Recognition of Hepatitis C Virus Coinfection in HIV-Positive Injecting Drug Users in Asia

12 years of universal access to hepatitis C treatment: Brazil's comprehensive response

Hepatitis C is considered one of the most neglected diseases in world. Worldwide about 150 million people are chronically infected by hepatitis C virus (HCV), and 60% to 70% of them will develop severe liver disease. This article describes Brazil's response to hepatitis C, from the first steps in 1993 to a national program in 2002. We reviewed the available literature, most of it in Brazilian Portuguese, and compiled them in order to share this experience with those seeking some pragmatic solutions. After 12 years, the national program has achieved universal coverage of treatment, resulting in saved lives and resources for the health system. There is abundant evidence that the HCV epidemic deserves attention. The overall consequence of long-term HCV infection is a negative impact on the health care economy. The Brazilian experience can be adapted to many countries in the world, in compliance with the 2010 World Health Organization World Health Assembly Resolution.

WHO guidance on the prevention of viral hepatitis B and C among people who inject drugs

Viral hepatitis B and C (HBV, HCV) disproportionately affect people who inject drugs (PWID) across the world. To date there has been little global action focusing on prevention, care and treatment of HBV and HCV among PWID. Here we report on the development process and discuss the implications of evidence informed WHO Guidelines for the Prevention of HBV and HCV in PWID. The World Health Organization (WHO) convened a Guideline Development Panel to develop recommendations on the prevention of HBV and HCV among PWID. The process followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It included the development of PICO (Population, Interventions, Comparator, Outcomes) questions and conducting systematic reviews. Quality of evidence was classified into 4 levels: high, moderate, low, and very low. In the process of moving from evidence to recommendations, the following were considered: quality of evidence, balance of benefits and harms, community values and preferences and resource use. The WHO recommendations include the following for working with PWID: offer the rapid HBV vaccination regimen; offer incentives to increase uptake and completion of the HBV vaccine schedule; needle and syringe programs should also provide low dead-space syringes for distribution; and offer peer interventions to reduce the incidence of viral hepatitis. This guideline complements other WHO documents regarding PWID, including HIV prevention initiatives such as needle and syringe programs and opioid substitution therapy. This guidance offers a first step in the prevention of HBV and HCV among PWID. However, the lack of high quality evidence in this area necessitates further research and resources for implementation.

HIV and viral hepatitis C coinfection in people who inject drugs: implications of new direct acting antivirals for hepatitis C virus treatment

PURPOSE OF REVIEW

The recent major shift toward oral direct acting hepatitis C virus (HCV) treatments has the potential to revolutionize the global response to HCV. People who inject drugs (PWID) are a large key affected population who stand to benefit from these new medications.

RECENT FINDINGS

There is a large number of new drug classes and targets with activity against HCV. Although effective for HCV treatment in monoinfection and coinfection with HIV, most direct-acting antivirals (DAAs) remain within the research pipeline, with only two having achieved regulatory approval to date. Clinical trial data are not available regarding HCV treatment for PWID with DAAs. This article reviews clinical data on HCV treatment for a number of promising compounds in HCV monoinfection and coinfection with HIV and discusses the barriers facing PWID in scale-up and roll-out of DAAs in the coming years.

SUMMARY

DAAs have the potential to revolutionize HCV treatment. There will be significant access barriers for people who inject drugs to these new medications.

HIV and hepatitis C coinfection

The significant burden of HIV/hepatitis C virus (HCV) coinfection is increasingly recognized worldwide, and in particular within the Asia-Pacific region. Individuals who are coinfected with both viruses are at risk from accelerated liver disease and consequently cirrhosis, liver failure, and hepatocellular carcinoma. In addition, coinfected individuals may have altered immunological responses to HAART and are at increased risk of highly active antiretroviral therapy (HAART)-related hepatotoxicity. Treatment for HCV infection in HIV-infected individuals is with standard pegylated interferon and ribavirin therapy, and all HIV/HCV coinfected subjects should undergo suitability for HCV treatment assessment. Response rates to HCV therapy are generally 10-15% lower than in HCV monoinfection, and therapy may be complicated by issues of drug interactions and significant toxicity. However, greater understanding of baseline factors can contribute to better prediction of treatment outcome, and monitoring of on-treatment virological responses increasingly allows individualization of therapy. Where possible, treatment of HCV is often advisable before HAART is required to avoid the issues of drug interactions on HCV therapy and the risk of HAART-related hepatotoxicity. Early diagnosis of both HIV and HCV infection is essential to most effectively manage HIV-HCV-coinfected individuals. New therapies, including HCV protease and polymerase inhibitors, are in development and may widen therapeutic options for HIV-HCV-coinfected individuals into the future.