Eliminating viral hepatitis C in Belgium: the micro-elimination approach

Ten years countdown to hepatitis C elimination in Belgium: a mathematical modeling approach

BACKGROUND

Chronic infection with the hepatitis C virus (HCV) remains a worldwide health problem. As a result, the World Health Organization (WHO) has set elimination targets by 2030. This study aims to examine the position of Belgium in meeting the WHO's targets by 2030.

METHODS

A Markov disease progression model, constructed in Microsoft Excel, was utilized to quantify the size of the HCV-infected population, by the liver disease stages, from 2015 to 2030. Two scenarios were developed to (1) forecast the disease burden in Belgium under the 2019 Base and (2) see what is needed to achieve the WHO targets.

RESULTS

It was estimated that the number of HCV RNA-positive individuals in Belgium in 2015 was 18,800. To achieve the WHO goals, Belgium needs to treat at least 1200 patients per year. This will only be feasible if the number of screening tests increases.

CONCLUSIONS

Belgium is on target to reach the WHO targets by 2030 but will have to make sustained efforts. However, eradicating HCV requires policy changes to significantly increase prevention, screening, and treatment, alongside public health promotion, to raise awareness among high-risk populations and health care providers.

Real-world outcomes of rapid regional hepatitis C virus treatment scale-up among people who inject drugs in Tayside, Scotland

BACKGROUND

In 2017, Tayside, a region in the East of Scotland, rapidly scaled-up Hepatitis C Virus (HCV) outreach and treatment among People Who Inject Drugs (PWID) using novel community care pathways.

AIMS

We aimed to determine treatment outcomes for PWID during the scale-up against pre-determined targets; and assess re-infection, mortality, and post-treatment follow up.

METHODS

HCV treatment was delivered in community pharmacies, drug treatment centres, nurse-led outreach clinics, prisons, and needle exchanges, alongside conventional hospital care. We retrospectively analysed clinical outcomes and compared pathways using logistic regression models.

RESULTS

Of 800 estimated HCV-infected PWID, 718 (90%) were diagnosed. 713 treatments commenced among 662 (92%) PWID, delivering 577 (81%) Sustained Virologic Responses (SVR). SVR was 91% among those who attended for testing. Forty-six individuals were treated more than once. Needle exchanges and community pharmacies initiated 49% of all treatments. Regression analyses implied pharmacies had superior follow-up, but there was no difference in likelihood of achieving SVR in community pathways relative to hospital care. Re-infection occurred 39 times over 256.57 person years (PY), yielding a rate of 15.20 per 100 PY (95% CI 10.81-20.78). 54 deaths occurred (29 drug related) over 1,553.04 PY, yielding a mortality rate of 3.48 per 100 PY (95% CI 2.61-4.54). Drug-related mortality was 1.87 per 100 PY (95% CI 1.25-2.68).

CONCLUSIONS

Rapid HCV treatment scale-up to PWID in community settings, whilst maintaining high SVR, is achievable. However, other interventions are required to minimise re-infection; reduce drug-related deaths; and improve post-SVR follow-up testing regionally.

Real-life experience of treating HCV co-infection among HIV-infected population in Egypt: single-center experience

BACKGROUND

Liver disease has emerged as a leading cause of death among PLHIV coinfected with HCV.

METHODS

A retrospective study involving all HCV viremic patients coinfected with HIV who presented to HCV/HIV multidisciplinary clinics located at Embaba fever hospital. Patients were assigned to receive DAAs according to the national treatment guidelines. The primary endpoint was SVR12.

RESULTS

Of the 519 patients enrolled, 38.73% LTFU; either not initiated (n = 170) or did not complete the treatment (n = 31). The main identified reasons behind LTFU were schedule conflict (19%) or hospitalization (13%). Among 318 patients who completed their DAAs course, nine patients had a relapse after the end of treatment and 97% had attained SVR12. There were significant differences among different virological response groups in baseline factors including smoking (p = 0.005), history of dental procedure (p = 0.007), CD4 count (p = 0.007), and HIV viral load (p = <0.001). Among responders (n = 309), there was a significant reduction of baseline hemoglobin and significant improvement of baseline platelets (p = 0.005) at on-treatment week 8. Baseline necro-inflammatory markers showed significant improvement across follow-up time points (p < 0.001).

CONCLUSIONS

DAAs are an effective and safe choice to treat HCV in PLHIV. Social stigma could be a major cause for lacking adherence to follow-up visits.Abbreviations: ALT: Alanine Aminotransferase; ARV: Antiretroviral treatment; AST: Aspartate Aminotransferase; DAAs: Direct acting antivirals; ARVs: antiretroviral therapy; EMR: Eastern Mediterranean region; HCV: Hepatitis C virus; kPa: Kilopascal; LTFU: Patient lost to follow up; NCCVH: The National Committee for Control of Viral Hepatitis; PWID: People who inject drugs; SVR: Sustained virological response;UNAIDS: The Joint United Nations Programme on HIV/AIDS.

On-site testing and case management to improve hepatitis C care in drug users: a prospective, longitudinal, multicenter study in the DAA era

Background

Screening and treatment of hepatitis C virus (HCV) infection in people who use drugs (PWUD) remains insufficient. Reducing the burden of HCV infection in PWUD requires interventions focusing on the different steps of the HCV care cascade.

Methods

We performed a prospective, multicenter study, evaluating the impact of an HCV care model on the HCV care cascade among PWUD attending an addiction care center in Belgium between 2015 and 2018. Interventions within the care model consisted of pre-test counseling, on-site HCV screening and case management services. A multiple logistic regression model was performed to identify the independent factors influencing the outcomes.

Results

During the study period, 441 PWUD were registered at the addiction care center, 90% (395/441) were contacted, 88% (349/395) were screened for HCV infection. PWUD were more likely to be screened if they had ever injected drugs (p < .001; AOR 6.411 95% CI 3.464–11.864). In 45% (157/349), the HCV antibody (Ab) test was positive, and in 27% (94/349) HCV RNA was positive. Within the Belgian reimbursement criteria (fibrosis stage ≥ F2), 44% (41/94) were treated. Specialist evaluation at the hospital was lower for PWUD receiving decentralized opioid agonist therapy (p = .005; AOR 0.430 95% CI 0.005–0.380), PWUD with unstable housing in the past 6 months before inclusion (p = .015; AOR 0.035 95% CI 0.002–0.517) or if they were recently incarcerated (p = .001; AOR 0.010 95% CI 0.001–0.164).

Conclusions

This HCV care model demonstrated high screening, linkage to care, and treatment initiation among PWUD in Belgium. Using the cascade of care to guide interventions is easy and necessary to monitor results. This population needs guidance, not only for screening and treatment initiation but also for the long-term follow-up since one in six had cirrhosis and could develop hepatocellular carcinoma. Further interventions are necessary to increase linkage to care and treatment initiation. Universal access to direct-acting antiviral therapy from 2019 will contribute to achieving HCV elimination in the PWUD population.

Trial registration

Clinical trial registration details: www.clinicaltrials.gov (NCT03106194).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11608-9.

A multicentre interventional study to assess blood-borne viral infections in Belgian prisons

BACKGROUND

Prevalence data on viral hepatitis B (HBV), hepatitis C (HCV), and HIV infection in prison are often scarce or outdated. There is currently no systematic screening for these blood-borne viral infections (BBV) in Belgian prisons. There is an urgency to assess the prevalence of these BBV to inform policymakers and public healthcare.

METHODS

This was a multicentre, interventional study to assess the prevalence of BBV using opt-in screening in prisons across Belgium, April 2019 - March 2020. Prisoners were tested using a finger prick and BBV risk factors were assessed using a questionnaire. A generalized linear mixed model was used to investigate the association between the various risk factors and HCV.

RESULTS

In total, 886 prisoners from 11 Belgian prisons were screened. Study uptake ranged from 16.9 to 35.4% in long-term facilities. The prevalence of HCV antibodies (Ab), hepatitis B surface antigen (Ag) and HIV Ab/Ag was 5.0% (44/886), 0.8% (7/886), and 0.2% (2/886). The adjusted odds for HCV Ab were highest in prisoners who ever injected (p < 0.001; AOR 24.6 CI 95% (5.5-215.2). The prevalence of detectable HCV RNA in the total cohort was 2.1% (19/886). Thirteen (68.4%) prisoners were redirected for follow-up of their HCV infection.

CONCLUSIONS

Opt-in testing for viral hepatitis B, C and HIV was relatively well-accepted in prisons. Compared with the general population, prisoners have a higher prevalence of infection with BBV, especially for HCV. Systematic screening for these BBV should be recommended in all prisons, preferably using opt-out to optimize screening uptake.

TRIAL REGISTRATION

Retrospectively registered at clinical trials NCT04366492 April 29, 2020.

Hepatitis C Virus Prevalence and Risk Factors in a Village in Northeastern Romania-A Population-Based Screening-The First Step to Viral Micro-Elimination

(1) Background: The World Health Organization adopted a strategy for the Global Health Sector on Viral Hepatitis in 2016, with the main objective of eliminating hepatitis C virus (HCV) by 2030. In this work, we aimed to evaluate the prevalence of HCV infection and risk factors in a Romanian village using population-based screening as part of the global C virus eradication program. (2) Methods: We conducted a prospective study from March 2019 to February 2020, based on a strategy as part of a project designed to educate, screen, treat and eliminate HCV infection in all adults in a village located in Northeastern Romania. (3) Results: In total, 3507 subjects were invited to be screened by rapid diagnostic orientation tests (RDOT). Overall, 2945 (84%) subjects were tested, out of whom 78 (2.64%) were found to have positive HCV antibodies and were scheduled for further evaluation in a tertiary center of gastroenterology/hepatology in order to be linked to care. In total, 66 (85%) subjects presented for evaluation and 55 (83%) had detectable HCV RNA. Of these, 54 (98%) completed antiviral treatment and 53 (99%) obtained a sustained virological response. (4) Conclusions: The elimination of hepatitis C worldwide has a higher chance of success if micro-elimination strategies based on mass screening are adopted.

Allocating treatment resources for hepatitis C in the UK: a constrained optimization modelling approach

Background and objective: Although the treatment of chronic hepatitis C (CHC) has significantly evolved with the introduction of direct-acting antivirals, the treatment uptake rates have been low especially among marginalized groups in the UK, such as people who inject drug (PWID) and men who have sex with men (MSM). Cutting health inequality is a major focus of healthcare agencies. This study aims to identify the optimal allocation of treatment budget for chronic hepatitis CHC among populations and treatments in the UK so that liver-related mortality in patients with CHC is minimized, given the constraint of treatment budget and equity issue. Methods: A constrained optimization modelling of resource allocation for the treatment of CHC was developed in Excel from the perspective of the UK National Health System over a lifetime horizon. The model was designated with the objective function of minimizing liver-related deaths by varying the decision variables, representing the number of patients receiving each treatment (elbasvir-grazoprevir, ombitasvir-paritaprevir-ritonavir-dasabuvir, sofosbuvir-ledipasvir, and pegylated interferon-ribavirin) in each population (the general population, PWID, and MSM). Two main constraints were formulated including treatment budget and the issue of equity. The model was populated with UK local data applying linear programming and underwent internal and external validation. Scenario analyses were performed to assess the robustness of model results. Results: Within the constraints of no additional funding over original spending in status quo and the consideration of the issue of equity among populations, the optimal allocation from the constrained optimization modelling (treating 13,122 PWID, 160 MSM, and 904 general patients with ombitasvir-paritaprevir-ritonavir-dasabuvir) was found to treat 2,430 more patients (relative change: 20.7%) and avert 78 liver-related deaths (relative change: 0.3%) compared with the current allocation. The number of patients receiving treatment increased 4,928 (relative change: 60.1%) among PWID and 42 (relative change: 35.8%) among MSM. Conclusion: The current allocation of treatment budget for CHC is not optimal in the UK. More patients would be treated, and more liver-related deaths would be avoided using a new allocation from a constrained optimization modelling without incurring additional spending and considering the issue of equity.

The hepatitis C cascade of care in the Belgian HIV population: One step closer to elimination

OBJECTIVES

The Belgian population of people living with HIV (PLHIV) has unrestricted access to direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection, since 2017. International literature claims that half of the patients remain untreated in high-income countries with unrestricted access to DAA. This study was initiated to provide an overview of the present situation in Belgium and recommendations for HCV care in PLHIV in other regions.

METHODS

This was a retrospective, multicenter study of PLHIV in Belgium, from January 1, 2007 to December 31, 2018. The HCV cascade of care was examined.

RESULTS

Out of 4607 unique PLHIV, 322 (7.0%) tested positive for HCV antibody and HCV RNA positivity was seen in 289 (6.3%). Of those with a proven HCV infection, 207/289 (71.6%) initiated treatment. Of the 171 (82.6%) persons with a sustained virologic response (SVR), 16 (9.4%) subjects were reinfected.

CONCLUSIONS

We present a care cascade of 4607 PLHIV in Belgium. Treatment initiation and SVR rates were high compared to other regions. Implementation of a national HCV register to track progress and yearly screening, especially in PLHIV with high-risk behavior, remains crucial. Identifying reasons for not initiating treatment is necessary to achieve elimination of HCV in PLHIV by 2030.

Progress and Barriers Towards Elimination of Chronic Hepatitis C in Children

Chronic hepatitis C (CHC) is a global health burden. Mother-to-child transmission (MTCT) accounts for most HCV infections in pediatric patients. Spontaneous viral clearance may occur in early childhood but is uncommon thereafter. Infection is usually asymptomatic during childhood, although without an effective treatment, vertically infected children may develop serious liver complications including cirrhosis and hepatocellular carcinoma in adulthood. Despite the lack of vaccine against hepatitis C and effective post-exposure methods of prevention of MTCT, treatment with direct-acting antiviral agents (DAAs) raised the prospect of eliminating HCV on a population level. Highly effective, well-tolerated, oral, and interferon-free regimens of short duration have revolutionized treatment of CHC. However, access to these therapies might be limited because of its high cost. In this review, we provide the current state of knowledge on the epidemiology, testing, monitoring and treating of HCV in children. We outline the remaining gaps in therapy and barriers to disease eradication.

Treatment Coverage and Drug Expenditure in Hepatitis C Patients From 2013 to 2019: A Journey of Improving Treatment Accessibility in Malaysia Through Government-led Initiatives

Background: Hepatitis C is a public health threat, affecting approximately 1.9% of the Malaysian population. Objectives: This study demonstrates how a series of initiatives taken by the Ministry of Health (MOH) of Malaysia have impacted the treatment coverage and drug expenditure for hepatitis C patients since 2013, the year in which the first direct-acting antiviral (DAA) was introduced in public health institutions. Methods: The data were obtained from all the 144 hospitals and 33 primary healthcare centers throughout the country, which were identified to have offered the pharmacological treatment to hepatitis C patients over the last seven years. Results: The total number of hepatitis C patients treated each year was shown to increase by more than 10 times, reaching 3,116 in 2019. However, the drug expenditure for hepatitis C relative to the overall health expenditure did not significantly increase over time (P = 0.094). The use of DAAs was once limited by its exorbitant cost. A remarkable elevation in the number of patients receiving the treatment only took place as of 2016, particularly following the engagement of the MOH in endeavors driven by non-profit organizations to enhance the accessibility of DAAs and the issuance of a compulsory license to sofosbuvir. Conclusions: Timely decisions of the MOH and the judicious use of policy tools were shown to have transformed the landscape of hepatitis C management in Malaysia without considerably raising the budgetary pressure. Yet, continuous efforts to massively upscale the screening and treatment of the disease are warranted going forward.