Diagnosis and Management of Hepatitis C Infection in Primary Care Settings

Phase 1 study of safety and tolerability of an oral contraceptive containing low-dose ethinyl oestradiol combined with glecaprevir/pibrentasvir treatment in healthy premenopausal women

Glecaprevir/pibrentasvir (GLE/PIB) is an approved guideline-recommended chronic hepatitis C virus infection treatment. GLE/PIB coadministration with ethinyl oestradiol (EE) is not recommended in current labels owing to a Phase 1 study observing Grade ≥2 alanine aminotransferase (ALT) elevation in 2 out of 12 healthy women cotreated for 11 days with GLE/PIB and oral contraceptive (OC) containing 35 μg/250 μg EE/norgestimate. No Grade ≥2 elevation was observed with low-dose (20 μg) EE (n = 14). This Phase 1 study examined safety/tolerability of GLE/PIB coadministered with an OC containing low-dose EE using a larger sample size and longer treatment duration. Healthy premenopausal women were treated with EE/levonorgestrel alone (20/100 μg, Cycles 1-2), followed by coadministration with GLE/PIB (300/120 mg; Cycles 3-4). A safety criterion of special interest was a confirmed Grade ≥2 ALT elevation (>3× upper normal limit). Adverse events (AEs) and study drugs concentrations were examined. Of 85 enrolled women, 72 initiated combined GLE/PIB + EE/levonorgestrel treatment, 66 completed the study and 19 discontinued prematurely (non-safety reason, n = 16; AE [deemed unelated to GLE/PIB], n = 3). No participant met the safety criterion of special interest of confirmed Grade ≥2 ALT elevation. No serious/Grade ≥3 AEs were reported. Study drug concentrations were within the expected ranges. GLE/PIB in combination with an OC containing low-dose EE was generally well tolerated with no confirmed Grade ≥2 ALT elevation and no evidence of drug-induced liver injury. No pattern to the reported AEs and no new safety issues were identified. This was a Phase 1 study of healthy volunteers, not a registered clinical trial.

Bioequivalence Study of Velpatasvir/Sofosbuvir Oral Coated Tablets in Healthy Volunteers Under Fasting Conditions

This study was conducted as a single-site, open-label, randomized, replicated crossover trial with 4 treatment periods. The aim was to evaluate the bioequivalence of a generic test drug containing velpatasvir and sofosbuvir compared to an established brand-name medication in healthy White subjects under fasting conditions. Blood samples were collected at specified intervals up to 72 hours after dosing to measure the concentrations of velpatasvir and sofosbuvir using a certified high-performance liquid chromatography with tandem mass spectrometry method. The bioequivalence of the 2 formulations was confirmed when statistical analysis showed that confidence intervals for the log-transformed peak concentration and area under the concentration-time curve from time 0 to the last quantifiable sample were within an acceptable range from 80% to 125%. Criteria for bioequivalence were met for both area under the concentration-time curve from time 0 until the last quantifiable sample and peak concentration parameters. No adverse effects were reported during this trial in both groups.

Chronic viral hepatitis C micro-elimination program using telemedicine in Guigang city

Hepatitis C virus (HCV) represents a formidable menace to human health, necessitating urgent attention. The objective of this study was to assess the efficacy and safety of HCV health management in the city of Guigang which consists of five districts, employing a comprehensive multi-modal approach. The study systematically carried out HCV screening in Guigang city which consists of five districts, such as Gangbei District, Gangnan District, Guiping District, Qintang District, and Pingnan District from 1 January 2016 to 30 December 2022. The target population consisted of individuals residing in these aforementioned districts, falling within the age range of 30-75 years. A multidisciplinary HCV management team was established to deliver anti-HCV screening, diagnosis, and direct-acting antiviral (DAA) therapy. The primary outcome of interest was the achievement of sustained virologic response (SVR). A total of 2489 individuals were included as the target population, with 1694 individuals residing in Gangbei District, 202 in Gangnan District, 111 in Qintang District, 167 in Pingnan District, and 315 in Guiping District. Out of these individuals, 2478 were subjected to anti-HCV screening. The screening rates varied across the districts, ranging from a peak of 99.55% in Guigang City to a nadir of 98.41% in Guiping District. Remarkably, within Guigang City, a noteworthy enhancement was observed in the HCV-RNA diagnosis rate from 23.4% prior to program implementation to a remarkable 100% following 7 years of intervention and management. Furthermore, the diagnosis and treatment coordination rate experienced a substantial improvement, rising from 26.8% before program inception to 80%. Importantly, a total of 1180 individuals affected by hepatitis C were successfully cured, equating to a 100% cure rate. Logistic regression analysis revealed a significant association between serological status and factors such as Aging, bilirubin, and glutamic oxalacetic transaminase. The findings from our investigation unveil a pioneering HCV management model, exemplified by the Guigang model, which has contributed crucially to HCV microclearance efforts and serves as an invaluable reference for future initiatives.

Purification of hepatitis C virus core protein in non-denaturing condition

Hepatitis C virus (HCV) is the major cause of chronic hepatitis and hepatocellular carcinoma. Among its structural proteins, the HCV core protein has been implicated in liver disease. Understanding the role of HCV core proteins in viral diseases is crucial to elucidating disease mechanisms and identifying potential drug targets. However, purification challenges hinder the comprehensive elucidation of the structure and biochemical properties of HCV core proteins. In this study, we successfully solubilized bacterially expressed core protein using a high-salt and detergent-containing buffer and bypassed the denaturing-refolding process. Size-exclusion chromatography revealed three distinct peaks in the HCV-infected cell lysate, with the bacterially expressed soluble core protein corresponding to its second peak. Using a combination of affinity, size exclusion, and multi-modal chromatography purification techniques, we achieved a purity of > 95% for the core protein. Analytical ultracentrifugation revealed monomer formation in the solution. Far UV Circular dichroism spectroscopy identified 25.53% alpha helices and 20.26% beta sheets. These findings strongly suggest that the purified core proteins retained one of the native structures observed in HCV-infected cells.

Real-world Experiences in the Transplantation of Hepatitis C-NAAT-positive Organs

Background

Hepatitis C virus (HCV) nucleic acid amplification test (NAAT)-positive donors have increased the organ pool. Direct-acting antivirals (DAAs) have led to high rates of treatment success and sustained virologic response (SVR) in recipients with donor-derived HCV infection without significant adverse effects, although variability remains in the timing and duration of antivirals.

Methods

This retrospective study analyzed all adult HCV-NAAT-negative transplant recipients who received an organ from HCV-NAAT-positive donors from November 24, 2018, to March 31, 2022, at Duke University Medical Center with protocolized delay of DAA initiation until after hospital discharge, with at least 180-d follow-up on all patients. Transplant and HCV-related outcomes were analyzed.

Results

Two hundred eleven transplants (111 kidneys, 41 livers, 34 hearts, and 25 lungs) were performed from HCV-NAAT-positive donors to HCV-NAAT-negative recipients. Ninety percent of recipients became viremic within 7 d posttransplant. Ninety-nine percent of recipients were initiated on pangenotypic DAAs in the outpatient setting a median of 52 d posttransplant, most commonly with 12-wk courses of sofosbuvir-velpatasvir (lungs) and glecaprevir-pibrentasvir (heart, kidney, and liver). Ninety-seven percent of recipients had SVR after a first-line DAA; all ultimately achieved SVR at 12 wk after subsequent treatment courses. The median peak HCV RNA for all organ systems was 2 436 512 IU/mL; the median time from antiviral to undetectable RNA was 48 d, although differences were noted between organ groups. No patient deaths or graft losses were directly attributable to HCV infection.

Conclusions

One hundred percent of transplant recipients of HCV-NAAT-positive organs ultimately developed SVR without significant adverse effects when HCV antivirals were initiated in the outpatient setting after transplant hospitalization, suggesting that this real-world treatment pathway is a viable option.

Hepatitis C Knowledge, Attitudes, and Perceptions Among People With HIV in South Texas

Direct-acting antivirals are overwhelmingly effective in curing hepatitis C (HCV). Barriers to HCV treatment exist for those co-infected with both HIV and HCV. Southern states represent the epicenter of the HIV epidemic in the United States. This study assessed HCV knowledge, attitudes, and perceptions in 318 co-infected individuals attending Ryan White HIV/AIDS Program (RWHAP) clinics in three South Texas cities. Two groups were compared, those tested for HCV and aware of their results (Group 1) and those uncertain if they were tested or tested and unaware of their results (Group 2). HCV knowledge was poor overall. Group 1 had a significantly higher mean HCV knowledge score than Group 2 by t-test (48.6 vs. 38.8; p < .01), but not by multivariable linear regression (p=.14). Factors predictive of greater HCV knowledge included self-identification as lesbian, gay, bisexual, transgender, queer and post high school educational attainment. Significantly more in Group 1 compared with Group 2 agreed that HCV medications would keep a person healthier for longer. Spanish speakers were more likely to disagree with a statement that people of color receive the same treatment for hepatitis C as white people. Study limitations identified include poor generalizability to people with HIV (PWH) receiving care in non-RWHAP settings and rural communities. Despite limitations, this study augments the paucity of information about knowledge, attitudes, and perceptions of HCV in PWH and can inform interventions to combat barriers to HCV treatment and to maximize opportunities for HCV screening, diagnosis, and linkage to curative care.

Expression of CYP2B6 Enzyme in Human Liver Tissue of HIV and HCV Patients

Background and Objectives: Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections present significant public health challenges worldwide. The management of these infections is complicated by the need for antiviral and antiretroviral therapies, which are influenced by drug metabolism mediated by metabolic enzymes and transporters. This study focuses on the gene expression of CYP2B6, CYP3A4, and ABCB1 transporters in patients with HIV, HCV, and HIV/HCV co-infection, aiming to assess their potential association with the choice of therapy, patohistological and clinical parameters of liver damage such as the stage of liver fibrosis, serum levels of ALT and AST, as well as the grade of liver inflammation and other available biochemical parameters. Materials and Methods: The study included 54 patients who underwent liver biopsy, divided into HIV-infected, HCV-infected, and co-infected groups. The mRNA levels of CYP2B6, CYP3A4, and ABCB1 was quantified and compared between the groups, along with the analysis of liver fibrosis and inflammation levels. Results: The results indicated a significant increase in CYP2B6 mRNA levels in co-infected patients, a significant association with the presence of HIV infection with an increase in CYP3A4 mRNA levels. A trend towards downregulation of ABCB1 expression was observed in patients using lamivudine. Conclusions: This study provides insight into gene expression of CYP2B6 CYP3A4, and ABCB1 in HIV, HCV, and HIV/HCV co-infected patients. The absence of correlation with liver damage, inflammation, and specific treatment interventions emphasises the need for additional research to elucidate the complex interplay between gene expression, viral co-infection, liver pathology, and therapeutic responses in these particular patients population.

Hepatitis C Elimination: Opportunities and Challenges in 2023

Hepatitis C Virus (HCV) infection is a leading etiology of liver cirrhosis and its associated complications, namely, decompensated cirrhosis. As such, hepatitis C potentially necessitates liver transplantation and may result in death. Recently, HCV treatment has evolved. Current HCV treatment is effective in curing HCV; some of the agents are pan-genotypic. Numerous countries have adopted an initiative to eliminate HCV. Achieving elimination poses many challenges; it requires improved availability and accessibility of pan-genotypic therapy. Barriers exist at the level of the collective healthcare system and at the level of the individual healthcare providers and patients. Therefore, organized national and local efforts are needed. Surmounting these barriers calls for interventions concerning screening, linkage to care, and treatment delivery. Pertinent barriers include inadequate availability of screening, ill-equipped laboratory testing before treatment, and insufficient access to treatment. Interventions should seek to decentralize laboratory testing and treatment provision, increase funding for resources and personnel, and spread awareness. Special consideration should be allocated to at-risk populations, such as intravenous drug users, refugees, and prisoners. Computerized medical filing and telemedicine have the potential to refine HCV management by enhancing detection, availability, accessibility, and cost-effectiveness.

Hepatitis C virus seroprevalence among patients enrolled at the opioid substitution therapy center in Bihar: A cross-sectional study

BACKGROUND AND AIM

Hepatitis C virus (HCV) infection poses a major public health challenge in Indian settings due to its huge population and easy transmissibility of HCV among individuals who inject drugs (PWID, which is increasing in India). The National AIDS Control Organization (NACO), India has started the Opioid Substitution Therapy (OST) centers to improve the health status of opioid dependent PWID and prevent the spread of HIV/AIDS among them. We conducted a cross-sectional study to find out the HCV sero-positive status and associated determinants in patients attending the OST centre in the ICMR-RMRIMS, Patna.

MATERIALS AND METHODS

We utilized the routinely collected (as a part of the National AIDS Control Program) and de-identified data from the OST center from 2014 to 2022 (N = 268). We abstracted the information for exposure variables (such as socio-demographic features and drug history) and outcome variable (HCV serostatus). The association of exposure variables with HCV serostatus was examined using robust Poisson regression.

RESULTS

All the enrolled participants were male and the prevalence of HCV seropositivity was 28% [95% confidence interval (CI): 22.7% - 33.8%)]. There was a rising prevalence of HCV seropositivity with number of years of injection use (p-trend <0.001) and age (p-trend 0.025). Approximately, 6.3% participants were injecting drugs for >10 years and reported the maximum prevalence of HCV seropositivity (47.1%, 95% CI: 23.3%-70.8%). In adjusted analyses, being employed compared to unemployed patients [adjusted prevalence ratio (aPR) = 0.59; 95% CI: 0.38-0.89]; graduated patients compared to illiterate patients [aPR = 0.11; 95% CI: 0.02-0.78]; and patients with education up to higher secondary compared to illiterate patients [aPR = 0.64; 95% CI: 0.43-0.94] had significantly lesser HCV seropositivity. A-one year increase in injection use [aPR = 1.07; 95% CI: 1.04-1.10] was associated with 7% higher prevalence of HCV seropositivity.

CONCLUSIONS

In this OST center-based study of 268 PWIDs residing in Patna, ~28% of patients were HCV seropositive, which was positively associated with years of injection use, unemployment, and illiteracy. Our findings suggest that OST centers offer an opportunity to reach a high-risk difficult to reach group for HCV infection and thus support the notion of integrating HCV care into the OST or de-addiction centres.

Uptake of hepatitis C direct-acting antiviral treatment in China: a retrospective study from 2017 to 2021

BACKGROUND

Direct-acting antivirals (DAAs) for hepatitis C treatment in China became available since 2017. This study expects to generate evidence to inform decision-making in a nationwide scale-up of DAA treatment in China.

METHODS

We described the number of standard DAA treatment at both national and provincial levels in China from 2017 to 2021 based on the China Hospital Pharmacy Audit (CHPA) data. We performed interrupted time series analysis to estimate the level and trend changes of the monthly number of standard DAA treatment at national level. We also adopted the latent class trajectory model (LCTM) to form clusters of the provincial-level administrative divisions (PLADs) with similar levels and trends of number of treatment, and to explore the potential enablers of the scale-up of DAA treatment at provincial level.

RESULTS

The number of 3-month standard DAA treatment at national level increased from 104 in the last two quarters of 2017 to 49,592 in the year of 2021. The estimated DAA treatment rates in China were 1.9% and 0.7% in 2020 and 2021, which is far below the global target of 80%. The national price negotiation at the end of 2019 resulted in DAA inclusion by the national health insurance in January 2020. In that month, the number of treatment increased 3668 person-times (P < 0.05). LCTM fits the best when the number of trajectory class is four. PLADs as Tianjin, Shanghai and Zhejiang that had piloted DAA price negotiations before the national negotiation and that had explored integration of hepatitis service delivery with prevention and control programme of hepatitis C within the existing services demonstrated earlier and faster scale-up of treatment.

CONCLUSIONS

Central negotiations to reduce prices of DAAs resulted in inclusion of DAA treatment under the universal health insurance, which are critical elements that support scaling up access to hepatitis C treatment in China. However, the current treatment rates are still far below the global target. Targeting the PLADs lagged behind through raising public awareness, strengthening capacity of the healthcare providers by roving training, and integrate prevention, screening, diagnosis, treatment and follow-up management of hepatitis C into the existing services are needed.

Management of in- and out-of-hospital screening for hepatitis C

Because of insidious progression and no significant clinical symptoms at early stage, chronic hepatitis C (CHC) is often diagnosed after the occurrence of cirrhosis and hepatocellular carcinoma. Highly effective and low drug resistance of direct-acting antiviral agents (DAAs) have enabled cure of CHC, encouraging the World Health Organization to propose a global viral hepatitis elimination program. To Date, vaccine for CHC is still under research. Therefore, reducing the source of infection is an important means of eliminating CHC other than cutting off the transmission route, which requires screening, diagnosing and treating as many patients in the population as possible. Hospital-based screening strategy have been found to be cost-effective in the management of CHC screening, as reported both nationally and internationally. Currently, China has issued In-hospital process for viral hepatitis C screening and management in China (Draft) in April, 2021, which provides a standardized implementation process and direction for in-hospital hepatitis C screening and treatment, but still requires medical institution to develop its own management process, taking into account its current situation and learning from domestic and international experience. In addition, screening for CHC outside the hospital among special populations, such as blood donors, pregnant women, homosexuals, intravenous drug users, prisoners, and residents in rural areas with scarce medical care resources, also requires attention and development of targeted and rational screening strategies. In this paper, we analyze and recommend the management of hepatitis C screening from both in-hospital and out-of-hospital perspectives, with the aim of contributing to the formulation of hepatitis C screening strategies.

Reliving it All Over Again: Uncanny Temporalities of Injection Drug Use and Hepatitis C Diagnosis in Southwest Virginia, USA

Clinicians typically view the intersection between hepatitis C and injection drug use in terms of simultaneity - with transmission occurring via shared needles - or sequentially - with some states requiring that people stop using drugs prior to treatment. Yet, for patients, the connection between substance use and HCV infection can follow a more complex temporal pathway. In this article, we explore the non-linear temporality of "reliving" as it shapes HCV illness experience, its complex intersection with injection drug use, and the barriers patients face as they reckon with existing healthcare system responses and treatment modalities.

Integrating Management of Hepatitis C Infection into Primary Care: the Key to Hepatitis C Elimination Efforts

Elimination of hepatitis C virus (HCV), a leading cause of liver disease in the USA and globally, has been made possible with the advent of highly efficacious direct acting antivirals (DAAs). DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy. With increasingly straightforward diagnostic and treatment algorithms, HCV infection can be managed not only by specialists, but also by primary care providers. Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality. However, barriers remain at each step in the HCV cascade of care from screening to evaluation and treatment. Since primary care is at the forefront of patient contact, it represents the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment.

Improving hepatitis C screening and access to treatment

ABSTRACT

The rising prevalence of opioid use disorder and injection drug use has resulted in an increasing incidence of chronic hepatitis C virus (HCV) infection. Although older adults historically have represented the bulk of HCV infections in the United States, demographics have shifted and most new infections are presenting in younger patients. As a result, screening guidelines for HCV have evolved, moving toward a near-universal screening paradigm. Rates of screening and linkage to care remain low, attributed to the fact that underserved populations are disproportionately affected and often have limited access to specialty care. Collaborative models to treat HCV using primary care providers have been proposed to facilitate linkage to care and reduce transmission.

Prevalence of HCV Infection Among Hemodialysis Patients in Lanzhou of Northwestern China

Objective

To investigate the prevalence of hepatitis C virus (HCV) infection among hemodialysis (HD) patients in Lanzhou of Northwestern China, we interviewed 565 patients from five randomly sampled HD centers in Lanzhou with a structured questionnaire including sociodemographic characteristics, past medical history and HD-related factors.

Methods

The testing results of anti-HCV and HCV-RNA in a recent HD from clinical information system were collected. A generalized estimated equation (GEE) logistic regression model was used to identify the determinants of HCV infection among HD patients.

Results

The prevalence of anti-HCV or HCV-RNA infection among HD patients was 1.77% or 1.42% respectively. GEE model showed that history of kidney transplantation (HCV-RNA: OR=19.79, 95%CI: 12.69–30.85) could dramatically increase the risk of current HCV infection in dialysis patients. Compared with never using of blood products, using of blood products (anti-HCV: OR=2.38, 95%CI: 1.22–4.64; HCV-RNA: OR=15.23, 95%CI: 1.79–129.49) could increase the risk of HCV infection in dialysis patients. Moreover, with the increase of HD duration, the risk increased one time or so (anti-HCV: OR=1.83, 95%CI: 1.22–2.72; HCV-RNA: OR=2.00, 95%CI: 1.11–3.61). Furthermore, dialysis in multiple hospitals possessed more than three times risk of HCV infection (anti-HCV: OR=3.56, 95%CI: 3.11–4.08; HCV-RNA: OR=3.35, 95%CI: 1.88–5.96). Besides, HD patients having the history of acupuncture (HCV-RNA: OR=5.56; 95%CI: 1.16–26.67) or surgery (HCV-RNA: OR=6.39; 95%CI: 2.86–14.29) caused an about-six-times risk of current infections.

Conclusion

It could be concluded that the prevalence of HCV infection was mild and using of blood products or kidney transplantation, long dialysis duration, dialysis in multiple hospitals, surgery or acupuncture treatment were some risk factors of HCV infection among HD patients in Lanzhou of Northwestern China.

Physician- and patient-reported barriers to hepatocellular carcinoma surveillance: A nationwide survey

Hepatocellular carcinoma (HCC) surveillance rates are suboptimal. We aimed to identify HCC surveillance barriers from both physician's and patient's perspectives and assess the effectiveness of physician education using social networks. A nationwide survey with 513 physicians and another single-center survey with 315 HCC-risk patients were conducted. Barriers to suboptimal surveillance were identified using univariate and multivariate logistic regression analysis. We educated 143 physicians by sending brief notes on HCC surveillance guidelines via social networks and re-evaluated their knowledge after 60 days using t test. Surveys showed 458 (86.3%), 254 (47.8%), and 225 (42.4%) physicians recommended surveillance in patients with cirrhosis, at-risk hepatitis B virus, and hepatitis C virus infection, respectively. Only 228 (42.9%) and 241 (38.0%) respondents adhered to recommended surveillance tools and interval, respectively. The main surveillance barriers among physicians were the lack of knowledge and resource limitations. The lack of a doctor's prescription was identified as a major barrier by patient' perspectives (odds ratio 1.4, 95% CI: 1.1-1.8, P = .024). Education via social networks enhanced physicians' knowledge, with pre- and post-education scores for guideline awareness of 63.0% versus 84.3% (P < .001) and for surveillance indication and tools of 40.0% versus 63.0% (P = .001), and 42.0% versus 59.3% (P = .015), respectively. Physicians' knowledge gap is a primary barrier for adherence to HCC surveillance protocols. Brief education via social networks shows effectiveness at increasing physicians' knowledge of HCC surveillance.

Hepatitis C virus (HCV) seroprevalence, RNA detection, and genotype distribution across Florida, 2015-2018

Chronic hepatitis C virus (HCV) infection is a leading cause of hepatocellular carcinoma (HCC) in the U.S. Due to high rates of HCV among baby boomers (born 1945-1965), it was recommended they receive universal screening. This was expanded to all U.S. adults in 2020 due to evidence of increasing rates of chronic HCV in younger adults. An assessment of HCV burden across demographics is crucial to understand the future burden of HCC and target under-screened adults for HCV. Using the OneFlorida Clinical Research Consortium, of more than one million individuals in Florida, all HCV antibody and viral RNA tests completed from 2015 to 2018 were identified. HCV seroprevalence, HCV viral load (active infection), and HCV genotype distribution by risk groups were assessed. Overall, HCV seroprevalence and active infection were highest among White non-Hispanic individuals, males, and baby boomers. However, odds of a positive HCV antibody test were higher among Black non-Hispanic individuals born before 1945 (aOR: 2.74; 95% CI: 1.98-3.78) or 1945-1965 (aOR: 1.46; 95% CI: 1.36-1.56) compared to White non-Hispanic individuals. In contrast, among individuals born after 1965, Black non-Hispanics were less likely than White non-Hispanics to test HCV antibody positive (aOR of 0.5-0.28). A similar age/race pattern was observed for active HCV infection. There was a higher prevalence of genotype 1A and 3 and lower prevalence of 1B in younger adults. Patterns of HCV seroprevalence and active HCV infection identified in our study support the recent shift from age and risk-based screening guidelines to universal adult screening.

Cancer in People with and without Hepatitis C Virus Infection: Comparison of Risk Before and After Introduction of Direct-Acting Antivirals

BACKGROUND

Chronic hepatitis C virus (HCV) infection is a leading cause of liver cancer. The association of HCV infection with extrahepatic cancers, and the impact of direct-acting antiviral (DAA) treatment on these cancers, is less well known.

METHODS

We conducted a cohort study in a healthcare delivery system. Using electronic health record data from 2007 to 2017, we determined cancer incidence, overall and by type, in people with HCV infection and by DAA treatment status. All analyses included comparisons with a reference population of people without HCV infection. Covariate-adjusted Poisson models were used to estimate incidence rate ratios.

RESULTS

2,451 people with HCV and 173,548 people without HCV were diagnosed with at least one type of cancer. Compared with people without HCV, those with HCV were at higher risk for liver cancer [adjusted incidence rate ratio (aIRR) = 31.4, 95% confidence interval (CI) = 28.9-34.0], hematologic cancer (aIRR = 1.3, 95% CI = 1.1-1.5), lung cancer (aIRR = 1.3, 95% CI = 1.2-1.5), pancreatic cancer (aIRR = 2.0, 95% CI = 1.6-2.5), oral/oropharynx cancer (aIRR = 1.4, 95% CI = 1.1-1.8), and anal cancer (aIRR = 1.6, 95% CI = 1.1-2.4). Compared with people without HCV, the aIRR for liver cancer was 31.9 (95% CI = 27.9-36.4) among DAA-untreated and 21.2 (95% CI = 16.8-26.6) among DAA-treated, and the aIRR for hematologic cancer was 1.5 (95% CI = 1.1-2.0) among DAA-untreated and 0.6 (95% CI = 0.3-1.2) among DAA-treated.

CONCLUSIONS

People with HCV infection were at increased risk of liver cancer, hematologic cancer, and some other extrahepatic cancers. DAA treatment was associated with reduced risk of liver cancers and hematologic cancers.

IMPACT

DAA treatment is important for reducing cancer incidence among people with HCV infection.

Sofosbuvir/Velpatasvir - A Promising Treatment for Chronic Hepatitis C Virus Infection

Hepatitis C virus (HCV) infection is a disease that affects millions of people worldwide and has an enormous global public health impact. Chronic HCV is a long-term infection that goes unnoticed until the virus destroys the liver enough to induce liver disease symptoms. The inadequate and poorly tolerated treatment contributes to the burden of chronic HCV. Treatments have improved over time - direct-acting antivirals (DAAs) that targeted different hepatitis C virus genomic sites have shown to be more effective and well-tolerated. Patients recover to a greater extent following a treatment regimen based on DAAs. We conducted this literature review to investigate the effectiveness of these medications in treating chronic HCV infection. Relevant articles were identified by searching PubMed and Google scholar databases. Our primary goal was to analyze the efficacy and safety of the DAA, sofosbuvir plus velpatasvir, with or without ribavirin, in cirrhotic or non-cirrhotic, naïve or previously treated, chronic HCV patients. We found that treating patients with sofosbuvir-velpatasvir for 12 weeks was highly effective with fewer adverse events, including those with compensated cirrhosis. The outcomes aided in improving HCV treatment, lowering the disease's burden and fatality rate.

Decreases in Hepatitis C Testing and Treatment During the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic has disrupted healthcare services, reducing opportunities to conduct routine hepatitis C virus antibody screening, clinical care, and treatment. Therefore, people living with undiagnosed hepatitis C virus during the pandemic may later become identified at more advanced stages of the disease, leading to higher morbidity and mortality rates. Further, unidentified hepatitis C virus-infected individuals may continue to unknowingly transmit the virus to others.

METHODS

To assess the impact of the COVID-19 pandemic, data were evaluated from a large national reference clinical laboratory and from national estimates of dispensed prescriptions for hepatitis C virus treatment. Investigators estimated the average number of hepatitis C virus antibody tests, hepatitis C virus antibody-positive test results, and hepatitis C virus RNA-positive test results by month in January-July for 2018 and 2019, compared with the same months in 2020. To assess the impact of hepatitis C virus treatment, dispensed hepatitis C virus direct-acting antiretroviral medications were examined for the same time periods. Statistical analyses of trends were performed using negative binomial models.

RESULTS

Compared with the 2018 and 2019 months, hepatitis C virus antibody testing volume decreased 59% during April 2020 and rebounded to a 6% reduction in July 2020. The number of hepatitis C virus RNA-positive results fell by 62% in March 2020 and remained 39% below the baseline by July 2020. For hepatitis C virus treatment, prescriptions decreased 43% in May, 37% in June, and 38% in July relative to the corresponding months in 2018 and 2019.

CONCLUSIONS

During the COVID-19 pandemic, continued public health messaging, interventions and outreach programs to restore hepatitis C virus testing and treatment to prepandemic levels, and maintenance of public health efforts to eliminate hepatitis C infections remain important.

Impact of coronavirus disease 2019 on prevention and elimination strategies for hepatitis B and hepatitis C

The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality since its first case was discovered in December 2019. Since then, multiple countries have witnessed a healthcare system collapse due to the overwhelming demand for COVID-19 care. Drastic measures have been taken globally in order to curb the spread of the virus. However, those measures have led to the disruption of other aspects of healthcare, increasing the burden due to other medical conditions. We have also stepped back in achieving the ambitious goal set in place by World Health Organization to eliminate viral hepatitis as a public threat by 2030. Hepatitis B and C are chronic conditions with a significant worldwide burden, and COVID-19 has resulted in many hepatitis elimination programs slowing or stopping altogether. In this review, we elucidate the impact of the ongoing COVID-19 pandemic on the interventions targeted towards the elimination of hepatitis B virus and hepatitis C virus. Some of the salient features that we have covered in this review include hindrance to screening and diagnostic tests, neonatal vaccinations, the transmission dynamics affecting hepatitis B virus and hepatitis C virus, role of limited awareness, restrictions to treatment accessibility, and disparity in healthcare services. We have highlighted the major issues and provided recommendations in order to tackle those challenges.

HCV Infection and Chronic Renal Disease

Chronic Hepatitis C virus (HCV) infection is defined as persistence of HCV RNA in the blood for more than six months. HCV is a major cause of chronic liver disease and cirrhosis. It’s serious public health problem, affects about 71 million people worldwide. HCV doesn’t destroy hepatocytes directly. It activates the host's innate and acquired immune system and causes liver injury indirectly. Behind hepatic, HCV can cause extra-hepatic manifestations. One of them is renal disease which can lead to end-stage renal disease, ESRD. The prevalence of HCV infection in patients on hemodialysis is high, ranging from 5% to 60%. HCV infection is a significant cause of morbidity and mortality in patients with ESRD on hemodialysis. In this review, we discuss HCV infection and chronic renal disease as comorbidities, their severity and outcome.

Abnormal Liver Blood Tests: Primary Care Approach

BACKGROUND

According to recent epidemiological data, annual deaths due to liver disease have increased dramatically, while predictions show that trends will continue to rise in the upcoming years.

SUMMARY

Abnormal liver blood tests are one of the most common challenges encountered in the primary care setting. The prevalence of mildly elevated transaminase levels is around 10-20% in the general population. The most common causes for the rising burden of liver disease are nonalcoholic fatty liver disease (NAFLD), alcohol-related liver disease (ARLD), and viral hepatitis. With improvements in the management of viral hepatitis over the last decades, the causes for the rising burden of liver disease are shifting toward ARLD and NAFLD. It is well-known that liver disease usually progresses silently for years or decades until the complications of cirrhosis occur. The majority of patients will not require referral to a specialist but will need further assessment in primary care. They should be evaluated for the etiology of liver disease irrespective of the duration of abnormal liver blood tests or unmarked clinical presentation. The evaluation should include a history of alcohol use, a history of medicines or herbal supplements, testing for viral hepatitis, and assessment for NAFLD, especially in obese patients and patients with type 2 diabetes. Abdominal ultrasound should be performed. Key Messages: The general practitioner may contribute significantly by identifying and screening patients at risk for chronic liver disease, as well as prioritize individuals with symptoms or signs of advanced liver disease to the specialist clinic.

Effectiveness and safety of glecaprevir/pibrentasvir in chronic hepatitis C patients: Results of the Italian cohort of a post-marketing observational study

BACKGROUND AND AIMS

The MARS post-marketing, observational study evaluates glecaprevir/pibrentasvir in a large population of Italian patients who are infected with HCV.

PATIENTS AND METHODS

Achievement of SVR12 was the primary endpoint in the overall population and by subpopulations of interest (treatment-naïve and treatment-experienced patients, subjects infected with different HCV genotype/sub-genotype, cirrhotic and non-cirrhotic patients, patients with different severity of fibrosis, patients with an APRI score ≥1, subjects with comorbidities, HIV-coinfected patients, elderly patients and people who use drugs). Safety and quality of life (assessed by SF-36 and Work Productivity and Activity Impairment) were also evaluated.

RESULTS

The SVR12 rate was 99.4% (319/321; 95% CI: 97.8-99.8%) in the core population with sufficient follow-up (n = 321), 99.7% (289/290) in 8-week treated patients, and high (>96%) across subgroups. Only three patients (0.9%) had treatment-related adverse events that led to treatment discontinuation. In total, 30.1% of patients showed an improvement of ≥2.5 points in the Physical Component Summary of the SF-36 from baseline to the end of treatment, and this figure raised to 37.5% with the achievement of SVR12. Corresponding values for MCS were 42.2% and 42.8%, respectively.

CONCLUSION

Glecaprevir/pibrentasvir is safe and effective across subpopulations who are underserved in clinical trials.

Management of liver disease patients in different clinical situations during COVID-19 pandemic

Chronic liver diseases are common worldwide, especially in developing countries. The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/(COVID-19) leads to the infection of many patients with underlying chronic liver diseases. As a relatively new disease, management of COVID-19, in the context of chronic liver disease, is mainly based on the experience of the treating physician and the available data. In this review, we summarize the available evidence about the management of liver disease patients, in the context of COVID-19 infection, which can increase the severity of viral hepatitis B. Also, its clearance in HBV patients is delayed. A sixfold increased severity of COVID-19 was reported in obese patients with metabolic associated fatty liver disease (MAFDL). In patients with autoimmune liver disease (AILD), it is not recommended to change their immunosuppressive therapy (as long as they are not infected with COVID-19), in order to avoid a flare of liver disease. However, immunosuppressant drugs should be modified, in the case of infection with COVID-19. To date, no data suggest an increased risk or severity in metabolic liver diseases, such as hemochromatosis, Wilson's disease, or alpha-1 antitrypsin deficiency. Patients with liver cirrhosis should be carefully managed with minimum exposure to healthcare facilities. Basic investigations for follow-up can be scheduled at wider intervals; if patients need admission, this should be in COVID-19-clean areas. Patients with hepatocellular carcinomas may have a poor prognosis according to preliminary reports from China. The course of COVID-19 in liver transplant recipients on immunosuppression seems to have a benign course, based on few reports in children and adults. The hepatotoxicity of COVID-19 drugs ranges from mild liver enzyme elevation to a flare of underlying liver diseases. Therefore, the decision should be customized. Telemedicine can minimize the exposure of healthcare workers and patients to infection with COVID-19 and decrease the consumption of personal protective equipment.

There's just not enough time: a mixed methods pilot study of hepatitis C virus screening among baby boomers in primary care

BACKGROUND

Liver cancer rates are rising and hepatitis C virus (HCV) is the primary cause. The CDC recommends a one-time HCV screening for all persons born 1945-1965 (baby boomers). However, 14% of baby boomers have been screened. Few studies have examined primary care providers' (PCP) perspectives on barriers to HCV screening. This study examines current HCV screening practices, knowledge, barriers, and facilitators to HCV screening recommendation for baby boomers among PCPs.

METHODS

We conducted a mixed methods pilot study of PCPs. Quantitative: We surveyed PCPs from 3 large academic health systems assessing screening practices, knowledge (range:0-9), self-efficacy to identify and treat HCV (range:0-32), and barriers (range:0-10). Qualitative: We conducted interviews assessing patient, provider, and clinic-level barriers to HCV screening for baby boomers in primary care. Interviews were audio recorded, transcribed, and analyzed with content analysis.

RESULTS

The study sample consisted of 31 PCPs (22 survey participants and nine interview participants). All PCPs were aware of the birth cohort screening recommendation and survey participants reported high HCV testing recommendation, but qualitative interviews indicated other priorities may supersede recommending HCV testing. Provider knowledge of viral transmission was high, but lower for infection prevalence. While survey participants reported very few barriers to HCV screening in primary care, interview participants provided a more nuanced description of barriers such as lack of time.

CONCLUSIONS

There is a need for provider education on both HCV treatment as well as how to effectively recommend HCV screening for their patients. As HCV screening guidelines continue to expand to a larger segment of the primary care population, it is important to understand ways to improve HCV screening in primary care.

Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region

BACKGROUND

Hepatitis C virus (HCV) and the opioid epidemic disproportionately affect the Appalachian region. Geographic and financial barriers prevent access to specialty care. Interventions are needed to address the HCV-opioid syndemic in this region.

METHODS

We developed an innovative, collaborative telehealth model in Southwest Virginia featuring bidirectional referrals from and to comprehensive harm reduction (CHR) programs and office-based opioid therapy (OBOT), as well as workforce development through local provider training in HCV management. We aimed to (1) describe the implementation process of provider training and (2) assess the effectiveness of the telehealth model by monitoring patient outcomes in the first year.

RESULTS

The provider training model moved from a graduated autonomy model with direct specialist supervision to a 1-day workshop with parallel tracks for providers and support staff followed by monthly case conferences. Forty-four providers and support staff attended training. Eight providers have begun treating independently. For the telehealth component, 123 people were referred, with 62% referred from partner OBOT or CHR sites; 103 (84%) attended a visit, 93 (76%) completed the treatment course, and 61 (50%) have achieved sustained virologic response. Rates of sustained virologic response did not differ by receipt of treatment for opioid use disorder.

CONCLUSIONS

Providers demonstrated a preference for an in-person training workshop, though further investigation is needed to determine why only a minority of those trained have begun treating HCV independently. The interdisciplinary nature of this program led to efficient treatment of hepatitis C in a real-world population with a majority of patients referred from OBOTs and CHR programs.

A Colocalized Hepatitis C Virus Clinic in a Primary Care Practice Improves Linkage to Care in a High Prevalence Population

BACKGROUND

There is an urgent need to increase patient access to treatment of chronic hepatitis C virus (HCV) infection. We developed a colocalized HCV clinic integrated within a primary care practice. We report the prevalence of HCV and evaluate the impact of the integrated clinic on the HCV cascade of care.

METHODS

We performed a retrospective study of patients with chronic HCV infection from 2 clinic practices, an integrated clinic practice and a similar nonintegrated clinic practice, between July 2015 and July 2016. Demographic, clinical, and HCV testing data were reviewed to estimate the prevalence of chronic HCV and to construct a cascade of care.

RESULTS

A total of 8405 primary care patients were included; 4796 (57.1%) received an HCV antibody test and 390 (8.1%) were positive. A total of 310 patients with chronic HCV were included in the analysis. There were 119 patients eligible for linkage to care in the nonintegrated clinic, of which 80 (67.2%) were referred, 38 (31.9%) were linked, and 18 (15.1%) initiated treatment during the study period. Among the 70 patients eligible for linkage to care in the integrated clinic practice, 51 (72.9%) were referred, 38 (54.3%) were linked, and 16 (22.9%) initiated treatment. In a multivariable analysis, patients in the integrated clinic practice had significantly higher odds of being linked to care than patients in the nonintegrated clinic practice (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] = 1.3-4.8).

CONCLUSIONS

We found a high seroprevalence of chronic HCV within our clinic population and demonstrate that a HCV clinic integrated into a primary care center increases linkage to care for patients with chronic HCV.

HCV Testing and Treatment in a National Sample of US Federally Qualified Health Centers during the Opioid Epidemic

BACKGROUND

Federally qualified health centers (FQHCs) serve diverse communities in the United States (U.S.) and could function as important venues to diagnose and treat hepatitis C virus (HCV) infections.

OBJECTIVE

To determine HCV testing proportion and factors associated with treatment initiation, and treatment outcomes in a large sample of FQHCs around the U.S.

DESIGN

Retrospective cohort study using electronic health records of three hundred and forty-one FQHC clinical sites participating in the OCHIN network in 19 U.S. states.

PARTICIPANTS

Adult patients (≥ 18 years of age) seen between January 01, 2012, and June 30, 2017.

MAIN MEASURES

HCV testing proportion, stratified by diagnosis of opioid use disorder (OUD); treatment initiation rates; and sustained virologic response (SVR), defined as undetectable HCV RNA 6 months after treatment initiation.

KEY RESULTS

Of the 1,508,525 patients meeting inclusion criteria, 88,384 (5.9%) were tested for HCV, and 8694 (9.8%) of individuals tested had reactive results. Of the 6357 with HCV RNA testing, 4092 (64.4%) had detectable RNA. Twelve percent of individuals with chronic HCV and evaluable data initiated treatment. Of those, 87% reached SVR. Having commercial insurance (aOR, 2.11; 95% CI, 1.46-3.05), older age (aOR, 1.07; 95% CI, 1.06-1.09), and being Hispanic/Latino (aOR, 1.87; 95% CI, 1.38-2.53) or Asian/Pacific Islander (aOR, 2.47; 95% CI, 1.46-4.19) were independently associated with higher odds of treatment initiation after multivariable adjustment. In contrast, women (aOR, 0.76; 95% CI, 0.60-0.97) and the uninsured (aOR, 0.15; 95% CI, 0.09-0.25) were less likely to initiate treatment. Only 8% of individuals with chronic HCV were tested for HIV, and 15% of individuals with identified OUD were tested for HCV.

CONCLUSIONS

Fewer than 20% of individuals with identified OUD were tested for HCV. SVR was lower than findings in other real-world cohorts. Measures to improve outcomes should be considered with the expansion of HCV management into community clinics.

Development of robust genotype 1a hepatitis C replicons harboring adaptive mutations for facilitating the antiviral drug discovery and study of virus replication

The hepatitis C virus (HCV) subgenomic replicon is a valuable tool for studying virus replication and HCV drug development. Despite the fact that HCV genotype 1a (HCV1a) is the most prevalent genotype in the United States, few HCV1a reporter replicon constructs have been reported, and their replication capacities are not as efficient as those of HCV1b or 2a, especially in transient expression. In this study, we selected efficient HCV1a replicons and characterized the novel adaptive mutations derived from stable HCV1a (strain H77) replicon cells after G418 selection. These novel adaptive mutations were scored in NS3 (A1065V, C1073S, N1227D, D1431Y, and E1556G), NS4A (I1694T and E1709V), and NS4B (G1871C). The D1431Y mutation alone or combinations of other adaptive mutations introduced into the parental HCV1a replicon construct was observed to differentially enhance either transient or stable expression of replicon. In particular, two replicon mutants VDYG (A1065V, N1227D, D1431Y, and E1556G within NS3) and VDYGRG, VDYG with two additional adaptive mutations (NS4A-K1691R and NS4B-E1726G), displayed robust replication and exhibited no impairment in the susceptibility of replicon activity to various known HCV inhibitors.