Syndemic Characterization of HCV, HBV, and HIV Co-infections in a Large Population Based Cohort Study

Syndemic Theory and Its Use in Developing Health Interventions and Programming: A Scoping Review

PURPOSE OF REVIEW

The central tenet of syndemics theory is that disease interactions are driven by social factors, and that these factors have to be understood in order to reduce the health burdens of local populations. Without an understanding of the theory and how it is being put into practice, there is a strong possibility of losing the potential for syndemic theory to positively impact change at community and individual level.

METHODS

Following an initial database search that produced 921 articles, we developed a multi-stage scoping review process identifying invention studies that employ syndemic theory. Inclusion was defined as the presence of healthcare interventions examining multiple social-biological outcomes, refering to a specific (local) at risk population, developing or attempting to develop interventions impacting upon multiple health and/or social targets, and explicit employment of syndemic theory in developing the intervention.

RESULTS

A total of 45 articles contained a substantial engagement with syndemic theory and an original healthcare intervention. However, only eleven studies out of all 921 articles met the inclusion criteria.

DISCUSSION/CONCLUSION

It is strongly suggested that when employing syndemic theory researchers focus close attention to demonstrating disease interactions, providing evidence of the social drivers of these disease interactions, and constructing interventions grounded in these analytical findings. We conclude that although frequently referred to, syndemic theory is rarely employed in its entirety and recommend that interventions be developed using a more thorough grounding in this important and powerful theory.

Self-reported hepatitis B testing among noninstitutionalized adults in the United States before the implementation of universal screening, 2013-2017: A nationwide population-based study

In 2023, the US Centers for Disease Control and Prevention recommended universal screening for hepatitis B virus (HBV); however, the proportion of US adults screened before implementing this recommendation is unknown. We analysed nationally representative data from the National Health Interview Survey (2013-2017) on self-reported HBV testing among noninstitutionalized US adults ≥18 years. We employed Poisson logistic regression to identify factors associated with self-reported testing, using a conceptual framework that included four overarching factors: sociodemographic characteristics, healthcare access, health-seeking behaviours and experiences, and access to internet-based health information. Among 149,628 survey respondents, the self-reported HBV testing rate was 27.2% (95% CI 26.2-28.7) and increased by 1.7% from 2013 to 2017 (p = .006). In adjusted analysis, health-seeking behaviours and experiences had the strongest associations of self-reported testing including a history of hepatitis (AOR 2.68, 95% CI 1.92-3.73), receipt of hepatitis B vaccination (AOR 5.11, 95% CI 4.61-5.68) and prior testing for hepatitis C (AOR 9.14, 95% CI 7.97-10.48) and HIV (AOR 2.69, 95% CI 2.44-2.97). Other factors associated with testing included being male (AOR 1.14, 95% CI 1.03-1.26), ages 30-44 years (AOR 1.37, 95% CI 1.17-1.61), 45-60 years (AOR 1.55, 95% CI 1.30-1.80) and ≥60 years (AOR 1.53, 95% CI 1.28-1.84), residence in the Western US region (AOR 1.23, 95% CI 1.06-1.43), and access to internet-based health information (AOR 1.32, 95% CI 1.18-1.47). Being Hispanic was associated with lower odds of testing (AOR 0.80, 95% CI 0.66-0.97). These findings may help guide optimal HBV screening in the universal testing era.

Impact of COVID-19 pandemic on hepatocellular carcinoma surveillance in British Columbia, Canada: An interrupted time series study

We assessed the impact of the COVID-19 pandemic on hepatocellular carcinoma (HCC) surveillance among individuals with HCV diagnosed with cirrhosis in British Columbia (BC), Canada. We used data from the British Columbia Hepatitis Testers Cohort (BC-HTC), including all individuals in the province tested for or diagnosed with HCV from 1 January 1990 to 31 December 2015, to assess HCC surveillance. To analyse the impact of the pandemic on HCC surveillance, we used pre-policy (January 2018 to February 2020) and post-policy (March to December 2020) periods. We conducted interrupted time series (ITS) analysis using a segmented linear regression model and included first-order autocorrelation terms. From January 2018 to December 2020, 6546 HCC screenings were performed among 3429 individuals with HCV and cirrhosis. The ITS model showed an immediate decrease in HCC screenings in March and April 2020, with an overall level change of -71 screenings [95% confidence interval (CI): -105.9, -18.9]. We observed a significant decrease in HCC surveillance among study participants, regardless of HCV treatment status and age group, with the sharpest decrease among untreated HCV patients. A recovery of HCC surveillance followed this decline, reflected in an increasing trend of 7.8 screenings (95% CI: 0.6, 13.5) per month during the post-policy period. There was no level or trend change in the number of individuals diagnosed with HCC. We observed a sharp decline in HCC surveillance among people living with HCV and cirrhosis in BC following the COVID-19 pandemic control measures. HCC screening returned to pre-pandemic levels by mid-2020.

Injection drug use and sexually transmitted infections among men who have sex with men: A retrospective cohort study at an HIV/AIDS referral hospital in Tokyo, 2013-2022

Men who have sex with men (MSM) who use injection drugs (MSM-IDU) are at high risk of sexually transmitted infections (STIs), but the long-term incidence is unclear. We conducted a single-centre retrospective cohort study using the clinical records of non-haemophilia men with human immunodeficiency virus (HIV) who visited the Institute of Medical Science, the University of Tokyo (IMSUT) Hospital, located in Tokyo, Japan, from 2013 to 2022. We analysed 575 patients including 62 heterosexual males and 513 MSM patients, of whom 6.8% (35/513) were injection drug use (IDU). Compared to non-IDU MSM, MSM-IDU had a higher incidence of hepatitis C virus (HCV) (44.8 vs 3.5 /1,000 person-years (PY); incidence rate ratio (IRR) [95% confidence interval (95% CI)], 12.8 [5.5-29.3], p < 0.001) and syphilis (113.8 vs 53.3 /1,000 PY; IRR, 2.1 [1.4-3.1], p < 0.001). The incidence of other symptomatic STIs (amoebiasis, chlamydia, and gonorrhoea infections) was <4/1,000 PY. In multivariable Poisson regression analysis, HCV incidence was associated with MSM (IRR, 1.8 × 106 [9.9 × 105-3.4 × 106], p < 0.001), IDU (IRR, 10.1 [4.0-25.6], p < 0.001), and syphilis infection during the study period (IRR, 25.0 [1.2-518.3]/time/year, p < 0.001). Among men with HIV, the prevalence of IDU in MSM and the long-term incidence of STIs in MSM-IDU were high. IDU and sexual contact are important modes of transmission of HCV among HIV-infected MSM in Tokyo.

Risk of COVID-19 hospitalization in people living with HIV and HIV-negative individuals and the role of COVID-19 vaccination: A retrospective cohort study

OBJECTIVE

To examine the risk of hospitalization within 14 days of COVID-19 diagnosis among people living with HIV (PLWH) and HIV-negative individuals who had laboratory-confirmed SARS-CoV-2 infection.

METHODS

We used Cox proportional hazard models to compare the relative risk of hospitalization in PLWH and HIV-negative individuals. Then, we used propensity score weighting to examine the influence of sociodemographic factors and comorbid conditions on risk of hospitalization. These models were further stratified by vaccination status and pandemic period (pre-Omicron: December 15, 2020, to November 21, 2021; Omicron: November 22, 2021, to October 31, 2022).

RESULTS

The crude hazard ratio (HR) for risk of hospitalization in PLWH was 2.44 (95% confidence interval [CI]: 2.04-2.94). In propensity score-weighted models that included all covariates, the relative risk of hospitalization was substantially attenuated in the overall analyses (adjusted HR [aHR]: 1.03; 95% CI: 0.85-1.25), in vaccinated (aHR 1.00; 95% CI: 0.69-1.45), inadequately vaccinated (aHR: 1.04; 95% CI: 0.76-1.41) and unvaccinated individuals (aHR: 1.15; 95% CI: 0.84-1.56).

CONCLUSION

PLWH had about two times the risk of COVID-19 hospitalization than HIV-negative individuals in crude analyses which attenuated in propensity score-weighted models. This suggests that the risk differential can be explained by sociodemographic factors and history of comorbidity, underscoring the need to address social and comorbid vulnerabilities (e.g., injecting drugs) that were more prominent among PLWH.

Hepatitis C virus/Hepatitis B virus coinfection: Current prospectives

In endemic areas, hepatitis C virus (HCV)/hepatitis B virus (HBV) coinfection is common, and patients with coinfection have a higher risk of developing liver disease such as hepatocellular carcinoma, liver fibrosis and cirrhosis. In such cases, HCV predominates, and HBV replication is suppressed by HCV. HCV core proteins and interferons that are activated by HCV are responsible for the suppression of HBV. Immunosuppression is also seen in patients with HCV and HBV coinfections. A decrease in HCV-neutralizing antibody response and circulation of Th1-like Tfh cells is observed in patients with HCV and HBV coinfection. Both viruses interacted in the liver, and treatment of HCV/HBV coinfection is genotype-based and complex due to the interaction of both viruses. In HCV-dominant cases, direct-acting antiviral drugs and peg interferon plus ribavirin are used for the treatment, with continuous monitoring of AST and ALT. HBV-dominant cases are less common and are treated with peg interferon and nucleoside nucleotide analogues with monitoring of AST and ALT. The SVR rate in HCV-HBV coinfection is higher than that in monoinfection when treated with direct-acting antiviral drugs. But there is a risk of reactivation of HBV during and after therapy. The rate of reactivation is lower in patients treated with direct-acting antiviral drugs as compared to those treated with peg interferon plus ribavirin. Biomarkers of HBV such as HBcrAg, HBV DNA and HBVpg RNA are not effective in the prediction of HBV reactivation; only the hepatitis B surface antigen titre can be used as a biomarker for HBV reactivation. HCV can also be reactive, but this is found in very rare cases in which HBV is present and is treated first.

Advancing virtual primary care for people with opioid use disorder (VPC OUD): a mixed-methods study protocol

INTRODUCTION

The emergence of COVID-19 introduced a dual public health emergency in British Columbia, which was already in the fourth year of its opioid-related overdose crisis. The public health response to COVID-19 must explicitly consider the unique needs of, and impacts on, communities experiencing marginalisation including people with opioid use disorder (PWOUD). The broad move to virtual forms of primary care, for example, may result in changes to healthcare access, delivery of opioid agonist therapies or fluctuations in co-occurring health problems that are prevalent in this population. The goal of this mixed-methods study is to characterise changes to primary care access and patient outcomes following the rapid introduction of virtual care for PWOUD.

METHODS AND ANALYSIS

We will use a fully integrated mixed-methods design comprised of three components: (a) qualitative interviews with family physicians and PWOUD to document experiences with delivering and accessing virtual visits, respectively; (b) quantitative analysis of linked, population-based administrative data to describe the uptake of virtual care, its impact on access to services and downstream outcomes for PWOUD; and (c) facilitated deliberative dialogues to co-create educational resources for family physicians, PWOUD and policymakers that promote equitable access to high-quality virtual primary care for this population.

ETHICS AND DISSEMINATION

Approval for this study has been granted by Research Ethics British Columbia. We will convene PWOUD and family physicians for deliberative dialogues to co-create educational materials and policy recommendations based on our findings. We will also disseminate findings via traditional academic outputs such as conferences and peer-reviewed publications.

Impact of COVID-19-related public health measures on HCV testing in British Columbia, Canada: An interrupted time series analysis

BACKGROUND & AIMS

Public health measures introduced to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), also disrupted various healthcare services in many regions worldwide, including British Columbia (BC), Canada. We assessed the impact of these measures, first introduced in BC in March 2020, on hepatitis C (HCV) testing and first-time HCV-positive diagnoses within the province.

METHODS

De-identified HCV testing data for BC residents were obtained from the provincial Public Health Laboratory. Weekly changes in anti-HCV, HCV RNA and genotype testing episodes and first-time HCV-positive (anti-HCV/RNA/genotype) diagnoses from January 2018 to December 2020 were assessed and associations were determined using segmented regression models examining rates before vs after calendar week 12 of 2020, when measures were introduced.

RESULTS

Average weekly HCV testing and first-time HCV-positive diagnosis rates fell immediately following the imposition of public health measures by 62.3 per 100 000 population and 2.9 episodes per 1 000 000 population, respectively (P < .0001 for both), and recovered in subsequent weeks to near pre-March 2020 levels. Average weekly anti-HCV positivity rates decreased steadily pre-restrictions and this trend remained unchanged afterwards.

CONCLUSIONS

Reductions in HCV testing and first-time HCV-positive diagnosis rates, key drivers of progression along the HCV care cascade, occurred following the introduction of COVID-19-related public health measures. Further assessment will be required to better understand the full impact of these service disruptions on the HCV care cascade and to inform strategies for the re-engagement of people who may have been lost to care because of these measures.

Epidemiological trends of HBV and HDV coinfection among Viennese HIV+ patients

BACKGROUND AND AIMS

Despite vaccination recommendations, hepatitis B (HBV) and D (HDV) coinfections are common in HIV+individuals.

METHODS

HBV immunization status (anti-HBs) as well as HBV (HBsAg/HBV-DNA) and HDV (anti-HDV) coinfection rates were assessed in 1870 HIV+individuals at HIV diagnosis (baseline, BL) and last follow-up (FU).

RESULTS

Sixty-eight (3.6%) HIV patients were never tested for HBV. At BL, 89/1802 (4.9%) HIV patients were HBV coinfected. Four hundred and fifteen (23.0%) showed virological HBV clearance [HBsAg(-)/anti-HBc(+)/anti-HBs(+)] and 210 (11.7%) presented with anti-HBc(+) only. Seven hundred and ten (39.4%) were HBV naïve [HBsAg(-)/anti-HBs(-)/anti-HBc(-)/HBV-DNA(-)], but only 378 (21.0%) received vaccinations with detectable anti-HBs(+) titres. Among the 89 HBV/HIV-coinfected patients, only 52 (58.4%) were tested for HDV: 11/49 (22.4%) had anti-HDV(+) and 3/12 (25.0%) showed HDV-RNA viraemia. During a median FU of 6.5 (IQR 7.2) years, 44 (4.6%) of the 953 retested BL HBV-negative patients acquired new HBV infection (including 15/304, 4.9% of vaccinated patients). Of the 89 patients, 22 (24.7%) patients cleared their HBsAg, resulting in 60/1625 (3.7%) HIV/HBV individuals at FU: 34 (56.7%) showed HBV-DNA suppression and 15 (25.0%) were HBV viraemic, while 12/89 (13.5%) remained without a FU test. Vaccinations induced anti-HBs(+) in 137 of the retested 649 (21.1%) BL HBV-naïve patients.

CONCLUSION

HBV testing is well established among Viennese HIV+patients with HBV coinfection rates around 4%-5%. HBV vaccinations are insufficiently implemented since anti-HBs titres were detected in only 21.1% of HBV-naive HIV(+) patients and new HBV infections occurred in previously vaccinated patients. HDV testing is not systematically performed despite up to 25% of HIV/HBV patients may show HDV coinfection.

A Computable Phenotype Model for Classification of Men Who Have Sex With Men Within a Large Linked Database of Laboratory, Surveillance, and Administrative Healthcare Records

Background: Most public health datasets do not include sexual orientation measures, thereby limiting the availability of data to monitor health disparities, and evaluate tailored interventions. We therefore developed, validated, and applied a novel computable phenotype model to classify men who have sex with men (MSM) using multiple health datasets from British Columbia, Canada, 1990-2015. Methods: Three case surveillance databases, a public health laboratory database, and five administrative health databases were linked and deidentified (BC Hepatitis Testers Cohort), resulting in a retrospective cohort of 727,091 adult men. Known MSM status from the three disease case surveillance databases was used to develop a multivariable model for classifying MSM in the full cohort. Models were selected using "elastic-net" (GLMNet package) in R, and a final model optimized area under the receiver operating characteristics curve. We compared characteristics of known MSM, classified MSM, and classified heterosexual men. Findings: History of gonorrhea and syphilis diagnoses, HIV tests in the past year, history of visit to an identified gay and bisexual men's clinic, and residence in MSM-dense neighborhoods were all positively associated with being MSM. The selected model had sensitivity of 72%, specificity of 94%. Excluding those with known MSM status, a total of 85,521 men (12% of cohort) were classified as MSM. Interpretation: Computable phenotyping is a promising approach for classification of sexual minorities and investigation of health outcomes in the absence of routinely available self-report data.

Syndemic Profiles and Sexual Minority Men's HIV-Risk Behavior: A Latent Class Analysis

Syndemic theory posits that "syndemic conditions" (e.g., alcohol misuse, polydrug use, suicidality) co-occur among sexual minority men and influence HIV-risk behavior, namely HIV acquisition and transmission risk. To examine how four syndemic conditions cluster among sexual minority men and contribute to HIV-risk behavior, we conducted latent class analysis (LCA) to: (1) classify sexual minority men (n = 937) into subgroups based on their probability of experiencing each syndemic condition; (2) examine the demographic (e.g., race/ethnicity) and social status (e.g., level of socioeconomic distress) characteristics of the most optimally fitting four syndemic classes; (3) examine between-group differences in HIV-risk behavior across classes; and (4) use syndemic class membership to predict HIV-risk behavior with sexual minority men reporting no syndemic conditions as the reference group. The four classes were: (1) no syndemic, (2) alcohol misuse and polydrug use syndemic, (3) polydrug use and HIV syndemic, and (4) alcohol misuse. HIV-risk behavior differed across these latent classes. Demographic and social status characteristics predicted class membership, suggesting that syndemic conditions disproportionately co-occur in vulnerable subpopulations of sexual minority men, such as those experiencing high socioeconomic distress. When predicting HIV-risk behavior, men in the polydrug use and HIV syndemic class were more likely (Adjusted Risk Ratio [ARR] = 2.93, 95% CI: 1.05, 8.21) and men in the alcohol misuse class were less likely (ARR = 0.17, 95% CI: 0.07, 0.44) to report HIV-risk behavior than were men in the no syndemic class. LCA represents a promising methodology to inform the development and delivery of tailored interventions targeting distinct combinations of syndemic conditions to reduce sexual minority men's HIV-risk behavior.

Sero-epidemiology study of hepatitis B virus surface antibodies from 2017 to 2019 among Chinese young adults in Hunan Province: A three-year retrospective study

BACKGROUND

Data on the epidemiology characteristics of hepatitis B surface antibodies (anti-HBs) are lacking among central southern undeveloped areas of China, especially for young adults. This study aims to demonstrate the sero-epidemiology characteristics of HBsAb among young adults.

AIMS

The aim of this study is to demonstrate the epidemiological characteristics in prevalence of serum anti-HBs in college students of a university in Hunan Province, China.

METHODS

Data were derived from the health records (including serum HBsAb data) among freshmen of a university from 2017 to 2019 in Hunan Province, China.

RESULTS

A total of 13,426 freshmen with complete data who were born in Hunan Province were collected. The 3-year total prevalence of anti-HBs in freshmen was 44.75% with no statistically significant sex difference, the prevalence of anti-HBs is 46.93%, 53.13%, and 34.79% for 2017, 2018, and 2019, respectively. There are significant geographic differences of prevalence of anti-HBs in freshmen from different areas. The lowest prevalence of anti-HBs was 31.80% in freshmen from Xiangtan, and the highest prevalence of anti-HBs was 53.10% in freshmen from Yongzhou.

CONCLUSION

The prevalence of serum anti-HBs among the freshmen in Hunan from 2017 to 2019 is much lower than the average national level, and the prevalence in 2019 is significantly lower than that in 2017 and 2019. There are significant differences in different time and areas of the prevalence of anti-HBs. There is a necessity to carry out area-specific intensive immunization plan in a timely manner among young population in Hunan Province, China.

Influence of chronic hepatitis C infection on the monocyte-to-platelet ratio: data analysis from the National Health and Nutrition Examination Survey (2009-2016)

BACKGROUND

Hepatitis C virus (HCV) causes life-threatening chronic infections. Implementation of novel, economical or widely available screening tools can help detect unidentified cases and facilitate their linkage to care. We investigated the relationship between chronic HCV infection and a potential complete blood count biomarker (the monocyte-to-platelet ratio) in the United States.

METHODS

The analytic dataset was selected from cycle years 2009-2016 of the National Health and Nutrition Examination Survey. Complete case data- with no missingness- was available for n = 5281 observations, one-hundred and twenty-two (n = 122) of which were exposed to chronic HCV. The primary analysis used survey-weighted logistic regression to model the effect of chronic HCV on the monocyte-to-platelet ratio adjusting for demographic and biological confounders in a causal inference framework. Missing data and propensity score methods were respectively performed as a secondary and sensitivity analysis.

RESULTS

In the analytic dataset, outcome data was available for n = 5281 (n = 64,245,530 in the weighted sample) observations of which n = 122 (n = 1,067,882 in the weighted sample) tested nucleic acid positive for HCV. Those exposed to chronic HCV infection in the United States have 3.10 times the odds of a high monocyte-to-platelet ratio than those not exposed (OR = 3.10, [95% CI: 1.55-6.18]).

CONCLUSION

A relationship exists between chronic HCV infection and the monocyte-to-platelet ratio in the general population of the United States. Reversing the direction of this association to predict chronic HCV infection from complete blood counts, could provide an economically feasible and universal screening tool, which would help link patients with care.

Complexities in the treatment of coinfection with HIV, hepatitis B, hepatitis C, and tuberculosis

HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) are commonly encountered blood-borne infectious microorganisms. Infection with these viruses typically requires long-lasting drug therapy. Coinfections, especially with tuberculosis, pose a challenge to the creation of a regimen with adequate efficacy and minimal drug-drug interactions and adverse effects. We present the case of a young man with a history of intravenous drug misuse who was diagnosed with disseminated tuberculosis and with a triple infection with HBV, HCV, and HIV. The treatment for tuberculosis was initiated first, followed 2 months later by antiretrovirals that were effective against both HIV and HBV. After 9 months of antitubercular therapy, HCV was successfully treated with 12 weeks of oral direct-acting antivirals. We describe the challenges faced in formulating a therapeutic plan for such patients and discuss the various drug interactions that can arise between antitubercular drugs, antiretrovirals, anti-HBV drugs, and direct-acting antivirals against HCV.

Differences in risk factors for hepatitis B, hepatitis C, and human immunodeficiency virus infection by ethnicity: A large population-based cohort study in British Columbia, Canada

OBJECTIVES

Addressing the needs of ethnic minorities will be key to finding undiagnosed individuals living with hepatitis B (HBV), hepatitis C (HCV), or human immunodeficiency virus (HIV). To inform screening initiatives in British Columbia (BC), Canada, the factors associated with HBV and/or HCV and/or HIV infection among different ethnic groups within a large population-based cohort were assessed.

METHODS

Persons diagnosed with HBV, HCV, or HIV in BC between 1990 and 2015 were grouped as East Asian, South Asian, Other Visible Minority (African, Central Asian, Latin American, Pacific Islander, West Asian, unknown ethnicity), and Not a Visible Minority, using a validated name-recognition software. Factors associated with infection within each ethnic group were assessed with multivariable multinomial logistic regression models.

RESULTS

Participants included 202 521 East Asians, 126 070 South Asians, 65 210 Other Visible Minorities, and 1 291 561 people who were Not a Visible Minority, 14.4%, 3.3%, 4.5%, and 6.3% of whom had HBV and/or HCV and/or HIV infections, respectively. Injection drug use was most prevalent among infection-positive people who were Not a Visible Minority (22.1%), and was strongly associated with HCV monoinfection, HBV/HCV coinfection, and HCV/HIV coinfection, but not with HBV monoinfection among visible ethnic minorities. Extreme material deprivation and social deprivation were more prevalent than injection drug use or problematic alcohol use among visible ethnic minorities.

CONCLUSIONS

Risk factor distributions varied among persons diagnosed with HBV and/or HCV and/or HIV of differing ethnic backgrounds, with lower substance use prevalence among visible minority populations. This highlights the need for tailored approaches to infection screening among different ethnic groups.

Elevated risk of colorectal, liver, and pancreatic cancers among HCV, HBV and/or HIV (co)infected individuals in a population based cohort in Canada

Introduction:

Studies of the impact of hepatitis C virus (HCV), hepatitis B virus (HBV) and HIV mono and co-infections on the risk of cancer, particularly extra-hepatic cancer, have been limited and inconsistent in their findings.

Methods:

In the British Columbia Hepatitis Testers Cohort, we assessed the risk of colorectal, liver, and pancreatic cancers in association with HCV, HBV and HIV infection status. Using Fine and Gray adjusted proportional subdistribution hazards models, we assessed the impact of infection status on each cancer, accounting for competing mortality risk. Cancer occurrence was ascertained from the BC Cancer Registry.

Results:

Among 658,697 individuals tested for the occurrence of all three infections, 1407 colorectal, 1294 liver, and 489 pancreatic cancers were identified. Compared to uninfected individuals, the risk of colorectal cancer was significantly elevated among those with HCV (Hazard ration [HR] 2.99; 95% confidence interval [CI] 2.55–3.51), HBV (HR 2.47; 95% CI 1.85–3.28), and HIV mono-infection (HR 2.30; 95% CI 1.47–3.59), and HCV/HIV co-infection. The risk of liver cancer was significantly elevated among HCV and HBV mono-infected and all co-infected individuals. The risk of pancreatic cancer was significantly elevated among individuals with HCV (HR 2.79; 95% CI 2.01–3.70) and HIV mono-infection (HR 2.82; 95% CI 1.39–5.71), and HCV/HBV co-infection.

Discussion/Conclusion:

Compared to uninfected individuals, the risk of colorectal, pancreatic and liver cancers was elevated among those with HCV, HBV and/or HIV infection. These findings highlight the need for targeted cancer prevention and diligent clinical monitoring for hepatic and extrahepatic cancers in infected populations.

Drug-related deaths in a population-level cohort of people living with and without hepatitis C virus in British Columbia, Canada

BACKGROUND

The majority of new HCV infections in Canada occur in people who inject drugs. Thus, while curative direct antiviral agents (DAAs) herald a promising new era in hepatitis C virus (HCV) treatment, improving the lives and wellbeing of people living with HCV (PLHCV) must be considered in the context of reducing overdose-related harms and with a syndemic lens. We measure drug-related deaths (DRDs) among HCV-negative people and PLHCV in British Columbia (BC), Canada, and the impact of potent contaminants like fentanyl on deaths.

METHODS

We identified DRDs among PLHCV and HCV-negative individuals from 2010 to 2018 in the BC Hepatitis Testers Cohort, a population-based dataset of ~1.7 million British Columbians comprising comprehensive administrative and clinical data. We estimated annual standardized liver- and drug-related mortality rates per 100,000 person-years (PY) and described the contribution of specific drugs, including fentanyl and its analogues, implicated in DRDs over time.

RESULTS

DRDs constituted 20.1% of deaths among PLHCV and 4.7% of deaths among HCV-negative individuals; a 4.3-fold (95% confidence interval: 4.0-4.5) difference. Drug-related mortality overtook liver-related mortality for PLHCV in 2015 and HCV-negative individuals in 2016 and rose from 241.7 to 436.5 per 100,000 PY from 2010 to 2018 amongPLHCV and from 20.0 to 57.1 per 100,000 PY for HCV-negative individuals over the same period. The proportion of deaths attributable to drugs among PLHCV and HCV-negative individuals increased from 15.1% to 26.1% and 3.1% to 8.0%, in 2010 and 2018, respectively. The proportion of DRDs attributed solely to synthetic opioids such as fentanyl averaged across both groups increased from 2.1% in 2010 to 69.6% in 2017.

CONCLUSION

Steep drug-related mortality increases among PLHCV and HCV-negative individuals over the last decade highlight the urgent need to address overdose-related drivers and harms in these populations using an integrated care approach.

Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes

Background

Hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections are associated with significant mortality globally and in North America. However, data on impact of concurrent multiple infections on mortality risk are limited. We evaluated the effect of HCV, HBV, and HIV infections and coinfections and associated factors on all-cause mortality in British Columbia (BC), Canada.

Methods

The BC Hepatitis Testers Cohort includes ~1.7 million individuals tested for HCV or HIV, or reported as a case of HCV, HIV, or HBV from 1990 to 2015, linked to administrative databases. We followed people with HCV, HBV, or HIV monoinfection, coinfections, and triple infections from their negative status to date of death or December 31, 2016. Extended Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with all-cause mortality.

Results

Of 658 704 individuals tested for HCV, HBV, and HIV, there were 33 804 (5.13%) deaths. In multivariable Cox regression analysis, individuals with HCV/HBV/HIV (HR, 8.9; 95% CI, 8.2–9.7) infections had the highest risk of mortality followed by HCV/HIV (HR, 4.8; 95% CI, 4.4–5.1), HBV/HIV (HR, 4.1; 95% CI, 3.5–4.8), HCV/HBV (HR, 3.9; 95% CI, 3.7–4.2), HCV (HR, 2.6; 95% CI, 2.6–2.7), HBV (HR, 2.2; 95% CI, 2.0–2.3), and HIV (HR, 1.6; 95% CI, 1.5–1.7). Additional factors associated with mortality included injection drug use, problematic alcohol use, material deprivation, diabetes, chronic kidney disease, heart failure, and hypertension.

Conclusions

Concurrent multiple infections are associated with high mortality risk. Substance use, comorbidities, and material disadvantage were significantly associated with mortality independent of coinfection. Preventive interventions, including harm reduction combined with coinfection treatments, can significantly reduce mortality.

Role of unsafe medical practices and sexual behaviours in the hepatitis B and C syndemic and HIV co-infection in Rwanda: a cross-sectional study

OBJECTIVES

This study describes the burden of the hepatitis B, C and HIV co-infections and assesses associated risk factors.

SETTING

This analysis used data from a viral hepatitis screening campaign conducted in six districts in Rwanda from April to May 2019. Ten health centres per district were selected according to population size and distance.

PARTICIPANTS

The campaign collected information from 156 499 participants (51 496 males and 104 953 females) on sociodemographic, clinical and behavioural characteristics. People who were not Rwandan by nationality or under 15 years old were excluded.

PRIMARY AND SECONDARY OUTCOMES

The outcomes of interest included chronic hepatitis C virus (HCV) infection, chronic hepatitis B virus (HBV) infection, HIV infection, co-infection HIV/HBV, co-infection HIV/HCV, co-infection HBV/HCV and co-infection HCV/HBV/HIV. Multivariable logistic regressions were used to assess factors associated with HBV, HCV and HIV, mono and co-infections.

RESULTS

Of 156 499 individuals screened, 3465 (2.2%) were hepatitis B surface antigen positive and 83% (2872/3465) of them had detectable HBV desoxy-nucleic acid (HBV DNA). A total of 4382 (2.8%) individuals were positive for antibody-HCV (anti-HCV) and 3163 (72.2%) had detectable HCV ribo-nucleic acid (RNA). Overall, 36 (0.02%) had HBV/HCV co-infection, 153 (0.1%) HBV/HIV co-infection, 238 (0.15%) HCV/HIV co-infection and 3 (0.002%) had triple infection. Scarification or receiving an operation from traditional healer was associated with all infections. Healthcare risk factors-history of surgery or transfusion-were associated with higher likelihood of HIV infection with OR 1.42 (95% CI 1.21 to 1.66) and OR 1.48 (1.29 to 1.70), respectively, while history of physical traumatic assault was associated with a higher likelihood of HIV and HBV/HIV co-infections with OR 1.69 (95% CI 1.51 to 1.88) and OR 1.82 (1.08 to 3.05), respectively.

CONCLUSIONS

Overall, mono-infections were common and there were differences in significant risk factors associated with various infections. These findings highlight the magnitude of co-infections and differences in underlying risk factors that are important for designing prevention and care programmes.

The OATH Syndemic: opioids and other substances, aging, alcohol, tobacco, and HIV

PURPOSE OF REVIEW

Persons living with HIV (PLWH) are aging, continue to use alcohol and other substances, and experience age-associated adverse effects. We explore a new syndemic: OATH (opioids and other substances, aging, alcohol, tobacco, and HIV).

RECENT FINDINGS

Frailty and falls are important problems that affect the health status of PLWH who continue to use alcohol and other substances. HIV, alcohol and other substance use, and aging each contributes to inflammaging. Multimorbidity and polypharmacy are also important pathways as alcohol and other substances interact with prescribed medications resulting in adverse-drug interactions leading to potentially serious consequences. Social conditions including racism, poverty, sex bias, stress, and stigma contribute to the existence and persistence of this syndemic.

SUMMARY

Substance use, HIV, and aging are linked in a new syndemic (OATH) that drives age-related outcomes such as frailty and falls. We need to expand our understanding of the 'healthcare team' so that we include social and political advocates who can support necessary structural change. Treatment of substance use should be better incorporated into the management of HIV, including a focus on potential medication/substance interactions. Finally, we need to explore treatment of frailty rather than individual manifestations of frailty (e.g., atherosclerosis, neurodegeneration).

Sustained virological response from interferon-based hepatitis C regimens is associated with reduced risk of extrahepatic manifestations

BACKGROUND & AIMS

HCV infection is associated with several extrahepatic manifestations (EHMs). We evaluated the impact of sustained virological response (SVR) on the risk of 7 EHMs that contribute to the burden of extrahepatic disease: type 2 diabetes mellitus, chronic kidney disease or end-stage renal disease, stroke, ischemic heart disease, major adverse cardiac events, mood and anxiety disorders, and rheumatoid arthritis.

METHODS

A longitudinal cohort study was conducted using data from the British Columbia Hepatitis Testers Cohort, which included ~1.3 million individuals screened for HCV. We identified all HCV-infected individuals who were treated with interferon-based therapies between 1999 and 2014. SVR was defined as a negative HCV RNA test ≥24 weeks post-treatment or after end-of-treatment, if unavailable. We computed adjusted subdistribution hazard ratios (asHR) for the effect of SVR on each EHM using competing risk proportional hazard models. Subgroup analyses by birth cohort, sex, injection drug exposure and genotype were also performed.

RESULTS

Overall, 10,264 HCV-infected individuals were treated with interferon, of whom 6,023 (59%) achieved SVR. Compared to those that failed treatment, EHM risk was significantly reduced among patients with SVR for type 2 diabetes mellitus (asHR 0.65; 95%CI 0.55-0.77), chronic kidney disease or end-stage renal disease (asHR 0.53; 95% CI 0.43-0.65), ischemic or hemorrhagic stroke (asHR 0.73; 95%CI 0.49-1.09), and mood and anxiety disorders (asHR 0.82; 95%CI 0.71-0.95), but not for ischemic heart disease (asHR 1.23; 95%CI 1.03-1.47), major adverse cardiac events (asHR 0.93; 95%CI 0.79-1.11) or rheumatoid arthritis (asHR 1.09; 95% CI 0.73-1.64).

CONCLUSIONS

SVR was associated with a reduction in the risk of several EHMs. Increased uptake of antiviral therapy may reduce the growing burden of EHMs in this population.

LAY SUMMARY

We estimated the rates of chronic comorbidities other than liver disease between those who were cured and those who failed treatment for hepatitis C virus (HCV) infection. Our findings showed that the rates of these non-liver diseases were largely reduced for those who were cured with interferon-based treatments. Early HCV treatments could provide many benefits in the prevention of various HCV complications beyond liver disease.

Effectiveness of Ledipasvir/Sofosbuvir and Sofosbuvir/Velpatasvir in People Who Inject Drugs and/or Those in Opioid Agonist Therapy

We evaluated the effectiveness of ledipasvir/sofosbuvir (LDV/SOF) in treating hepatitis C virus (HCV) genotype 1 and SOF/velpatasvir (SOF/VEL) for all genotypes among people who inject drugs (PWID) and those not injecting drugs and who were on or off opioid agonist therapy (OAT). Study participants comprised a population-based cohort in British Columbia, Canada. The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV from 1990 to 2016 that are integrated with medical visits, hospitalization, and prescription drug data. We classified study participants as off OAT/recent injection drug use (off-OAT/RIDU), off OAT/past IDU (off-OAT/PIDU), off OAT/no IDU (off-OAT/NIDU), on OAT/IDU (on-OAT/IDU), and on OAT/no IDU (on-OAT/NIDU). We assessed sustained virologic response (SVR) 10 weeks after HCV treatment among study groups treated with LDV/SOF or SOF/VEL until January 13, 2018. Analysis included 5,283 eligible participants: 390 off-OAT/RIDU, 598 off-OAT/PIDU, 3,515 off-OAT/NIDU, 609 on-OAT/IDU, and 171 on-OAT/NIDU. The majority were male patients (64%-74%) and aged ≥50 years (58%-85%). The SVRs for off-OAT/RIDU, off-OAT/PIDU, off-OAT/NIDU, on-OAT/IDU, and on-OAT/NIDU were 91% (355/390), 95% (570/598), 96% (3,360/3,515), 93% (567/609), and 95% (163/171), respectively. Among those with no SVR, 14 individuals died while on treatment or before SVR assessment, including 4 from illicit drug overdose. In the overall multivariable model, off-OAT/RIDU, on-OAT/IDU, male sex, cirrhosis, treatment duration <8 weeks, treatment duration 8 weeks, and treatment with SOF/VEL were associated with not achieving SVR. Conclusion: In this large real-world cohort, PWID and/or those on OAT achieved high SVRs, although slightly lower than people not injecting drugs. This finding also highlights the need for additional measures to prevent loss to follow-up and overdose-related deaths among PWID.

The need for integrated public health surveillance to address sexually transmitted and blood-borne syndemics

A national approach to addressing sexually transmitted and blood-borne infections (STBBIs) was recently articulated in the Public Health Agency of Canada's new A Pan-Canadian Framework for Action: Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030. This Framework promotes an integrated approach, with a focus on the key populations that are affected by overlapping epidemics (i.e., syndemics). We advance the idea that integrating surveillance would be helpful in characterizing and understanding the populations, locations, risk behaviours and other drivers that contribute to STBBI syndemics. The creation of matched or linked data systems that would allow routine reporting of integrated data is challenged by the technical barriers of integrating data silos as well as by the privacy and ethical considerations of merging sensitive individual-level data. Lessons can be learned from jurisdictions where an improved understanding of syndemics, through integrated STBBI surveillance, has led to more efficient and effective operational, program and policy decisions. Emerging enablers include the development of data standards and guidelines, investment in resources to overcome technical challenges and community engagement to support the ethical and non-stigmatizing use of integrated data. The Framework's call to action offers an opportunity for national discussion on priorities and resources needed to advance STBBI syndemic surveillance for local, regional and national reporting in Canada.