCV neutralizing antibodies and their subsequent use for rational vaccine design. It is now recognized that neutralizing antibodies to conserved antigenic sites of the virus can cross-neutralize diverse HCV genotypes and protect against infection in vivo. Structural characterization of the neutralizing epitopes has provided valuable information for design of candidate immunogens.

A window of opportunity: maximizing the effectiveness of new HCV regimens in the United States with the expansion of the Affordable Care Act

Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management. New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.

Barriers to HCV treatment in the era of triple therapy: a prospective multi-centred study in clinical practice

BACKGROUND & AIMS

(i) To describe the demographic, clinical, virological and histological characteristics of the patients undergoing evaluation for indication of triple therapy against hepatitis C virus genotype 1, and to identify the reasons why candidate patients are excluded; and (ii) to evaluate the characteristics of the healthcare environment related to treatment.

METHODS

Observational, prospective and multi-centred study involving 16 hospitals of Spain. Data were collected on 1122 patients receiving attention in the outpatient clinics between June and December 2012.

RESULTS

Of the 1122 patients evaluated, 769 were finally included in this study; 27% (211/769) had contraindications to the therapy. Of those without contraindications, 54% (301/558) did not receive the treatment, and so, only about a third of the patients (33%-257/769) underwent therapy. The reasons for not initiating therapy were as follows: patient refusal (30%), mild disease/awaiting new treatments (34%), restrictions by the health service (30%), other reasons (6%). In univariate analyses, the probability of receiving treatment was related to: age <60 years, male gender, high education level, advanced fibrosis, having had previous treatment, being assessed in a centre of excellence. In multivariate analyses, the factors independently related to the probability of receiving treatment were as follows: high education level of the patients (P = 0.004), advanced fibrosis (P < 0.001) and centres of excellence (P = 0.009).

CONCLUSION

Despite the high efficacy of triple therapy, only a small proportion of patients receive the treatment. The causes related to non-treatment depend on patient factors, disease stage and characteristics of the health-service provision.

Prevalence and treatment of chronic hepatitis C virus infection in the US Department of Veterans Affairs

Chronic hepatitis C virus (HCV) is the most common blood-borne pathogen in the United States. HCV disproportionately affects Veterans Affairs (VA) health-care users: 174,302 HCV-infected veterans were in VA care in 2013, making the VA the world's largest HCV care provider. This systematic review identified 546 articles related to HCV in the VA. After assessment by 2 independent reviewers, 28 articles describing prevalence and treatment of HCV in VA users ultimately met inclusion criteria. Most VA patients currently living with HCV infection were born between 1945 and 1965 and were infected with HCV between 1970 and 1990. To prevent HCV-related complications such as cirrhosis, hepatocellular carcinoma, and death, medical personnel must identify and treat HCV. However, antiviral therapy has historically been limited by medication side effects, contraindications, and patient acceptance. Although treatment initiation rates are higher in the VA than in the general United States, only 23% of VA HCV patients have received treatment and, of those, only a minority were cured. Recent development of more effective and tolerable antiviral agents represents a major pharmacological breakthrough. Eradication of HCV is theoretically possible for the majority of HCV patients for the first time, although new barriers, such as high drug costs, may limit future uptake.

Rate, delay and predictors of hepatitis C treatment in British Columbia

BACKGROUND

The current treatment rate for chronic hepatitis C virus (HCV) infection is suboptimal despite the availability of efficacious antiviral therapy.

OBJECTIVE

To determine the rate, delay and predictors of treatment in patients with chronic HCV infection.

METHODS

A retrospective chart review of chronic HCV patients who were being evaluated at a tertiary hepatology centre in Vancouver, British Columbia, was performed.

RESULTS

One hundred sixty-four patients with chronic HCV infection who were assessed for treatment between February 2008 and January 2013 were reviewed. Treatment was initiated in 25.6% (42 of 164). In multivariate analyses, male sex (OR 7.90 [95% CI 1.35 to 46.15]) and elevated alanine aminotransferase (ALT) level (>1.5 times the upper limit of normal) (OR 3.10 [95% CI 1.32 to 7.27]) were positive predictors of treatment, whereas active smoking (OR 0.09 [95% CI 0.02 to 0.53]) and Charlson comorbidity index (per point increase) (OR 0.47 [95% CI 0.27 to 0.83]) were negative predictors of treatment. The most common reasons for treatment deferral were no or minimal liver fibrosis in 57.7% (n=30), persistently normal ALT levels in 57.7% (n=30) and patient unreadiness in 28.8% (n=15). The most common reasons for treatment noninitiation were patient refusal in 59.1% (n=26), medical comorbidities in 36.4% (n=16), psychiatric comorbidities in 9.1% (n=4) and decompensated cirrhosis in 9.1% (n=4). There was a statistically significant difference in the median time delay from HCV diagnosis to general practitioner referral between the treated and untreated patients (66.3 versus 119.5 months, respectively [P=0.033]). The median wait time from general practitioner referral to hepatologist consult was similar between the treated and untreated patients (1.7 months versus 1.5 months, respectively [P=0.768]). Among the treated patients, the median time delay was 6.8 months from hepatologist consult to treatment initiation.

CONCLUSIONS

The current treatment rate for chronic HCV infection remains suboptimal. Medical and psychiatric comorbidities represent a major obstacle to HCV treatment. Minimal hepatic fibrosis may no longer be a major reason for treatment deferral as more efficacious and tolerable antiviral therapies become available in the future. Greater educational initiatives for primary care physicians would promote early referral of patients. More nursing support would alleviate the backlog of patients awaiting treatment.

Hepatitis C crónica: aspectos clínicos, serológicos y de tratamiento en dos centros de atención en Bogotá, Colombia

Introducción: el virus de la hepatitis C afecta a cerca de 170 millones de personas en el mundo. La organización mundial de la salud (OMS) estima una prevalencia mundial del 2%. La respuesta global al tratamiento en la era de la terapia dual para genotipo 1 es del orden de 40%. En Colombia hay datos limitados que confirmen un comportamiento similar y que describan las características clínicas de los pacientes con esta infección. Metodología: se revisaron retrospectivamente las historias clínicas de pacientes con diagnóstico de hepatitis C crónica que asistieron a consulta externa del servicio de Hepatología en la Clínica Universitaria Colombia y de la consulta externa del servicio de Hepatología de uno de los autores durante el periodo comprendido entre el 1 de enero del 2010 y el 30 de mayo de 2013, se describen las características clínicas, serológicas y de respuesta al tratamiento. Resultados: se evaluaron las historias clínicas de 163 pacientes, 62% mujeres y 38% hombres, con una edad promedio de 58,2 años. El principal factor de riesgo para la adquisición de la hepatitis C fue historia de transfusiones antes de 1992 en 62% de los pacientes. La decisión de iniciar tratamiento se tomó en 77 pacientes (47,2%) y en 86 (52,8%) no se inició por diferentes razones dentro de las cuales la edad avanzada y cirrosis avanzada suman más de 50%; otras razones para no iniciar el tratamiento fueron: enfermedad mínima (4,7%), enfermedad mínima más edad avanzada (10,5%), curación espontánea (14%), poca probabilidad de respuesta (3,3%) y otras (14%). De 62 pacientes de los que se contaba con información acerca de tratamientos previos o tratados recientemente 30,6% presentaron respuesta viral sostenida (RVS), 29,0% fueron clasificados como reincidentes o relapser, 8,1% como respondedores parciales, 19,4% no tuvieron respuesta y 12,9% suspendieron el tratamiento por intolerancia. Conclusiones: el antecedente más frecuente para la adquisición del VHC en el grupo de pacientes estudiado fue la historia de transfusiones antes de 1992 asociada con cirugía ginecológica. Cerca de la mitad de los pacientes se diagnostican tardíamente. Se muestra una mayor tendencia al tratamiento de la hepatitis con tasas de RVS similares a las encontradas en otras series. Este estudio abre puertas a la realización de otros que permitan definir de forma más amplia la prevalencia, factores de riesgo y variables de respuesta al tratamiento de esta entidad en nuestro país.

Relative effects of heavy alcohol use and hepatitis C in decompensated chronic liver disease in a hospital inpatient population

BACKGROUND

Heavy alcohol use has been hypothesized to accelerate disease progression to end-stage liver disease in patients with hepatitis C virus (HCV) infection. In this study, we estimated the relative influences of heavy alcohol use and HCV in decompensated chronic liver disease (CLD).

METHODS

Retrospectively, 904 patients with cirrhotic disease admitted to our hospitals during January 2010-December 2012 were identified based on ICD9 codes. A thorough chart review captured information on demographics, viral hepatitis status, alcohol use and progression of liver disease (i.e. decompensation). Decompensation was defined as the presence of ascites due to portal hypertension, bleeding esophageal varices, hepatic encephalopathy or hepatorenal syndrome. Heavy alcohol use was defined as a chart entry of greater than six daily units of alcohol or its equivalent.

RESULTS

347 patients were included based on our selection criteria of documented heavy alcohol use (n = 215; 62.0%), hepatitis titers (HCV: n = 182; 52.5%) and radiological evidence of CLD with or without decompensation (decompensation: n = 225; 64.8%). Independent of HCV infection, heavy alcohol use significantly increased the risk of decompensation (OR = 1.75, 95% CI 1.11-2.75, p < 0.02) relative to no heavy alcohol use. No significance was seen with age, sex, race, HIV, viral hepatitis and moderate alcohol use for risk for decompensation. Additionally, dose-relationship regression analysis revealed that heavy, but not moderate alcohol use, resulted in a three-fold increase (p = 0.013) in the risk of decompensation relative to abstinence.

CONCLUSIONS

While both heavy alcohol use and HCV infection are associated with risk of developing CLD, our data suggest that heavy, but not moderate, alcohol consumption is associated with a greater risk for hepatic decompensation in patients with cirrhosis than does HCV infection.

Effectiveness and safety of reduced-dose telaprevir-based triple therapy in chronic hepatitis C patients

AIM

To compare the early virological effectiveness, sustained virological response and safety of telaprevir 1500 mg/day with telaprevir 2250 mg/day, when combined in triple therapy with pegylated interferon and ribavirin in Japanese patients with high viral loads of genotype 1 hepatitis C virus.

METHODS

The telaprevir 2250 mg/day and 1500 mg/day groups each contained 60 patients matched by age, sex and history of previous interferon-based treatment. Serum levels of genotype 1 hepatitis C virus RNA, hemoglobin levels, drug adherence and drug discontinuation rates were monitored during and after triple therapy.

RESULTS

Patients receiving telaprevir 1500 mg/day had significantly lower telaprevir adherence and lower initial ribavirin dose but similar or superior pegylated interferon and ribavirin adherence and a lower rate of telaprevir discontinuation than did those receiving telaprevir 2250 mg/day. The early virological responses and sustained virological response rates were similar in both groups. Hemoglobin levels decreased to a greater extent in patients treated with telaprevir 2250 mg/day.

CONCLUSION

Compared to triple therapy including telaprevir 2250 mg/day, that including telaprevir at a reduced dose of 1500 mg/day was associated with lower rates of anemia and similar antiviral efficacy. Such a regimen may meaningfully improve sustained virological response rates, especially among female and elderly Japanese patients.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection

In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.

Continued low uptake of treatment for hepatitis C virus infection in a large community-based cohort of inner city residents

BACKGROUND & AIMS

Despite advances in HCV treatment, recent data on treatment uptake is sparse. HCV treatment uptake and associated factors were evaluated in a community-based cohort in Vancouver, Canada.

METHODS

The CHASE study is a cohort of inner city residents recruited from January 2003-June 2004. HCV status and treatment were retrospectively and prospectively determined through data linkages with provincial virology and pharmacy databases. Logistic regression analyses were used to identify factors associated with HCV treatment uptake.

RESULTS

Among 2913, HCV antibody testing was performed in 2405, 64% were HCV antibody-positive (n = 1533). Individuals with spontaneous clearance (18%, n = 276) were excluded. Among the remaining 1257 HCV antibody-positive participants (mean age 42, 71% male), 29% were Aboriginal. At enrolment, the majority reported recent injecting (60%) and non-injecting drug use (87%). Between January 1998 and March 2010, 6% (77 of 1257) initiated HCV treatment. In adjusted analyses, Aboriginal ethnicity [adjusted odds ratio (AOR) 0.23; 95% CI 0.10, 0.51] and crack cocaine use (AOR 0.61; 95% CI 0.37, 0.99) were associated with a decreased odds of receiving HCV treatment, while methamphetamine injecting (AOR 0.16; 95% CI 0.02, 1.18) trended towards a lower odds of receiving treatment. HCV treatment uptake ranged from 0.2 (95% CI 0.0, 0.7) per 100 person-years (PYs) in 2003 to 1.6 (95% CI 0.9, 2.6) per 100 PYs in 2009.

CONCLUSION

HCV treatment uptake remains low in this large community-based cohort of inner city residents with a high HCV prevalence and access to universal healthcare.

The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis

Background

Identifying gaps in care for people with chronic hepatitis C virus (HCV) infection is important to clinicians, public health officials, and federal agencies. The objective of this study was to systematically review the literature to provide estimates of the proportion of chronic HCV-infected persons in the United States (U.S.) completing each step along a proposed HCV treatment cascade: (1) infected with chronic HCV; (2) diagnosed and aware of their infection; (3) with access to outpatient care; (4) HCV RNA confirmed; (5) liver fibrosis staged by biopsy; (6) prescribed HCV treatment; and (7) achieved sustained virologic response (SVR).

Methods

We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for articles published between January 2003 and July 2013. Two reviewers independently identified articles addressing each step in the cascade. Studies were excluded if they focused on specific populations, did not present original data, involved only a single site, were conducted outside of the U.S., or only included data collected prior to 2000.

Results

9,581 articles were identified, 117 were retrieved for full text review, and 10 were included. Overall, 3.5 million people were estimated to have chronic HCV in the U.S. Fifty percent (95% CI 43–57%) were diagnosed and aware of their infection, 43% (CI 40–47%) had access to outpatient care, 27% (CI 27–28%) had HCV RNA confirmed, 17% (CI 16–17%) underwent liver fibrosis staging, 16% (CI 15–16%) were prescribed treatment, and 9% (CI 9–10%) achieved SVR.

Conclusions

Continued efforts are needed to improve HCV care in the U.S. The proposed HCV treatment cascade provides a framework for evaluating the delivery of HCV care over time and within subgroups, and will be useful in monitoring the impact of new screening efforts and advances in antiviral therapy.

Clinical outcomes in a cohort of anti-hepatitis C virus-positive patients with significant barriers to treatment referred to a Norwegian outpatient clinic

OBJECTIVE

Patient selection and management of chronic hepatitis C (CHC) in Norwegian outpatient clinics is not well studied. The aim of the study was to characterize CHC patients referred to a large university hospital in Norway, identify treatment barriers, and investigate the course and outcomes of treatment.

MATERIAL AND METHODS

In this retrospective observational cohort study, all anti-HCV-positive patients referred to Haukeland University Hospital, Bergen, for treatment evaluation during the period 2007-2010 were included. Demographics, clinical, laboratory, and treatment results were obtained from electronic medical records.

RESULTS

A total of 256 patients were included. The patients were young (mean age 36 ± 10.3), with a high prevalence of genotypes 3 (55%) and 1 (43%) and low levels of fibrosis (77% <F2). The majority of patients were former or current injection drug users (85%). Treatment uptake among patients attending the clinic was 47% (n = 91). Treatment was significantly less common in patients who were unemployed, those who had nonattendances during clinical evaluation, those with genotypes 1 or 4, those ≥50 years of age, and patients with no biopsy. For patients initiating treatment, the total sustained virologic response (SVR) rate was 63% (by complete case analysis 73%). For genotypes 1 and 3, SVR was achieved in 44% and 75%, respectively, by intention to treat.

CONCLUSIONS

A high treatment uptake of CHC patients in a cohort with high prevalence of injection drug use was found. Young age, low degrees of fibrosis, and good patient attendance ensured a high rate of SVR.

Using surveillance data to determine treatment rates and outcomes for patients with chronic hepatitis C virus infection

The aim of this work was to develop and validate an algorithm to monitor rates of, and response to, treatment of patients infected with hepatitis C virus (HCV) across England using routine laboratory HCV RNA testing data. HCV testing activity between January 2002 and December 2011 was extracted from the local laboratory information systems of a sentinel network of 23 laboratories across England. An algorithm based on frequency of HCV RNA testing within a defined time period was designed to identify treated patients. Validation of the algorithm was undertaken for one center by comparison with treatment data recorded in a clinical database managed by the Trent HCV Study Group. In total, 267,887 HCV RNA test results from 100,640 individuals were extracted. Of these, 78.9% (79,360) tested positive for viral RNA, indicating an active infection, 20.8% (16,538) of whom had a repeat pattern of HCV RNA testing suggestive of treatment monitoring. Annual numbers of individuals treated increased rapidly from 468 in 2002 to 3,295 in 2009, but decreased to 3,110 in 2010. Approximately two thirds (63.3%; 10,468) of those treated had results consistent with a sustained virological response, including 55.3% and 67.1% of those with a genotype 1 and non-1 virus, respectively. Validation against the Trent clinical database demonstrated that the algorithm was 95% sensitive and 93% specific in detecting treatment and 100% sensitive and 93% specific for detecting treatment outcome.

CONCLUSIONS

Laboratory testing activity, collected through a sentinel surveillance program, has enabled the first country-wide analysis of treatment and response among HCV-infected individuals. Our approach provides a sensitive, robust, and sustainable method for monitoring service provision across England.

Uptake of hepatitis C treatment among people who inject drugs attending Needle and Syringe Programs in Australia, 1999-2011

The majority of new and existing cases of hepatitis C virus (HCV) infection occur among people who inject drugs (PWID). Despite safe and efficacious HCV antiviral therapy, uptake remains low in this population. This study examined trends in HCV treatment uptake among a large national sample of PWID attending Australian Needle and Syringe Programs between 1999 and 2011. Annual cross-sectional sero-surveys conducted among PWID since 1995 involve completion of a self-administered questionnaire and provision of a dried blood spot for HCV antibody testing. Multivariate logistic regression identified variables independently associated with HCV treatment uptake among 9478 participants with both self-reported and serologically confirmed prior HCV infection. Between 1999 and 2011, the proportion currently receiving treatment increased from 1.1% to 2.1% (P < 0.001), while the proportion having ever received treatment increased from 3.4% to 8.6% (P < 0.001). Men were significantly more likely than women to have undertaken HCV treatment (P = 0.002). Among men, independent predictors of HCV treatment uptake were homosexual identity and older age; among women, independent predictors included homosexual identity and an incarceration history. Despite increases in HCV treatment among Australian PWID between 1999 and 2011, uptake remains low. Strategies are required to increase the proportion of PWID assessed and treated for HCV infection to address the increasing burden of disease. Specific approaches that target women may also be warranted. Continued surveillance of HCV treatment uptake among PWID will be important to monitor the roll-out of simple, safe and more effective HCV treatments expected to be available in the future.

Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study

BACKGROUND

Access to hepatitis C virus (HCV) treatment remains extremely limited among people who inject drugs (PWID). HCV assessment and treatment was evaluated through an innovative model for the provision of HCV care among PWID with chronic HCV infection.

METHODS

Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) was a prospective observational cohort. Recruitment was through 5 opioid substitution treatment (OST) clinics, 2 community health centers, and 1 Aboriginal community controlled health organization in New South Wales, Australia.

RESULTS

Among 387 enrolled participants, mean age was 41 years, 71% were male, and 15% were of Aboriginal ethnicity. Specialist assessment was undertaken in 191 (49%) participants, and 84 (22%) commenced interferon-based treatment. In adjusted analysis, HCV specialist assessment was associated with non-Aboriginal ethnicity (adjusted odds ratio [AOR], 4.02; 95% confidence interval [CI], 2.05-7.90), no recent benzodiazepine use (AOR, 2.06; 95% CI, 1.31-3.24), and non-1 HCV genotype (AOR, 2.13; 95% CI, 1.32-3.43). In adjusted analysis, HCV treatment was associated with non-Aboriginal ethnicity (AOR, 4.59; 95% CI, 1.49-14.12), living with the support of family and/or friends (AOR, 2.15; 95% CI, 1.25-3.71), never receiving OST (AOR, 4.40; 95% CI, 2.27-8.54), no recent methamphetamine use (AOR, 2.26; 95% CI, 1.12-4.57), and non-1 HCV genotype (AOR, 3.07; 95% CI, 1.67-5.64).

CONCLUSIONS

HCV treatment uptake was relatively high among this highly marginalized population of PWID. Potentially modifiable factors associated with treatment include drug use and social support.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In the developed world, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). The burden of HCV-related liver disease in this group is increasing, but treatment uptake among PWID remains low. Among PWID, there are a number of barriers to care that should be considered and systematically addressed, but these barriers should not exclude PWID from HCV treatment. Furthermore, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment. Further research is needed to evaluate strategies to enhance assessment, adherence, and SVR among PWID, particularly as new treatments for HCV infection become available.

Association between facility characteristics and the process of care delivered to patients with hepatitis C virus infection

BACKGROUND

Available data suggest problems in the process of care provided to patients with chronic hepatitis C (HCV). However, the solutions to these problems are less obvious. Healthcare facility factors are potentially modifiable and may enhance process quality in HCV treatment.

METHODS

We evaluated the relationship between the process of HCV care and facility factors including number of weekly half-day HCV clinics per 1,000 HCV patients, HCV-specific quality-improvement initiatives, and administrative service of the HCV clinic (gastroenterology, infectious disease, primary care) for a cohort of 34,258 patients who sought care in 126 Veterans Affairs facilities during 2003-2006. We measured HCV care on the basis of 23 HCV-specific process measures capturing pretreatment (seven measures), preventive and/or comorbid (seven measures), and treatment and treatment monitoring care (nine measures).

RESULTS

Patients seen at a facility with >8 half-day clinics were 52 % more likely to receive overall indicated care (OR 1.52, 95 % CI 1.13-2.05). Patients seen at a facility with >3 HCV quality improvement initiatives were more likely to receive better preventive and/or comorbid care (OR 1.32, 95 % CI 1.00-1.74). Compared with patients in facilities with no dedicated HCV clinic, patients at facilities with gastroenterology-based clinics received better pretreatment care (OR 1.36, 95 % CI 1.01-1.85) and more antiviral treatment (OR 1.45, 95 % CI 1.06-1.97) whereas those at facilities with infectious disease-based or primary care-based clinics received better preventive and/or comorbid care (OR 1.59, 95 % CI 1.06-2.39 and 1.84, 95 % CI 1.21-2.79 respectively).

CONCLUSION

Several facility factors affected the process of HCV care. These factors may serve as targets for quality-improvement efforts.

Can hepatitis C virus infection be eradicated in people who inject drugs?

People who inject drugs (PWID) represent the core of the hepatitis C virus (HCV) epidemic in many countries and HCV-related disease burden continues to rise. There are compelling data demonstrating that with the appropriate programs, treatment for HCV infection among PWID is successful, with responses to therapy similar those observed in large randomized controlled trials in non-PWID. However, assessment and treatment for HCV infection lags far behind the numbers who could benefit from therapy, related to systems-, provider- and patient-related barriers to care. The approaching era of interferon-free directly acting antiviral therapy has the potential to provide one of the great advances in clinical medicine. Simple, tolerable and highly effective therapy will likely address many of these barriers, thereby enhancing the numbers of PWID cured of HCV infection. This commentary will consider why we should strive for the eradication of HCV infection among PWID, whether eradication of HCV infection among PWID is feasible, components that would be needed to achieve eradication of HCV infection in PWID, potential settings and strategies required to establish programs targeted towards eradicating HCV infection among PWID and the feasibility of eradication versus elimination of HCV infection among PWID. This article forms part of a symposium in Antiviral Research on "Hepatitis C: next steps toward global eradication."

Interleukin 28B gene polymorphisms in hepatitis C virus-related cryoglobulinemic vasculitis

OBJECTIVE

Single-nucleotide polymorphisms (SNP) in the interleukin 28B (IL-28B) gene region are strongly predictive of the response of infected patients to antiviral therapy for hepatitis C virus (HCV). We sought to determine the prevalence of SNP IL-28B rs12979860 C/C and non-C/C (C/T plus T/T) genotypes in HCV-related cryoglobulinemic vasculitis (CV), as compared with HCV-positive patients without CV. We also searched for their association with peculiar clinical manifestations of CV and potential influence on the complete response (virological, molecular, and immunological) to the therapy.

METHODS

The study cohort comprised 159 and 172 HCV-infected patients with and without CV, respectively, prospectively followed starting from 1990. SNP rs12979860 genotyping was performed by Taq-Man allelic discrimination. In 106 patients (66.6%) with CV, the profile of circulating B cell clonalities was determined as well. All patients with CV were treated with pegylated interferon-α/ribavirin-based antiviral therapy.

RESULTS

The T/T IL-28B genotype was more common in patients with CV than in those without (17% vs 8.1%, p = 0.02). In patients with CV, compared with non-C/C variants, the IL-28B C/C genotype was associated with a higher rate of complete response (52.6% vs 39.2%, p = 0.13), whereas a treatment response of 61.4% was demonstrated when solely virological response was considered (p = 0.008). A higher frequency of expanded B cell clonalities in the circulation (84.2% vs 55.9%; p = 0.005), kidney involvement (21% vs 2.9%; p = 0.003), and B cell non-Hodgkin lymphoma (17.5% vs 6.8%; p = 0.048), were also observed.

CONCLUSION

In HCV-positive patients with CV, the IL-28B C/C genotype is distinguished biologically by a higher frequency of restriction of B cell response and clinically by a higher risk of cryoglobulinemic nephropathy and B cell malignancies, while acting as an independent predictor of a sustained virological response to antiviral therapy. In addition, we found that IL-28B T/T variant was more prevalent in patients with CV than in those without.

The new paradigm of hepatitis C therapy: integration of oral therapies into best practices

Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.