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Kondili LA, Lazarus JV, Jepsen P, Murray F, Schattenberg JM, Korenjak M, Craxì L, Buti M. Inequities in primary liver cancer in Europe: The state of play. J Hepatol 2024; 80:645-660. [PMID: 38237866 DOI: 10.1016/j.jhep.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 02/12/2024]
Abstract
Given the increasing burden of liver cancer in Europe, it is crucial to investigate how social determinants of health (SDoH) affect liver cancer risk factors and access to care in order to improve health outcomes equitably. This paper summarises the available evidence on the differential distribution of liver cancer risk factors, incidence, and health outcomes in the European Economic Area and the United Kingdom from an SDoH perspective. Vulnerable and marginalised populations have low socio-economic and educational levels and are the most affected by liver cancer risk factors. Reasons for this include varied access to hepatitis B virus vaccination and limited access to viral hepatitis B and C screening, harm reduction, and treatment. Additionally, alcohol-related liver disease remains highly prevalent among individuals with low education, insecure employment, economic instability, migrants, and deprived populations. Moreover, significant variation exists across Europe in the proportion of adults with steatotic liver disease, overweight/obesity, and diabetes, based on geographical area, gender, socio-economic and educational background, and density of ultra-processed food outlets. Inequities in cirrhosis mortality rates have been reported, with the highest death rates among individuals living in socio-economically disadvantaged areas and those with lower educational levels. Furthermore, insufficient healthcare access for key populations with primary liver cancer is influenced by complex healthcare systems, stigmatisation, discrimination, low education, language barriers, and fear of disclosure. These challenges contribute to inequities in liver cancer care pathways. Future studies are needed to explore the different SDoH-interlinked effects on liver cancer incidence and outcomes in European countries. The ultimate goal is to develop evidence-based multilevel public health interventions that reduce the SDoH impact in precipitating and perpetuating the disproportionate burden of liver cancer in specific populations.
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Affiliation(s)
- Loreta A Kondili
- National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy, UniCamillus International Medical University, Rome, Italy
| | - Jeffrey V Lazarus
- CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, NY, USA; Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Murray
- Beaumont Private Clinic, Beaumont, Dublin 9, Ireland
| | - Jörn M Schattenberg
- Department of Internal Medicine II, Saarland University Medical Center, Homburg and Saarland University, Saarbrücken, Germany
| | | | - Lucia Craxì
- Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Maria Buti
- Liver Unit, Hospital Universitario Vall d'Hebrón, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
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Thomadakis C, Gountas I, Duffell E, Gountas K, Bluemel B, Seyler T, Pericoli FM, Kászoni-Rückerl I, El-Khatib Z, Busch M, Schmutterer I, Vanwolleghem T, Klamer S, Plettinckx E, Mortgat L, Van Beckhoven D, Varleva T, Kosanovic Licina ML, Nemeth Blazic T, Nonković D, Theophanous F, Nemecek V, Maly M, Christensen PB, Cowan S, Rüütel K, Brummer-Korvenkontio H, Brouard C, Steffen G, Krings A, Dudareva S, Zimmermann R, Nikolopoulou G, Molnár Z, Kozma E, Gottfredsson M, Murphy N, Kondili LA, Tosti ME, Ciccaglione AR, Suligoi B, Nikiforova R, Putnina R, Jancoriene L, Seguin-Devaux C, Melillo T, Boyd A, van der Valk M, Op de Coul E, Whittaker R, Kløvstad H, Stępień M, Rosińska M, Valente C, Marinho RT, Popovici O, Avdičová M, Kerlik J, Klavs I, Maticic M, Diaz A, del Amo J, Lundberg Ederth J, Axelsson M, Nikolopoulos G. Prevalence of chronic HCV infection in EU/EEA countries in 2019 using multiparameter evidence synthesis. THE LANCET REGIONAL HEALTH. EUROPE 2024; 36:100792. [PMID: 38188273 PMCID: PMC10769889 DOI: 10.1016/j.lanepe.2023.100792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024]
Abstract
Background Epidemiological data are crucial to monitoring progress towards the 2030 Hepatitis C Virus (HCV) elimination targets. Our aim was to estimate the prevalence of chronic HCV infection (cHCV) in the European Union (EU)/European Economic Area (EEA) countries in 2019. Methods Multi-parameter evidence synthesis (MPES) was used to produce national estimates of cHCV defined as: π = πrecρrec + πexρex + πnonρnon; πrec, πex, and πnon represent cHCV prevalence among recent people who inject drugs (PWID), ex-PWID, and non-PWID, respectively, while ρrec, ρex, and ρnon represent the proportions of these groups in the population. Information sources included the European Centre for Disease Prevention and Control (ECDC) national operational contact points (NCPs) and prevalence database, the European Monitoring Centre for Drugs and Drug Addiction databases, and the published literature. Findings The cHCV prevalence in 29 of 30 EU/EEA countries in 2019 was 0.50% [95% Credible Interval (CrI): 0.46%, 0.55%]. The highest cHCV prevalence was observed in the eastern EU/EEA (0.88%; 95% CrI: 0.81%, 0.94%). At least 35.76% (95% CrI: 33.07%, 38.60%) of the overall cHCV prevalence in EU/EEA countries was associated with injecting drugs. Interpretation Using MPES and collaborating with ECDC NCPs, we estimated the prevalence of cHCV in the EU/EEA to be low. Some areas experience higher cHCV prevalence while a third of prevalent cHCV infections was attributed to PWID. Further efforts are needed to scale up prevention measures and the diagnosis and treatment of infected individuals, especially in the east of the EU/EEA and among PWID. Funding ECDC.
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Affiliation(s)
| | - Ilias Gountas
- Medical School, University of Cyprus, Nicosia, Cyprus
| | - Erika Duffell
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Benjamin Bluemel
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Thomas Seyler
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | | | - Irene Kászoni-Rückerl
- VII/A/11 Communicable Diseases and Disease Control, Federal Ministry of Social Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Ziad El-Khatib
- Institute for Surveillance & Infectious Disease Epidemiology, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - Martin Busch
- Addiction Competence Center, Austrian National Public Health Institute, Vienna, Austria
| | - Irene Schmutterer
- Addiction Competence Center, Austrian National Public Health Institute, Vienna, Austria
| | - Thomas Vanwolleghem
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - Sofieke Klamer
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Els Plettinckx
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Laure Mortgat
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | | | - Tonka Varleva
- Scientific Research Institute, Medical University, Pleven, Bulgaria
| | | | - Tatjana Nemeth Blazic
- Department for HIV, Sexual and Blood Transmitted Diseases, Reference Center of the Epidemiology of the Ministry of Health, Croatian Institute of Public Health, Zagreb, Croatia
| | - Diana Nonković
- Teaching Institute of Public Health Split and Dalmatia County, Split, Croatia
- Department of Health Studies, University of Split, Split, Croatia
| | | | - Vratislav Nemecek
- National Reference Laboratory for Viral Hepatitis, National Institute of Public Health, Prague, Czech Republic
| | - Marek Maly
- Department of Biostatistics, National Institute of Public Health, Prague, Czech Republic
| | - Peer Brehm Christensen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Susan Cowan
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Kristi Rüütel
- National Institute of Health Development, Tallinn, Estonia
| | | | - Cécile Brouard
- Santé Publique France, The National Public Health Agency, Saint-Maurice, France
| | - Gyde Steffen
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Amrei Krings
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Sandra Dudareva
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Ruth Zimmermann
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | | | - Zsuzsanna Molnár
- National Center for Public Health and Pharmacy, Budapest, Hungary
| | - Emese Kozma
- National Center for Public Health and Pharmacy, Budapest, Hungary
| | - Magnús Gottfredsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavík, Iceland
- Landspitali University Hospital, Reykjavík, Iceland
| | - Niamh Murphy
- HSE Health Protection Surveillance Centre, Dublin, Ireland
| | - Loreta A. Kondili
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
- UniCamillus-Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Maria Elena Tosti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Anna Rita Ciccaglione
- Viral Hepatitis, Oncovirus and Retrovirus Disease Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Barbara Suligoi
- National AIDS Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | | | - Renate Putnina
- The Centre for Disease Prevention and Control, Riga, Latvia
| | - Ligita Jancoriene
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Carole Seguin-Devaux
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Tanya Melillo
- Infectious Disease Prevention and Control Unit, Health Promotion and Disease Prevention Directorate, Department of Health Regulation, Ministry for Health, Gwardamangia, Malta
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- stichting hiv monitoring, Amsterdam, the Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc van der Valk
- stichting hiv monitoring, Amsterdam, the Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Eline Op de Coul
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Robert Whittaker
- Section for Respiratory, Blood-borne and Sexually Transmitted Infections, Department of Infection Control and Vaccines, Norwegian Institute of Public Health, Oslo, Norway
| | - Hilde Kløvstad
- Section for Respiratory, Blood-borne and Sexually Transmitted Infections, Department of Infection Control and Vaccines, Norwegian Institute of Public Health, Oslo, Norway
| | - Małgorzata Stępień
- Department of Infectious Disease Epidemiology and Surveillance, National Institute of Public Health NIH – National Research Institute, Warsaw, Poland
| | - Magdalena Rosińska
- Department of Infectious Disease Epidemiology and Surveillance, National Institute of Public Health NIH – National Research Institute, Warsaw, Poland
| | - Cristina Valente
- Department of Infectious Diseases, Hospitais da Universidade de Coimbra, Directorate General of Health, Coimbra, Portugal
| | - Rui Tato Marinho
- Centro Hospitalar Universitário Lisboa Norte, Medical School of Lisbon, Directorate General of Health, Ministry of Health, Lisbon, Portugal
| | - Odette Popovici
- National Centre for Surveillance and Control of Communicable Diseases, National Institute of Public Health Romania, Bucharest, Romania
| | - Mária Avdičová
- Department of Epidemiology, Regional Authority of Public Health in Banská Bystrica, Banská Bystrica, Slovakia
| | - Jana Kerlik
- Department of Epidemiology, Regional Authority of Public Health in Banská Bystrica, Banská Bystrica, Slovakia
| | - Irena Klavs
- National Institute of Public Health, Ljubljana, Slovenia
| | - Mojca Maticic
- Clinic for Infectious Diseases, University Medical Centre Ljubljana and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Asuncion Diaz
- National Centre of Epidemiology, Carlos III Health Institute, CIBER in Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - Julia del Amo
- Division for HIV, STI, Viral Hepatitis and Tuberculosis Control, Ministry of Health, Madrid, Spain
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Cozma EC, Banciu LM, Soare C, Găman MA, Voiculescu VM. Vasculitis-Like Hemorrhagic Herpes Zoster and HIV Infections: An Intricate Association. Cureus 2023; 15:e50609. [PMID: 38226125 PMCID: PMC10788595 DOI: 10.7759/cureus.50609] [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: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
Herein, we report the case of a 69-year-old patient who presented to our dermatology clinic for a skin eruption characterized by grouped hemorrhagic vesicles and erosions covered by hemorrhagic crusts on an erythematous background located on the lower right limb. The lesions were small, clustered, and variable in size (diameters between one and 10 mm) and located at the level of the L4-L5 dermatomes. The rash had started three to five days after the complete COVID-19 vaccination scheme with the BNT162b2 Pfizer BioNTech vaccine and had been accompanied by a flu-like syndrome. The histopathological examination established the diagnosis of leukocytoclastic vasculitis potentially in the context of a cytopathic zoster phenomenon. The atypical aspect of the zosterian eruption required additional laboratory work-up to identify possible causes of immunosuppression, i.e., screening for the presence of the human immunodeficiency virus (HIV) infection, solid cancers, as well as measurement of serum immunoglobulin concentrations, which revealed that the subject was HIV-positive. Antiviral treatment was started, with a favorable evolution of the lesions, and the patient was referred to an infectious diseases clinic for initiation of antiretroviral therapy (ART).
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Affiliation(s)
- Elena Codruța Cozma
- Pathophysiology, University of Medicine and Pharmacy of Craiova, Craiova, ROU
- Dermatology, Elias Emergency University Hospital, Bucharest, ROU
| | | | - Cristina Soare
- Dermatology, Elias Emergency University Hospital, Bucharest, ROU
| | - Mihnea-Alexandru Găman
- Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest, ROU
- Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Vlad Mihai Voiculescu
- Dermatology, Elias Emergency University Hospital, Bucharest, ROU
- Dermatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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Omar H, Waked I, Elakel W, Salama R, Abdel-Razik W, Elmakhzangy H, Abdel-Rahman YO, Saeed R, Elshafaey A, Ziada DH, Ismail SA, Dabbous HM, Esmat G. Evolution of liver fibrosis after interferon-based anti-hepatitis C virus therapy failure in 3,049 chronic hepatitis C patients without cirrhosis. Arab J Gastroenterol 2023; 24:65-72. [PMID: 36725374 DOI: 10.1016/j.ajg.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/11/2022] [Accepted: 01/03/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND STUDY AIMS Liver fibrosis is the underlying causeof hepatitis C virus (HCV)-related disease progression to endpoints such as cirrhosis, liver failure, and hepatocellular carcinoma. The aim of our study was to assess changes in hepatic fibrosis in patients with chronic HCV who had a fibrosis evaluation at two time points at least six months apart. PATIENTS AND METHODS This was a retrospective cohort study that included patients who had failed interferon therapy and received HCV retreatment with direct-acting antivirals (DAAs) at least six months later. Patients were evaluated previously for fibrosis according to liver biopsy and fibrosis biomarkers were evaluated before pegylated interferon and ribavirin (PEG/RBV) therapy. Fibrosis was re-evaluated with fibrosis-4 (FIB-4) scores before starting DAAs. RESULTS A total of 3,049 patients were included [age 43.47 ± 9.07 years, 55.20 % males] and baseline histopathology showed F1, F2, and F3 in 16.86 %, 46.21 %, and 36.93 %, respectively. The mean time interval between the last dose of previously failed IFN-therapy to the first dose of DAAs was 2.38 (±1.07) years. Overall, there was a significant increase in FIB-4 scores at retreatment times (from 11.71 ± 1.13 to 22.26 ± 1.68, p < 0.001). Patients with baseline FIB-4 < 1.45 (n = 1,569) and between 1.45 and 3.25 (n = 1,237) had significant increases in their FIB-4 at the retreatment time point [median difference; 0.41 (0.91) and 0.24 (1.5), p < 0.001, respectively], whereas patients with FIB-4 > 3.25 had significant reduction of their FIB-4 score at a retreatment timepoint [-0.98 (2.93), p ≤ 0.001]. CONCLUSION Fibrosis progressed in most patients, even within six months for some patients, and this indicates retreatment of non-system vascular resistance patients even if they do not have significant fibrosis.
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Affiliation(s)
- Heba Omar
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt.
| | - Imam Waked
- Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El Kom, Egypt
| | - Wafaa Elakel
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt
| | - Rabab Salama
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt
| | - Wael Abdel-Razik
- Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El Kom, Egypt
| | - Hesham Elmakhzangy
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt
| | | | | | - Arwa Elshafaey
- Public Health and Community Medicine, Cairo University, Cairo, Egypt
| | - Dina H Ziada
- Tropical Medicine and Infectious Disease, Tanta University, Egypt
| | | | - Hany M Dabbous
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Gamal Esmat
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt
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Global change in hepatitis C virus prevalence and cascade of care between 2015 and 2020: a modelling study. Lancet Gastroenterol Hepatol 2022; 7:396-415. [PMID: 35180382 DOI: 10.1016/s2468-1253(21)00472-6] [Citation(s) in RCA: 211] [Impact Index Per Article: 105.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the release of the first global hepatitis elimination targets in 2016, and until the COVID-19 pandemic started in early 2020, many countries and territories were making progress toward hepatitis C virus (HCV) elimination. This study aims to evaluate HCV burden in 2020, and forecast HCV burden by 2030 given current trends. METHODS This analysis includes a literature review, Delphi process, and mathematical modelling to estimate HCV prevalence (viraemic infection, defined as HCV RNA-positive cases) and the cascade of care among people of all ages (age ≥0 years from birth) for the period between Jan 1, 2015, and Dec 31, 2030. Epidemiological data were collected from published sources and grey literature (including government reports and personal communications) and were validated among country and territory experts. A Markov model was used to forecast disease burden and cascade of care from 1950 to 2050 for countries and territories with data. Model outcomes were extracted from 2015 to 2030 to calculate population-weighted regional averages, which were used for countries or territories without data. Regional and global estimates of HCV prevalence, cascade of care, and disease burden were calculated based on 235 countries and territories. FINDINGS Models were built for 110 countries or territories: 83 were approved by local experts and 27 were based on published data alone. Using data from these models, plus population-weighted regional averages for countries and territories without models (n=125), we estimated a global prevalence of viraemic HCV infection of 0·7% (95% UI 0·7-0·9), corresponding to 56·8 million (95% UI 55·2-67·8) infections, on Jan 1, 2020. This number represents a decrease of 6·8 million viraemic infections from a 2015 (beginning of year) prevalence estimate of 63·6 million (61·8-75·8) infections (0·9% [0·8-1·0] prevalence). By the end of 2020, an estimated 12·9 million (12·5-15·4) people were living with a diagnosed viraemic infection. In 2020, an estimated 641 000 (623 000-765 000) patients initiated treatment. INTERPRETATION At the beginning of 2020, there were an estimated 56·8 million viraemic HCV infections globally. Although this number represents a decrease from 2015, our forecasts suggest we are not currently on track to achieve global elimination targets by 2030. As countries recover from COVID-19, these findings can help refocus efforts aimed at HCV elimination. FUNDING John C Martin Foundation, Gilead Sciences, AbbVie, ZeShan Foundation, and The Hepatitis Fund.
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The global NAFLD policy review and preparedness index: Are countries ready to address this silent public health challenge? J Hepatol 2022; 76:771-780. [PMID: 34895743 DOI: 10.1016/j.jhep.2021.10.025] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/05/2021] [Accepted: 10/28/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent, yet largely underappreciated liver condition which is closely associated with obesity and metabolic disease. Despite affecting an estimated 1 in 4 adults globally, NAFLD is largely absent on national and global health agendas. METHODS We collected data from 102 countries, accounting for 86% of the world population, on NAFLD policies, guidelines, civil society engagement, clinical management, and epidemiologic data. A preparedness index was developed by coding questions into 6 domains (policies, guidelines, civil awareness, epidemiology and data, NAFLD detection, and NAFLD care management) and categorising the responses as high, medium, and low; a multiple correspondence analysis was then applied. RESULTS The highest scoring countries were India (42.7) and the United Kingdom (40.0), with 32 countries (31%) scoring zero out of 100. For 5 of the domains a minority of countries were categorised as high-level while the majority were categorised as low-level. No country had a national or sub-national strategy for NAFLD and <2% of the different strategies for related conditions included any mention of NAFLD. National NAFLD clinical guidelines were present in only 32 countries. CONCLUSIONS Although NAFLD is a pressing public health problem, no country was found to be well prepared to address it. There is a pressing need for strategies to address NAFLD at national and global levels. LAY SUMMARY Around a third of the countries scored a zero on the NAFLD policy preparedness index, with no country scoring over 50/100. Although NAFLD is a pressing public health problem, a comprehensive public health response is lacking in all 102 countries. Policies and strategies to address NAFLD at the national and global levels are urgently needed.
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Levander XA, Vega TA, Seaman A, Korthuis PT, Englander H. Utilising an access to care integrated framework to explore the perceptions of hepatitis C treatment of hospital-based interventions among people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103356. [PMID: 34226111 PMCID: PMC8568624 DOI: 10.1016/j.drugpo.2021.103356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Gaps remain in the hepatitis C virus (HCV) care cascade for people who use drugs (PWUD). Acute medical or surgical illnesses requiring hospitalisation are an opportunity to address addiction, but how inpatient strategies could affect HCV care accessibility for PWUD remains unknown. We explored patient perspectives of hospital-based interventions using an integrated framework of access to HCV care. METHODS We conducted a qualitative study of hospitalised adults (n=27) with HCV and addiction admitted to an urban academic medical centre in the United States between June and November 2019. Individual interviews were audio-recorded, transcribed, and dual-coded. We analysed data with coding specific for hospital-based interventions including screening, conducting HCV-related laboratory work-up, starting treatment, connecting with peers, and coordinating outpatient care. We analysed coded data at the semantic level for emergent themes using a framework approach based off an integrated framework of access to HCV care. RESULTS The majority of participants primarily used opioids (78%), were white (85%) and men (67%). Participants frequently reported HCV screening during previous hospitalisation with rare inpatient connection to HCV-related services. Participants expressed willingness to discuss HCV treatment candidacy during hospitalisation; however, lack of inpatient conversations led to perception that "nothing could be done" during admission. Participants expressed interest in completing inpatient HCV work-up to "get the ball rollin'" - consolidating care would enhance outpatient service permeability by reducing barriers. Others resisted HCV care coordination, preferring to focus on "immediate" issues including health conditions and addiction treatment. Participants also expressed openness to engaging with peers about HCV, noting shared drug use experience as critical to a peer relationship when discussing HCV. CONCLUSION Hospitalised PWUD have varied priorities, necessitating adaptable interventions for addressing HCV. Hospitalisation can be an opportunity to address HCV access to care including identification of treatment eligibility, consolidation of care, and facilitation of HCV-related referrals.
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Affiliation(s)
- Ximena A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239 United States.
| | - Taylor A Vega
- School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States
| | - Andrew Seaman
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239 United States; Central City Concern, 232 NW 6th Ave., Portland, OR, 97209, United States
| | - P Todd Korthuis
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239 United States
| | - Honora Englander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239 United States; Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239 United States
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Ward Z, Mafirakureva N, Stone J, Keevans M, Betts-Symonds G, Crowley D, McHugh T, Avramovic G, Lambert JS, Vickerman P. Cost-effectiveness of mass screening for Hepatitis C virus among all inmates in an Irish prison. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103394. [PMID: 34412938 DOI: 10.1016/j.drugpo.2021.103394] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/05/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND In Irish prisons, there is a high proportion of people who inject drugs (PWID; 26%) and a high prevalence of HCV (16%), making prison a high priority setting for HCV testing and treatment. We evaluate the cost-effectiveness of a mass HCV screening intervention in Mountjoy Prison, Dublin, compared to the standard-of-care of intermittent screening on committal. METHODS Primary cost data was collected from the intervention using an overall provider perspective. Standard-of-care (SOC) costs were estimated through interview. All costs were inflated to 2020 Euros. An HCV transmission and disease progression model among incarcerated and community PWID and ex-injectors was calibrated to the Dublin HCV epidemic, allowing inclusion of population-level health benefits. The model used intervention data, suggesting 419 individuals were screened, 50 HCV infections diagnosed and 32 individuals initiated treatment, to project the resulting costs and health benefits (quality adjusted life years or QALYs) over 50 years with 5% discounting. The incremental cost effectiveness ratio (ICER), cost per QALY gained, was estimated for the screening intervention compared to the standard-of-care. Probabilistic sensitivity analyses (PSA) determined the probability that the intervention was cost-effective compared to a willingness-to-pay threshold of €30,000/QALY as used in Ireland. The ICER for 1- or 3-yearly mass screening in all Dublin prisons was also calculated. RESULTS The total direct costs of the intervention (not including treatment drug costs) was €82,392, with most costs being due to staff (43%) and overhead or management costs (38%). Despite having little epidemiological impact due to the small numbers treated, over 50 years the incremental cost of the intervention was €36,592 and 3.8 QALYs were gained, giving a mean ICER of €9,552/QALY. The majority (84%) of PSA runs were below the willingness-to-pay threshold. Yearly mass screening had an ICER of €2,729/QALY compared to SOC and gave a higher net monetary benefit (€7,393,382) than screening every 3 years (€6,252,816). CONCLUSION Prison mass screening could be a cost-effective initiative for increasing testing and treatment of HCV in Ireland.
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Affiliation(s)
- Zoe Ward
- University of Bristol, Bristol, United Kingdom.
| | | | - Jack Stone
- University of Bristol, Bristol, United Kingdom
| | - Mary Keevans
- Irish Prison Service, Dublin, Republic of Ireland
| | - Graham Betts-Symonds
- Irish Prison Service, Dublin, Republic of Ireland; Irish Red Cross, Dublin, Republic of Ireland
| | - Desmond Crowley
- Irish College of General Practitioners, Dublin, Republic of Ireland
| | - Tina McHugh
- Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - Gordana Avramovic
- School of Medicine, University College Dublin, Dublin, Republic of Ireland
| | - John S Lambert
- Mater Misericordiae University Hospital, Dublin, Republic of Ireland; School of Medicine, University College Dublin, Dublin, Republic of Ireland
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9
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Telemedicine and decentralized hepatitis C treatment as a strategy to enhance retention in care among people attending drug treatment centres. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103235. [PMID: 33838399 DOI: 10.1016/j.drugpo.2021.103235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND People attending drug treatment centres have a high burden of hepatitis C virus (HCV) and face barriers to diagnosis and treatment. Dried blood spot (DBS) testing has been proposed to simplify diagnosis, but many patients remain untreated. In this retrospective study, we evaluated the reasons for non-retention in care in an intervention using on-site DBS testing and the effect of telemedicine and decentralized care compared to standard of care among people attending drug treatment centres who were lost to follow-up. METHODS In a first phase, retention in care, adherence to treatment, and predictive factors in the DBS testing program of patients in drug treatment centres were analyzed and compared to a cohort of patients treated at the hospital outpatient clinic. Subsequently, in a second phase we evaluated in patients lost to follow-up from drug treatment centres the efficacy of one-step testing and telemedicine linked to a decentralized dispensation of HCV treatment or standard of care. RESULTS Among 512 patients attending drug treatment centres, 467 (91.2%) agreed to be tested and 53.4% (237 patients/444 valid tests) tested positive (46 ± 9 years, 87.3% male) for HCV antibodies. After excluding patients negative for RNA or under surveillance, 178 patients were scheduled to meet with a specialist. Overall, 44 patients did not attend and 25 did not complete the pre-treatment evaluation. The only factor associated with retention in care was patient's knowledge of HCV infection. Treated patients attending drug treatment centres (n = 68) compared to the hospital outpatient clinic cohort (n = 135) had lower rates of treatment adherence. Among the patients who attended drug treatment centres that were lost to follow-up (n = 69), the proportion of patients who completed the program was significantly higher among those assisted by telemedicine than by standard of care (62.5% vs. 24.3%, p = 0.002). CONCLUSION Although there was a high participation rate in a DBS testing program in drug treatment centres, non-retention in care is a challenge. Importantly, telemedicine linked to a decentralized dispensation of HCV treatment re-engages patients and may be effective for HCV microelimination.
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10
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Maticic M, Pirnat Z, Leicht A, Zimmermann R, Windelinck T, Jauffret-Roustide M, Duffell E, Tammi T, Schatz E. The civil society monitoring of hepatitis C response related to the WHO 2030 elimination goals in 35 European countries. Harm Reduct J 2020; 17:89. [PMID: 33213481 PMCID: PMC7678126 DOI: 10.1186/s12954-020-00439-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) account for the majority of new cases of hepatitis C virus (HCV) infection in Europe; however, HCV testing, and treatment for PWID remain suboptimal. With the advent of direct acting antivirals (DAAs) the World Health Organization (WHO) adopted a strategy to eliminate HCV as public health threat by 2030. To achieve this, key policies for PWID must be implemented and HCV continuum of care needs to be monitored. This study presents results of the first monitoring led by civil society that provide harm reduction services for PWID. METHODS In 2019, harm reduction civil society organizations representing focal points of Correlation-European Harm Reduction Network in 36 European countries were invited to complete a 27-item online survey on four strategic fields: use/impact of guidelines on HCV testing and treatment for PWID, availability/functioning of continuum of care, changes compared to the previous year and, the role of harm reduction services and non-governmental organizations (NGOs) of PWID. A descriptive analysis of the responses was undertaken. RESULTS The response rate was 97.2%. Six countries reported having no guidelines on HCV treatment (17.1%). Twenty-three (65.7%) reported having treatment guidelines with specific measures for PWID; guidelines that impact on accessibility to HCV testing/treatment and improve access to harm reduction services in 95.6% and 86.3% of them, respectively. DAAs were available in 97.1% of countries; in 26.4% of them they were contraindicated for active drug users. HCV screening/confirmatory tests performed at harm reduction services/community centers, prisons and drug dependence clinics were reported from 80.0%/25.7%, 60.0%/48.6%, and 62.9%/34.3% of countries, respectively. Provision of DAAs at drug dependence clinics and prisons was reported from 34.3 to 42.9% of countries, respectively. Compared to the previous year, HCV awareness campaigns, testing and treatment on service providers' own locations were reported to increase in 42.9%, 51.4% and 42.9% of countries, respectively. NGOs of PWID conducted awareness campaigns on HCV interventions in 68.9% of countries, and 25.7% of countries had no such support. CONCLUSION Further improvements in continuum-of-care interventions for PWID are needed, which could be achieved by including harm reduction and PWID organizations in strategic planning of testing and treatment and in efforts to monitor progress toward WHO 2030 elimination goal.
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Affiliation(s)
- M Maticic
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia. .,Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia.
| | - Z Pirnat
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - R Zimmermann
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | | | | | - E Duffell
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - E Schatz
- Correlation-European Harm Reduction Network, Amsterdam, The Netherlands
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11
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Zhang J, Liu X, Wu J, Zhou W, Tian J, Guo S, Jia SS, Meng Z, Ni M. A bioinformatics investigation into the pharmacological mechanisms of the effect of the Yinchenhao decoction on hepatitis C based on network pharmacology. BMC Complement Med Ther 2020; 20:50. [PMID: 32050950 PMCID: PMC7076901 DOI: 10.1186/s12906-020-2823-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/20/2020] [Indexed: 12/29/2022] Open
Abstract
Background Globally, more than 170 million people are infected with hepatitis C virus, a major cause of cirrhosis and hepatocellular carcinoma. The Yinchenhao Decoction (YCHD) is a classic formula comprising three herbal medicines. This decoction have long been used in China for clinically treating acute and chronic infectious hepatitis and other liver and gallbladder damp heat-accumulation disorders. Methods In this study, we identified 32 active ingredients and 200 hepatitis C proteins and established a compound-predicted target network and a hepatitis C protein–protein interaction network by using Cytoscape 3.6.1. Then, we systematically analyzed the potential targets of the YCHD for the treatment of hepatitis C. Finally, molecular docking was applied to verify the key targets. In addition, we analyzed the mechanism of action of the predicted targets by the Kyoto Encyclopedia of Genes and Genomes and gene ontology analyses. Results This study adopted a network pharmacology approach, mainly comprising target prediction, network construction, module detection, functional enrichment analysis, and molecular docking to systematically investigate the mechanisms of action of the YCHD in hepatitis C. The targets of the YCHD in the treatment of hepatitis C mainly involved PIK3CG, CASP3, BCL2, CASP8, and MMP1. The module and pathway enrichment analyses showed that the YCHD had the potential to influence varieties of biological pathways, including the TNF signaling pathway, Ras signaling pathway, PI3K-Akt signaling pathway, FoxO signaling pathway, and pathways in cancer, that play an important role in the pathogenesis of hepatitis C. Conclusion The results of this study preliminarily verified the basic pharmacological effects and related mechanisms of the YCHD in the treatment of hepatitis C.
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Affiliation(s)
- Jingyuan Zhang
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Xinkui Liu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Jiarui Wu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China.
| | - Wei Zhou
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 222 Tianshui South Road, Lanzhou City, China
| | - Siyu Guo
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Shan Shan Jia
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Ziqi Meng
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Mengwei Ni
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
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12
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Elimination of hepatitis C in Europe: can WHO targets be achieved? Clin Microbiol Infect 2020; 26:818-823. [PMID: 31978546 DOI: 10.1016/j.cmi.2020.01.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/04/2020] [Accepted: 01/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection affects 71 million people worldwide. The availability of highly efficient direct-acting antivirals has revolutionized the treatment landscape with over 95% cure rates. The WHO has launched a global programme to achieve rather ambitious HCV elimination targets for 2030. OBJECTIVES This article aims to provide a critical overview of the current HCV elimination programmes in Europe highlighting the elements that should be implemented to achieve elimination and those that are already in place to promote this process. SOURCES Review of the recently published literature and opinion of experts in the field. CONTENT Elimination of hepatitis C as a public health threat appears to be a difficult task, which should be subdivided into smaller targets, the so-called micro-elimination goals, to increase chances of success. Macro-elimination strategies based on mass-screening are difficult to implement. Evidence supporting the efficacy of micro-elimination comes from key populations, such as people who inject drugs. HCV elimination is proceeding at different speeds in Europe. Some countries are on target with the WHO's objectives whereas others lack economic support and political advocacy, and have insufficient infrastructures to achieve this. The absence of an effective prophylactic vaccine is hampering the process and should be overcome. IMPLICATIONS Elimination of hepatitis C worldwide appears plausible, but in several countries probably not within the time frame suggested by the WHO. In the absence of vaccination, universal access to HCV treatment would act as a 'therapeutic' option to reduce transmission, especially in high-risk populations.
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13
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Marcellin F, Roux P, Lazarus JV, Rolland B, Carrieri P. France removes hepatitis C treatment prescriber restrictions-But what is the impact of the delay for key populations? Liver Int 2019; 39:2418-2419. [PMID: 31436366 DOI: 10.1111/liv.14208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Fabienne Marcellin
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France.,ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Perrine Roux
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France.,ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), CH Le Vinatier, Université de Lyon, UCBL, Bron, France
| | - Patrizia Carrieri
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France.,ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
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14
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Lazarus JV, Pericàs JM, Picchio C, Cernosa J, Hoekstra M, Luhmann N, Maticic M, Read P, Robinson EM, Dillon JF. We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade. J Intern Med 2019; 286:503-525. [PMID: 31472002 DOI: 10.1111/joim.12972] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.
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Affiliation(s)
- J V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J M Pericàs
- Infectious Diseases and Clinical Microbiology Territorial Direction, Translational Research Group on Infectious Diseases of Lleida (TRIDLE), Biomedical Research Institute Dr Pifarré Foundation, Lleida, Spain
| | - C Picchio
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J Cernosa
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M Hoekstra
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - N Luhmann
- Médecins du Monde France, Paris, France
| | - M Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Read
- Kirketon Road Centre, Sydney, NSW, Australia
| | - E M Robinson
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - J F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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