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Carty PG, Teljeur C, De Gascun CF, Gillespie P, Harrington P, McCormick A, O'Neill M, Smith SM, Ryan M. Another Step Toward Hepatitis C Elimination: An Economic Evaluation of an Irish National Birth Cohort Testing Program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1947-1957. [PMID: 35778325 DOI: 10.1016/j.jval.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES We aimed to evaluate the cost-effectiveness of offering once-off birth cohort testing for hepatitis C virus (HCV) to people in Ireland born between 1965 and 1985, the cohort with the highest reported prevalence of undiagnosed chronic HCV infection. METHODS Systematic and opportunistic HCV birth cohort testing programs, implemented over a 4-year timeframe, were compared with the current practice of population risk-based testing only in a closed-cohort decision tree and Markov model hybrid over a lifetime time horizon. Outcomes were expressed in quality-adjusted life-years (QALYs). Costs were presented from the health system's perspective in 2020 euro (€). Uncertainty was assessed via deterministic, probabilistic, scenario, and threshold analyses. RESULTS In the base case, systematic testing yielded the largest cost and health benefits, followed by opportunistic testing and risk-based testing. Compared with risk-based testing, the incremental cost-effectiveness ratio for opportunistic testing was €14 586 (95% confidence interval €4185-€33 527) per QALY gained. Compared with opportunistic testing, the incremental cost-effectiveness ratio for systematic testing was €16 827 (95% confidence interval €5106-€38 843) per QALY gained. These findings were robust across a range of sensitivity analyses. CONCLUSIONS Both systematic and opportunistic birth cohort testing would be considered an efficient use of resources, but systematic testing was the optimal strategy at willingness-to-pay threshold values typically used in Ireland. Although cost-effective, any decision to introduce birth cohort testing for HCV (in Ireland or elsewhere) must be balanced with considerations regarding the feasibility and budget impact of implementing a national testing program given high initial costs and resource use.
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Affiliation(s)
- Paul G Carty
- RCSI University of Medicine and Health Sciences, Dublin, Ireland; Health Information and Quality Authority, Dublin, Ireland.
| | - Conor Teljeur
- Health Information and Quality Authority, Dublin, Ireland
| | - Cillian F De Gascun
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Paddy Gillespie
- Health Economics & Policy Analysis Centre, National University of Ireland Galway, Galway, Ireland; CÚRAM, The SFI Research Centre for Medical Devices (12/RC/2073_2), National University of Ireland Galway, Galway, Ireland
| | | | | | | | - Susan M Smith
- Department of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Ireland
| | - Mairin Ryan
- Health Information and Quality Authority, Dublin, Ireland; Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Health Sciences, St James's Hospital, Dublin, Ireland
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2
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Thieneman C, Frederick E, Palmer E, Spencer C, Vories S, Maier C. Evaluation of cure rate in patients with hepatitis C virus completing shortened courses of treatment. J Am Pharm Assoc (2003) 2021; 62:232-236. [PMID: 34454865 DOI: 10.1016/j.japh.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Guidelines recommend treatment with direct-acting antivirals for a minimum duration of 8 weeks in all patients with hepatitis C virus. Minimizing treatment duration is desirable because of decreased cost and increased adherence. Studies with treatment durations of less than 8 weeks have conflicting data. OBJECTIVE The purpose of this study was to evaluate the clinical efficacy of hepatitis C treatment in patients who did not complete the guideline-recommended duration of therapy. METHODS This was a retrospective, observational case series of patients with hepatitis C virus treated with 7 weeks or less of direct-acting antivirals between November 1, 2017 and July 31, 2019 at a large, academic medical center. The primary end point was cure, defined as sustained virologic response at 12 weeks after the end of treatment. Secondary end points included average duration of therapy, direct-acting antiviral used, and reason for early discontinuation. RESULTS Of the 472 patients treated, 13 met criteria for inclusion. Sustained virologic response was achieved in 61.5% of the patients. Two patients (15.3%) were not cured, and 3 patients (23.1%) were lost to follow-up. Median duration of therapy was 4 weeks. All patients who received at least 4 weeks of therapy and remained in care were cured. CONCLUSION In situations in which patients inadvertently stop hepatitis C treatment early, there is still the possibility of cure. Further studies are needed to determine which patient population may benefit from a shorter duration of therapy.
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3
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Cooke GS, Pett S, McCabe L, Jones C, Gilson R, Verma S, Ryder SD, Collier JD, Barclay ST, Ala A, Bhagani S, Nelson M, Ch'Ng C, Stone B, Wiselka M, Forton D, McPherson S, Halford R, Nguyen D, Smith D, Ansari A, Dennis E, Hudson F, Barnes EJ, Walker AS. Strategic treatment optimization for HCV (STOPHCV1): a randomised controlled trial of ultrashort duration therapy for chronic hepatitis C. Wellcome Open Res 2021; 6:93. [PMID: 34405118 PMCID: PMC8361811 DOI: 10.12688/wellcomeopenres.16594.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 01/07/2023] Open
Abstract
Background: The World Health Organization (WHO) has identified the need for a better understanding of which patients with hepatitis C virus (HCV) can be cured with ultrashort course HCV therapy. Methods: A total of 202 individuals with chronic HCV were randomised to fixed-duration shortened therapy (8 weeks) vs variable-duration ultrashort strategies (VUS1/2). Participants not cured following first-line treatment were retreated with 12 weeks' sofosbuvir/ledipasvir/ribavirin. The primary outcome was sustained virological response 12 weeks (SVR12) after first-line treatment and retreatment. Participants were factorially randomised to receive ribavirin with first-line treatment. Results: All evaluable participants achieved SVR12 overall (197/197, 100% [95% CI 98-100]) demonstrating non-inferiority between fixed-duration and variable-duration strategies (difference 0% [95% CI -3.8%, +3.7%], 4% pre-specified non-inferiority margin). First-line SVR12 was 91% [86%-97%] (92/101) for fixed-duration vs 48% [39%-57%] (47/98) for variable-duration, but was significantly higher for VUS2 (72% [56%-87%] (23/32)) than VUS1 (36% [25%-48%] (24/66)). Overall, first-line SVR12 was 72% [65%-78%] (70/101) without ribavirin and 68% [61%-76%] (69/98) with ribavirin (p=0.48). At treatment failure, the emergence of viral resistance was lower with ribavirin (12% [2%-30%] (3/26)) than without (38% [21%-58%] (11/29), p=0.01). Conclusions: Unsuccessful first-line short-course therapy did not compromise retreatment with sofosbuvir/ledipasvir/ribavirin (100% SVR12). SVR12 rates were significantly increased when ultrashort treatment varied between 4-7 weeks rather than 4-6 weeks. Ribavirin significantly reduced resistance emergence in those failing first-line therapy. ISRCTN Registration: 37915093 (11/04/2016).
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Affiliation(s)
- Graham S. Cooke
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
- NIHR Biomedical Research Centre, Imperial College NHS Trust, London, W2 1NY, UK
| | - Sarah Pett
- MRC Clinical Trials Unit, University College London Medical School, London, UK
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
- Institute of Global Health, University College London Medical School, London, UK
| | - Leanne McCabe
- MRC Clinical Trials Unit, University College London Medical School, London, UK
| | - Chris Jones
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
- NIHR Biomedical Research Centre, Imperial College NHS Trust, London, W2 1NY, UK
| | - Richard Gilson
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
- Institute of Global Health, University College London Medical School, London, UK
| | - Sumita Verma
- Hepatology, Brighton and Sussex Medical School, Brighton, UK
| | - Stephen D. Ryder
- Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Aftab Ala
- Clinical and Experimental Medicine, University of Surrey, Guilford, UK
| | - Sanjay Bhagani
- Infectious Diseases, Royal Free Hampstead NHS Trust Hospital, London, UK
| | - Mark Nelson
- HIV Medicine, Chelsea & Westminster NHS Trust, London, UK
| | | | - Ben Stone
- Infectious Diseases, Sheffield Teaching Hospitals Nhs Foundation Trust, Sheffield, UK
| | - Martin Wiselka
- Infectious Diseases, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel Forton
- Hepatology, St George's Hospital, London, London, UK
| | - Stuart McPherson
- Heaptology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle, UK
| | | | - Dung Nguyen
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
| | - David Smith
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
| | - Azim Ansari
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
| | - Emily Dennis
- MRC Clinical Trials Unit, University College London Medical School, London, UK
| | - Fleur Hudson
- MRC Clinical Trials Unit, University College London Medical School, London, UK
| | - Eleanor J. Barnes
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Ann Sarah Walker
- MRC Clinical Trials Unit, University College London Medical School, London, UK
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4
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Cooke GS, Pett S, McCabe L, Jones C, Gilson R, Verma S, Ryder SD, Collier JD, Barclay ST, Ala A, Bhagani S, Nelson M, Ch'Ng C, Stone B, Wiselka M, Forton D, McPherson S, Halford R, Nguyen D, Smith D, Ansari A, Dennis E, Hudson F, Barnes EJ, Walker AS. Strategic treatment optimization for HCV (STOPHCV1): a randomised controlled trial of ultrashort duration therapy for chronic hepatitis C. Wellcome Open Res 2021; 6:93. [PMID: 34405118 PMCID: PMC8361811 DOI: 10.12688/wellcomeopenres.16594.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 04/05/2024] Open
Abstract
Background: The world health organization (WHO) has identified the need for a better understanding of which patients with hepatitis C virus (HCV) can be cured with ultrashort course HCV therapy. Methods: A total of 202 individuals with chronic HCV were randomised to fixed-duration shortened therapy (8 weeks) vs variable-duration ultrashort strategies (VUS1/2). Participants not cured following first-line treatment were retreated with 12 weeks' sofosbuvir/ledipasvir/ribavirin. The primary outcome was sustained virological response 12 weeks (SVR12) after first-line treatment and retreatment. Participants were factorially randomised to receive ribavirin with first-line treatment. Results: All evaluable participants achieved SVR12 overall (197/197, 100% [95% CI 98-100]) demonstrating non-inferiority between fixed-duration and variable-duration strategies (difference 0% [95% CI -3.8%, +3.7%], 4% pre-specified non-inferiority margin). First-line SVR12 was 91% [86%-97%] (92/101) for fixed-duration vs 48% [39%-57%] (47/98) for variable-duration, but was significantly higher for VUS2 (72% [56%-87%] (23/32)) than VUS1 (36% [25%-48%] (24/66)). Overall, first-line SVR12 was 72% [65%-78%] (70/101) without ribavirin and 68% [61%-76%] (69/98) with ribavirin (p=0.48). At treatment failure, the emergence of viral resistance was lower with ribavirin (12% [2%-30%] (3/26)) than without (38% [21%-58%] (11/29), p=0.01). Conclusions: Unsuccessful first-line short-course therapy did not compromise retreatment with sofosbuvir/ledipasvir/ribavirin (100% SVR12). SVR12 rates were significantly increased when ultrashort treatment varied between 4-7 weeks rather than 4-6 weeks. Ribavirin significantly reduced resistance emergence in those failing first-line therapy. ISRCTN Registration: 37915093 (11/04/2016).
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Affiliation(s)
- Graham S. Cooke
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
- NIHR Biomedical Research Centre, Imperial College NHS Trust, London, W2 1NY, UK
| | - Sarah Pett
- MRC Clinical Trials Unit, University College London Medical School, London, UK
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
- Institute of Global Health, University College London Medical School, London, UK
| | - Leanne McCabe
- MRC Clinical Trials Unit, University College London Medical School, London, UK
| | - Chris Jones
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
- NIHR Biomedical Research Centre, Imperial College NHS Trust, London, W2 1NY, UK
| | - Richard Gilson
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
- Institute of Global Health, University College London Medical School, London, UK
| | - Sumita Verma
- Hepatology, Brighton and Sussex Medical School, Brighton, UK
| | - Stephen D. Ryder
- Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Aftab Ala
- Clinical and Experimental Medicine, University of Surrey, Guilford, UK
| | - Sanjay Bhagani
- Infectious Diseases, Royal Free Hampstead NHS Trust Hospital, London, UK
| | - Mark Nelson
- HIV Medicine, Chelsea & Westminster NHS Trust, London, UK
| | | | - Ben Stone
- Infectious Diseases, Sheffield Teaching Hospitals Nhs Foundation Trust, Sheffield, UK
| | - Martin Wiselka
- Infectious Diseases, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel Forton
- Hepatology, St George's Hospital, London, London, UK
| | - Stuart McPherson
- Heaptology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle, UK
| | | | - Dung Nguyen
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
| | - David Smith
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
| | - Azim Ansari
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
| | - Emily Dennis
- MRC Clinical Trials Unit, University College London Medical School, London, UK
| | - Fleur Hudson
- MRC Clinical Trials Unit, University College London Medical School, London, UK
| | - Eleanor J. Barnes
- Peter Medawar Buildling for Pathogen Research, Oxford, UK
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Ann Sarah Walker
- MRC Clinical Trials Unit, University College London Medical School, London, UK
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5
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Simmonds P, Cuypers L, Irving WL, McLauchlan J, Cooke GS, Barnes E, Ansari MA. Impact of virus subtype and host IFNL4 genotype on large-scale RNA structure formation in the genome of hepatitis C virus. RNA (NEW YORK, N.Y.) 2020; 26:1541-1556. [PMID: 32747607 PMCID: PMC7566573 DOI: 10.1261/rna.075465.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/29/2020] [Indexed: 05/03/2023]
Abstract
Mechanisms underlying the ability of hepatitis C virus (HCV) to establish persistent infections and induce progressive liver disease remain poorly understood. HCV is one of several positive-stranded RNA viruses capable of establishing persistence in their immunocompetent vertebrate hosts, an attribute previously associated with formation of large-scale RNA structure in their genomic RNA. We developed novel methods to analyze and visualize genome-scale ordered RNA structure (GORS) predicted from the increasingly large data sets of complete genome sequences of HCV. Structurally conserved RNA secondary structure in coding regions of HCV localized exclusively to polyprotein ends (core, NS5B). Coding regions elsewhere were also intensely structured based on elevated minimum folding energy difference (MFED) values, but the actual stem-loop elements involved in genome folding were structurally poorly conserved, even between subtypes 1a and 1b. Dynamic remodeling was further evident from comparison of HCV strains in different host genetic backgrounds. Significantly higher MFED values, greater suppression of UpA dinucleotide frequencies, and restricted diversification were found in subjects with the TT genotype of the rs12979860 SNP in the IFNL4 gene compared to the CC (nonexpressing) allele. These structural and compositional associations with expression of interferon-λ4 were recapitulated on a larger scale by higher MFED values and greater UpA suppression of genotype 1 compared to genotype 3a, associated with previously reported HCV genotype-associated differences in hepatic interferon-stimulated gene induction. Associations between innate cellular responses with HCV structure and further evolutionary constraints represent an important new element in RNA virus evolution and the adaptive interplay between virus and host.
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Affiliation(s)
- Peter Simmonds
- Nuffield Department of Medicine, Peter Medawar Building for Pathogen Research, University of Oxford, OX1 3SY, Oxford, United Kingdom
| | - Lize Cuypers
- University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Research, BE 3000, Leuven, Belgium
| | - Will L Irving
- Faculty of Medicine and Health Sciences, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, United Kingdom
| | - John McLauchlan
- MRC-University of Glasgow Centre for Virus Research, Glasgow, G61 1QH, United Kingdom
| | | | - Ellie Barnes
- Nuffield Department of Medicine, Peter Medawar Building for Pathogen Research, University of Oxford, OX1 3SY, Oxford, United Kingdom
| | - M Azim Ansari
- Nuffield Department of Medicine, Peter Medawar Building for Pathogen Research, University of Oxford, OX1 3SY, Oxford, United Kingdom
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6
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Fawsitt CG, Vickerman P, Cooke GS, Welton NJ. Cost-Effectiveness Analysis of Baseline Testing for Resistance-Associated Polymorphisms to Optimize Treatment Outcome in Genotype 1 Noncirrhotic Treatment-Naïve Patients With Chronic Hepatitis C Virus. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:180-190. [PMID: 32113623 PMCID: PMC7057278 DOI: 10.1016/j.jval.2019.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 08/13/2019] [Accepted: 08/26/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Direct-acting antivirals containing nonstructural protein 5A (NS5A) inhibitors administered over 8 to 12 weeks are effective in ∼95% of patients with hepatitis C virus. Nevertheless, patients resistant to NS5A inhibitors have lower cure rates over 8 weeks (<85%); for these patients, 12 weeks of treatment produces cure rates greater than 95%. We evaluated the lifetime cost-effectiveness of testing for NS5A resistance at baseline and optimizing treatment duration accordingly in genotype 1 noncirrhotic treatment-naïve patients from the perspective of the UK National Health Service. METHODS A decision-analytic model compared (1) standard 12-week treatment (no testing), (2) shortened 8-week treatment (no testing), and (3) baseline testing with 12-/8-week treatment for those with/without NS5A polymorphisms. Patients who failed first-line therapy were retreated for 12 weeks. Model inputs were derived from published studies. Costs, quality-adjusted life-years, and the probability of cost-effectiveness were calculated. RESULTS Baseline testing had an incremental net monetary benefit (INMB) of £11 838 versus standard 12 weeks of therapy (no testing) and low probability (31%) of being the most cost-effective, assuming £30 000 willingness to pay. Shortened 8 weeks of treatment (no testing) had an INMB of £12 294 and the highest probability (69%) of being most cost-effective. Scenario analyses showed baseline testing generally had the highest INMB and probability of being most cost-effective if first- and second-line drug prices were low (<£20k). CONCLUSIONS Optimizing treatment duration based on NS5A polymorphisms for genotype 1 noncirrhotic treatment-naive patients in the United Kingdom is not cost-effective if the drug costs are high; the strategy is generally most cost-effective when drug prices are low (<£20k).
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Affiliation(s)
- Christopher G Fawsitt
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Peter Vickerman
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Graham S Cooke
- Department of Medicine, Imperial College London, London, England, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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7
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Walker JG, Kuchuloria T, Sergeenko D, Fraser H, Lim AG, Shadaker S, Hagan L, Gamkrelidze A, Kvaratskhelia V, Gvinjilia L, Aladashvili M, Asatiani A, Baliashvili D, Butsashvili M, Chikovani I, Khonelidze I, Kirtadze I, Kuniholm MH, Otiashvili D, Sharvadze L, Stvilia K, Tsertsvadze T, Zakalashvili M, Hickman M, Martin NK, Morgan J, Nasrullah M, Averhoff F, Vickerman P. Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study. Lancet Glob Health 2020; 8:e244-e253. [PMID: 31864917 PMCID: PMC7025283 DOI: 10.1016/s2214-109x(19)30483-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/21/2019] [Accepted: 10/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Georgia has a high prevalence of hepatitis C, with 5·4% of adults chronically infected. On April 28, 2015, Georgia launched a national programme to eliminate hepatitis C by 2020 (90% reduction in prevalence) through scaled-up treatment and prevention interventions. We evaluated the interim effect of the programme and feasibility of achieving the elimination goal. METHODS We developed a transmission model to capture the hepatitis C epidemic in Georgia, calibrated to data from biobehavioural surveys of people who inject drugs (PWID; 1998-2015) and a national survey (2015). We projected the effect of the administration of direct-acting antiviral treatments until Feb 28, 2019, and the effect of continuing current treatment rates until the end of 2020. Effect was estimated in terms of the relative decrease in hepatitis C incidence, prevalence, and mortality relative to 2015 and of the deaths and infections averted compared with a counterfactual of no treatment over the study period. We also estimated treatment rates needed to reach Georgia's elimination target. FINDINGS From May 1, 2015, to Feb 28, 2019, 54 313 patients were treated, with approximately 1000 patients treated per month since mid 2017. Compared with 2015, our model projects that these treatments have reduced the prevalence of adult chronic hepatitis C by a median 37% (95% credible interval 30-44), the incidence of chronic hepatitis C by 37% (29-44), and chronic hepatitis C mortality by 14% (3-30) and have prevented 3516 (1842-6250) new infections and averted 252 (134-389) deaths related to chronic hepatitis C. Continuing treatment of 1000 patients per month is predicted to reduce prevalence by 51% (42-61) and incidence by 51% (40-62), by the end of 2020. To reach a 90% reduction by 2020, treatment rates must increase to 4144 (2963-5322) patients initiating treatment per month. INTERPRETATION Georgia's hepatitis C elimination programme has achieved substantial treatment scale-up, which has reduced the burden of chronic hepatitis C. However, the country is unlikely to meet its 2020 elimination target unless treatment scales up considerably. FUNDING CDC Foundation, National Institute for Health Research, National Institutes of Health.
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Affiliation(s)
- Josephine G Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Tinatin Kuchuloria
- Centers for Disease Control and Prevention Foundation, Tbilisi, Georgia; TEPHINET, Tbilisi, Georgia
| | - David Sergeenko
- Ministry of Labor Health and Social Affairs of Georgia, Tbilisi, Georgia
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Shadaker
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Liesl Hagan
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Amiran Gamkrelidze
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | | | - Lia Gvinjilia
- Centers for Disease Control and Prevention Foundation, Tbilisi, Georgia; TEPHINET, Tbilisi, Georgia
| | - Malvina Aladashvili
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Alexander Asatiani
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Davit Baliashvili
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Irma Khonelidze
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Irma Kirtadze
- Addiction Research Center Alternative Georgia, Tbilisi, Georgia; Ilia State University, Faculty of Arts and Sciences, Institute of Addiction Studies, Tbilisi, Georgia
| | - Mark H Kuniholm
- Department of Epidemiology and Biostatistics, University at Albany, State University of New York, Rensselaer, NY, USA
| | | | | | - Ketevan Stvilia
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Tengiz Tsertsvadze
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Division of Infectious Diseases and Global Public Health, UC San Diego, California, USA
| | - Juliette Morgan
- Division of Global Health Protection, South Caucasus Centers for Disease Control and Prevention Office, Tbilisi, Georgia
| | - Muazzam Nasrullah
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Francisco Averhoff
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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8
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Jones CR, Flower BF, Barber E, Simmons B, Cooke GS. Treatment optimisation for hepatitis C in the era of combination direct-acting antiviral therapy: a systematic review and meta-analysis. Wellcome Open Res 2019; 4:132. [PMID: 31754636 PMCID: PMC6854875 DOI: 10.12688/wellcomeopenres.15411.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Prior to direct-acting antiviral (DAA) therapy, personalised medicine played an important role in the treatment of hepatitis C virus (HCV). Whilst simplified treatment strategies are central to treatment scale-up, some patients will benefit from treatment optimisation. This systematic review and meta-analysis explores treatment optimisation strategies in the DAA era. Methods: We systematically searched Medline, Embase, and Web of Science for studies that adopted a stratified or personalised strategy using a licensed combination DAA regimen, alone or with additional agents. We performed a thematic analysis to classify optimisation strategies and a meta-analysis of sustained virologic response rates (SVR), exploring heterogeneity with subgroup analyses and meta-regression. Results: We included 64 studies (9450 participants). Thematic analysis found evidence of three approaches: duration, combination, and/or dose optimisation. We separated strategies into those aiming to maintain SVR in the absence of predictors of failure, and those aiming to improve SVR in the presence of predictors of failure. Shortened duration regimens achieve pooled SVR rates of 94.2% (92.3-95.9%) for 8 weeks, 81.1% (75.1-86.6%) for 6 weeks, and 63.1% (39.9-83.7%) for ≤4 weeks. Personalised strategies (100% vs 87.6%; p<0.001) and therapy shortened according to ≥3 host/viral factors (92.9% vs 81.4% or 87.2% for 1 or 2 host/viral factors, respectively; p=0.008) offer higher SVR rates when shortening therapy. Hard-to-treat HCV genotype 3 patients suffer lower SVR rates despite treatment optimisation (92.6% vs 98.2%; p=0.001). Conclusions: Treatment optimisation for individuals with multiple predictors of treatment failure can offer high SVR rates. More evidence is needed to identify with confidence those individuals in whom SVR can be achieved with shortened duration treatment.
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Affiliation(s)
| | - Barnaby F. Flower
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Ella Barber
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
| | - Bryony Simmons
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
| | - Graham S. Cooke
- Department of Infectious Disease, Imperial College London, London, W2 1NY, UK
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