African americans are less likely to have clearance of hepatitis C virus infection: the findings from recent U.S. population data

Prevalence and associated risk factors of current hepatitis C infection among U.S. general population and injection drug users aged 20-59 years: NHANES 2009-2018

INTRODUCTION

The people who inject drugs (PWID) are attributed to high-risk groups for transmission of the Hepatitis C virus (HCV). This study assessed the prevalence and associated factors of current HCV infection (CHI) among U.S. general population and PWID of ages between 20 and 59 years old.

METHODS

This study utilized cross-sectional data from the 2009-2018 National Health and Nutrition Examination Survey, conducting separate analyses for the U.S. general population, including PWID and non-PWID, as well as specific analyses focusing solely on PWID. The analytical methods included the estimation of CHI prevalence, Rao-Scott chi-square test to compare CHI-positive and CHI-negative groups, and univariate and multivariable logistic regressions models to evaluate the associated risk factors of CHI.

RESULTS

The prevalence of CHI among general population and PWID were 1% and 19%, respectively. Compared to non-PWID, the odds of CHI were significantly higher among PWID (OR = 32.6, 95% CI = 17.7-60.3) in general population. Among PWID, male vs. female (OR = 2.6, 95% CI = 1.1-5.9), adults aged 40-59 vs. 20-39 years old (OR = 2.9, 95% CI = 1.2-7.3), Non-Hispanic Black vs. White (OR = 4.6, 95% CI = 1.5-13.6), with high school diploma or less educational attainment vs. above college degree (OR = 3.5, 95% CI = 1.4-9.2) showed higher odds of having CHI.

CONCLUSION

The prevalence of CHI was found to be higher among PWID especially those who were male, aged 40-59 years old, Non-Hispanic Black, and had lower educational attainment. Targeted intervention such as screening and awareness program among PWID population is recommended to reduce the burden of new HCV infections in the U.S.

Hepatitis C Epidemiology in a Large Urban Jail: A Changing Demographic

OBJECTIVES

Nearly 1 in 3 people with hepatitis C virus (HCV) infection pass through the criminal justice system annually; the system is a crucial location for HCV screening, education, and linkage to care. We aimed to (1) determine the prevalence and incidence of HCV antibody positivity and (2) evaluate the demographic characteristics of people with HCV in a large urban jail.

METHODS

We offered universal opt-out HCV testing to any person undergoing a routine blood test at the Dallas County Jail from June 2015 through December 2019 (N = 14 490). We extracted data on demographic characteristics from the electronic medical record and collected data on risk factors from people with HCV antibody positivity. We performed univariate and multivariate analyses.

RESULTS

The prevalence of HCV antibody positivity was 16.7%; the incidence was 13.5 cases per 1000 person-years. HCV antibody positivity was significantly associated with older age (P < .001), female sex (P = .004), non-Hispanic White race versus non-Hispanic Black race (P < .001), and being released to prison versus not (P < .001). Among people born after 1965, those who were HCV antibody-positive were more frequently non-Hispanic White and Hispanic women, whereas among those born in 1965 or before, those who were HCV antibody-positive were more frequently non-Hispanic Black men.

CONCLUSIONS

The high prevalence and incidence of HCV antibody positivity in a large county jail argue for routine, universal HCV testing and prevention counseling in criminal justice settings. Changing demographic characteristics mirror those of the national injection drug use epidemic and shed insight into designing interventions for risk reduction, education, linkage to care, and treatment.

Universal HCV Screening of Baby Boomers is Feasible, but It is Difficult

BACKGROUND/OBJECTIVE

Our objective was to assess the impact of mass mailing and the inclusion of Best Practice Advisory (BPA) "Pop-Up" tool in the electronic medical record (EMR) on HCV screening rates.

METHODS

Between June 2015 and March 2020, two interventions were developed for primary care physicians (PCP). An educational letter along with a blood requisition form, signed on behalf of the PCPs, was sent to patients. We also developed a BPA "Pop-Up" screening tool to alert PCPs to order HCV screening tests on patients with no previous screening. Data were collected and analyzed prospectively.

RESULTS

When we started the screening program in June 2015, 33,736 baby boomers were eligible for screening, and the hospital system added an additional 26,027 baby boomers between June 2015 and March 2020. Of the 89 primary care providers employed by the hospital, 75 agreed to participate at different time periods. We screened 23,291 (43.5%) of 53,526 eligible patients during study period. Of these, 399 (1.7%) had HCV antibody, but HCV RNA was positive in only 195 (1%). HCV antibody positivity rates were higher in men, blacks, and in 1951-1960 birth cohorts. Spontaneous clearance rates appeared to be lower in men (OR 0.59, 95% CI 0.39-0.90, P = 0.015) and in blacks (OR 0.31, 95% CI 0.20-0.50, P < 0.001).

CONCLUSION

Although a formal screening program increased screening rates for HCV among baby boomers, about 50% of baby boomers remained unscreened. In this community screening program, we found that men and blacks are less likely to have spontaneous HCV clearance.

New Face of Hepatitis C

Chronic hepatitis C viral (HCV) infection continues to carry a high burden of disease despite recent and emerging advancements in treatment. The persistently high prevalence of HCV is attributed to the rising opioid epidemic, with a history of injection drug use as the primary risk factor for infection. As a result, the epidemiology of HCV-infected individuals is changing. Previously a disease of "Baby Boomers," males, and non-Hispanic blacks, the new generation of patients with HCV includes younger adults from 20 to 39 years of age, both men and women similarly represented, and non-Hispanic whites. Shifting trends in these demographics may be attributed to the use of injection drugs, which also has suggested impact on fibrosis progression in infected individuals. Awareness of the changing face of HCV is necessary to expand and revise recommendations regarding screening, outreach, and care engagement of infected individuals, in order to best identify patients at-risk for infection.

Multi-Ancestry Genome-Wide Association Study of Spontaneous Clearance of Hepatitis C Virus

BACKGROUND & AIMS

Spontaneous clearance of hepatitis C virus (HCV) occurs in approximately 30% of infected persons and less often in populations of African ancestry. Variants in major histocompatibility complex (MHC) and in interferon lambda genes are associated with spontaneous HCV clearance, but there have been few studies of these variants in persons of African ancestry. We performed a dense multi-ancestry genome-wide association study of spontaneous clearance of HCV, focusing on individuals of African ancestry.

METHODS

We performed genotype analyses of 4423 people from 3 ancestry groups: 2201 persons of African ancestry (445 with HCV clearance and 1756 with HCV persistence), 1739 persons of European ancestry (701 with HCV clearance and 1036 with HCV persistence), and 486 multi-ancestry Hispanic persons (173 with HCV clearance and 313 with HCV persistence). Samples were genotyped using Illumina (San Diego, CA) arrays and statistically imputed to the 1000 Genomes Project. For each ancestry group, the association of single-nucleotide polymorphisms with HCV clearance was tested by log-additive analysis, and then a meta-analysis was performed.

RESULTS

In the meta-analysis, significant associations with HCV clearance were confirmed at the interferon lambda gene locus IFNL4-IFNL3 (19q13.2) (P = 5.99 × 10-50) and the MHC locus 6p21.32 (P = 1.15 × 10-21). We also associated HCV clearance with polymorphisms in the G-protein-coupled receptor 158 gene (GPR158) at 10p12.1 (P = 1.80 × 10-07). These 3 loci had independent, additive effects of HCV clearance, and account for 6.8% and 5.9% of the variance of HCV clearance in persons of European and African ancestry, respectively. Persons of African or European ancestry carrying all 6 variants were 24-fold and 11-fold, respectively, more likely to clear HCV infection compared with individuals carrying none or 1 of the clearance-associated variants.

CONCLUSIONS

In a meta-analysis of data from 3 studies, we found variants in MHC genes, IFNL4-IFNL3, and GPR158 to increase odds of HCV clearance in patients of European and African ancestry. These findings could increase our understanding of immune response to and clearance of HCV infection.

Racial Disparities in Hepatitis C Treatment Eligibility

BACKGROUND

Hepatitis C (HCV) is more prevalent in African Americans than in any other racial group in the United States. However, African Americans are more likely to be deemed ineligible for HCV treatment than non-African Americans. There has been limited research into the origins of racial disparities in HCV treatment eligibility.

AIM

The purpose of this study was to compare medical and non-medical characteristics commonly assessed in clinical practice that could potentially contribute to HCV treatment ineligibility disparities between African American and non-African American patients.

MATERIAL AND METHODS

Patients with confirmed HCV RNA considering treatment (n = 309) were recruited from university-affiliated and VA liver and infectious disease clinics.

RESULTS

African Americans and non-African Americans did not differ in prevalence of lifetime and current psychiatric disorders and risky behaviors, and HCV knowledge. HCV clinical characteristics were similar between both groups in terms of HCV exposure history, number of months aware of HCV diagnosis, stage of fibrosis, and HCV virologic levels. African Americans did have higher proportions of diabetes, renal disease, and bleeding ulcer.

CONCLUSIONS

No clinical evidence was found to indicate that African Americans should be more often deemed ineligible for HCV treatment than other racial groups. Diabetes and renal disease do not fully explain the HCV treatment ineligibility racial disparity, because HCV patients with these conditions are priority patients for HCV treatment because of their greater risk for cirrhosis, steatosis, and hepatocellular carcinoma. The findings suggest that an underlying contributor to the HCV treatment eligibility disparity disfavoring African Americans could be racial discrimination.

Ledipasvir/Sofosbuvir Effectively Treats Hepatitis C Virus Infections in an Underserved Population

BACKGROUND

Underserved populations have an unequal burden of HCV infections and poor outcomes with interferon-based treatments. Direct-acting antivirals have the potential to reduce these inequalities.

AIMS

We aimed to estimate sustained virologic response (SVR) following treatment with sofosbuvir-based regimens for HCV infections among underserved individuals and summarize the frequency of SVR across published studies of underserved populations.

METHODS

We used data from a clinical cohort of patients aged ≥ 18 years who initiated sofosbuvir-based regimens for HCV infection between February 2014 and June 2016 at an urban public hospital network that serves as the healthcare safety-net for Tarrant County, Texas. We estimated SVR with corresponding 95% confidence limits (CL). In addition, we systematically reviewed the evidence to identify other studies of direct-acting antivirals among underserved populations.

RESULTS

Our study population comprised 435 patients. The majority of patients were aged ≥ 50 years (76%), male (52%), non-Hispanic White (54%), HCV genotype 1 (79%) and treated with ledipasvir/sofosbuvir (69%). Overall SVR was 89% (95% CL 86, 92%) and highest for ledipasvir/sofosbuvir (SVR = 95%, 95% CL 92, 97%). The reported SVR following direct-acting antivirals among 837 underserved patients from three other studies ranged between 90 and 99%.

CONCLUSIONS

Our results suggest that direct-acting antivirals, particularly ledipasvir/sofosbuvir, are generally effective for achieving SVR among underserved patients with HCV infections and may help reduce inequalities in HCV prevalence and outcomes for this vulnerable population.

Decreasing racial disparity with the combination of ledipasvir-sofosbuvir for the treatment of chronic hepatitis C

African Americans (AA) in the US are twice as likely to be infected with hepatitis C virus (HCV) compared to the non-Hispanic-white US population (Cau). They are also more likely to be infected with HCV genotype 1, more likely to develop hepatocellular carcinoma, and, in addition, have a lower response rate to interferon-based therapies. With the increase in response rates reported for combinations of direct-acting antivirals, the possibility that racial disparity would be eliminated by agents that directly inhibit virus replication has become a reality. The objective of this review is to evaluate the literature from clinical studies and retrospective analysis with respect to the response of AA to the most prescribed antiviral combination sofosbuvir plus ledipasvir. While few studies have focused on AA patients, sufficient information is availed from the literature and studies in our predominately AA clinic population to confirm that ledipasvir–sofosbuvir has a similar effectiveness in AA as compared to Cau.

Treatment Considerations for Unique Patient Populations With HCV Genotype 1 Infection

OBJECTIVE

To review the literature for the treatment of hepatitis C virus (HCV) genotype 1 in certain populations of patients that require further considerations before therapy initiation.

DATA SOURCES

A systematic electronic literature search using the MEDLINE database was performed using the search terms hepatitis C, chronic hepatitis C, drug therapy, end stage liver disease, liver transplantation, HIV, hepatitis B, African Americans, renal insufficiency, obesity, pregnancy, and pediatrics.

STUDY SELECTION AND DATA EXTRACTION

English language studies from January 1985 to March 2015 were considered. Additional references were identified from ongoing trials obtained from clinicaltrials.gov, conference proceedings, online databases, and citations in relevant review articles.

DATA SELECTION

Direct-acting antivirals are first-line recommendations for the treatment of HCV genotype 1 infection, and these include combinations of sofosbuvir, simeprevir, ledipasvir/sofosbuvir, ombitasvir/paritaprevir/ritonavir plus dasabuvir, and ribarvirin. Historical and clinical data focusing on the treatment of HCV with these agents in the following populations were selected: decompensated cirrhosis, post-liver transplant, HIV, African Americans, obesity, hepatitis B coinfection, renal impairment, pregnancy, and pediatrics.

CONCLUSION

Depending on the population studied, clinicians must consider differences in efficacy outcomes, potential drug interactions, and adverse effects that patients may experience.

Hepatitis C in African Americans

The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.

Polypharmacy and comorbidity are associated with a lower early virologic response in hepatitis C patients treated with first generation protease inhibitor triple therapy: a preliminary analysis

BACKGROUND AND AIMS

The protease inhibitors (PIs) boceprevir and telaprevir are currently standard treatment as part of triple therapy regimens (TTx) for chronic HCV genotype 1 (GT1) patients. In this preliminary analysis, we have compared demographic variables, polypharmacy, and Charlson's comorbid index (CCI) with Rapid Virological Response (RVR) and extended RVR (eRVR) rates in HCV GT1 patients receiving PI containing TTx.

METHODS

Retrospective descriptive cohort study.

RESULTS

Among 74 HCV patients (46 M, 28 F; age: 54.43 ± 9.52 years; African Americans: 59.5 %) in this initial analysis, 44 % achieved RVR. All these RVR patients also achieved eRVR. Patients achieving RVR and eRVR were 50 ± 11.7 (mean ± SD) years old, compared to 58 ± 5.2 years without an RVR (p < 0.005). The average number of medications taken by patients achieving RVR and eRVR was 5 ± 2.7 compared to 9.24 ± 3.4 in patients not achieving RVR and eRVR (p < 0.005). Twenty-five percent of patients who were not on CYP3A4 inhibitors had an RVR and eRVR compared to 63.2 % who were taking CYP3A4 inhibitors (p = 0.001). Patients achieving RVR and eRVR had a lower CCI (1.61 ± 1.37) compared to those not achieving RVR and eRVR (2.8 ± 2.7; p = 0.02). Multivariate analysis also revealed a significant correlation between increased polypharmacy and CCI with lower RVR and eRVR rates.

CONCLUSIONS

These preliminary treatment data demonstrate that increased polypharmacy and higher degrees of comorbidity decrease RVR and eRVR rates among patients receiving first generation PI-containing TTx regimens.