Seroprevalence of HCV and HIV infections by year of birth in Spain: impact of US CDC and USPSTF recommendations for HCV and HIV testing

Hepatitis C and HIV combined screening in primary care: A cluster randomized trial

Hepatitis C virus (HCV) and HIV are major causes of worldwide disease. We aimed to evaluate the effect of a combined screening programme, which included a risk-assessment questionnaire and rapid tests for point-of-care diagnosis, on screening and new diagnosis rates. This prospective, cluster randomized study was carried out in primary care. The intervention arm included a 4-hour educational programme, the use of a risk-assessment questionnaire and rapid tests. In the control centres, only the educational intervention was provided. The main variables compared were the screening coverage and the number and rate of new HCV and HIV diagnoses. Of a total of 7991 participants, 4670 (58.5%) and 2894 (36.2%) presented a risk questionnaire for HIV or HCV, respectively. The younger participants, men and those from Latin America and Eastern Europe, showed the greatest risk of presenting with a positive questionnaire. The overall screening coverage was higher within the intervention arm (OR 17.7; 95% CI 16.2-19.5; P < .001). Only two HIV-positives were identified compared to one in control centres. The rate of HCV diagnoses was higher among intervention centres, with 37 versus seven positive tests (OR 5.2; 95% CI 2.3-11.6; P < .001). Of them, 10 were new diagnoses and 27 had been previously diagnosed, although not linked to care. In conclusion, a simple operational programme can lead to an increase in HCV and HIV screening rates, compared to an exclusively educational programme. The selection of at-risk patients with a self-questionnaire and the use of rapid tests significantly increased the diagnostic rate of HCV infection.

Significant decrease in the prevalence of hepatitis C infection after the introduction of direct acting antivirals

BACKGROUND AND AIM

Accurate information on the epidemiology of hepatitis C and B infection is mandatory to establish a national/regional plan. We aim to update the prevalence of hepatitis C and B infection in Catalonia using point-of-care tests to analyze the risk factors related and to implement a linkage-to-care circuit.

METHODS

This is a community-based study. A random list of adult individuals was retrieved from censuses of primary care centers. Point-of-care tests for anti-hepatitis C virus (HCV) and HBV surface antigen (HBsAg) and a questionnaire for risk factor assessment were performed. Positive results were validated and a circuit for linkage-to-care was established.

RESULTS

A total of 3328 individuals were included. The anti-HCV and HBsAg overall prevalence were lower than expected [1.02%, 95% confidence interval (CI) 0.65-1.39; and 0.52%, 95% CI 0.26-0.77, respectively]. Anti-HCV positive subjects were mostly (88%) autochthonous. The prevalence increased with age; only 12% were under age 40. The associated risk factors were drug use, blood transfusion, relative with HCV, and diabetes. Notably, the prevalence of active infection was only 0.49% (95% CI 0.23-0.74), 40% less than previously reported, reflecting the impact of direct acting antiviral therapy. Differently, HBsAg positive subjects were mostly foreign migrants (53%) with no other risk factors. Despite the implementation of a linkage-to-care circuit, one third of HBsAg positive subjects were lost.

CONCLUSIONS

The prevalence of HCV infection was lower than previously reported, showing a strong impact of direct acting antiviral therapy in the last years. Because of hepatitis B universal vaccination, HBV infection in Catalonia is mainly associated with migrant population. Linkage-to-care in patients with hepatitis B was challenging and warrants additional efforts.

Geographic analysis and estimation of hepatitis C cases in migrant populations living in Spain: is a country-based screening strategy appropriate?

BACKGROUND

Spain needs to increase the number of new known cases in order to achieve the goal of eliminating hepatitis C virus (HCV) by 2030. The aim of this study was to estimate the number of HCV cases among the migrant population in Spain and propose different scenarios for micro-elimination strategies, targeting the most relevant migrant groups.

METHODOLOGY

this epidemiological and demographic cross-sectional descriptive study employed a systematic approach to estimate the number of migrants infected by HCV in Spain. Estimates are based on demographic data and details the size of the foreign-born population living in every Spanish province and the anti-HVC+ prevalence rates in their respective countries of origin.

RESULTS

in Spain, there are 100,268 estimated cases of anti-HCV+ among the total adult migrant population who live in the country. The estimated cases of anti-HCV+ among migrants from moderate-high endemic countries with a prevalence of ≥ 2%, > 3%, > 4% and > 5% are 48,979, 48,029, 24,176 and 15,646, respectively. The anti-HCV+ endemic countries (≥ 2%) that contribute to the highest number of estimated cases in Spain are Romania, Italy, Pakistan, Ukraine, Senegal, Russia and Nigeria. The autonomous communities with the highest prevalence and number of estimated anti-HCV+ cases among migrant population are Catalonia, Valencian Community, Madrid and Andalusia, respectively.

CONCLUSION

these data show the need to establish HCV screening strategies for the migrant population in Spain and, particularly, in the most affected areas. The strategy should target those migrant communities with a higher prevalence and a higher number of estimated cases, such as people from Eastern Europe, Sub-Saharan Africa and Pakistan.

Hepatitis B and C testing strategies in healthcare and community settings in the EU/EEA: A systematic review

An estimated 9 million individuals are chronically infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) across the European Union/European Economic Area (EU/EEA), many of which are yet to be diagnosed. We performed a systematic review to identify interventions effective at improving testing offer and uptake in the EU/EEA. Original research articles published between 1 January 2008 and 1 September 2017 were retrieved from PubMed and EMBASE. Search strings combined terms for HBV/HCV, intervention, testing and geographic terms (EU/EEA). Out of 8331 records retrieved, 93 studies were selected. Included studies reported on testing initiatives in primary health care (9), hospital (12), other healthcare settings (31) and community settings (41). Testing initiatives targeted population groups such as migrants, drug users, prisoners, pregnant women and the general population. Testing targeted to populations at higher risk yielded high coverage rates in many settings. Implementation of novel testing approaches, including dried blood spot (DBS) testing, was associated with increased coverage in several settings including drug services, pharmacies and STI clinics. Community-based testing services were effective in reaching populations at higher risk for infection, vulnerable and hard-to-reach populations. In conclusion, our review identified several successful testing approaches implemented in healthcare and community settings, including testing approaches targeting groups at higher risk, community-based testing services and DBS testing. Combining a diverse set of testing opportunities within national testing strategies may lead to higher impact both in terms of testing coverage and in terms of reduction, on the undiagnosed fraction.

Healthcare value of implementing hepatitis C screening in the adult general population in Spain

BACKGROUND

Elimination of hepatitis C virus (HCV) infection requires high diagnostic rates and universal access to treatment. Around 40% of infected individuals are unaware of their infection, which indicates that effective screening strategies are needed. We analyzed the efficiency (incremental cost-utility ratio, ICUR) of 3 HCV screening strategies: a) general population of adults, b) high-risk groups, and c) population with the highest anti-HCV prevalence plus high-risk groups.

METHODS

An analytical decision model, projecting progression of the disease over a lifetime, was used to establish the candidate population for HCV screening. HCV data were obtained from the literature: anti-HCV prevalence (0.56%-1.54%), viremic patients (31.5%), and percentage of undiagnosed persons among those with viremia (35%). It was assumed that most patients would be treated and have HCV therapy response (98% SVR); transition probabilities, utilities, and disease management annual costs were obtained from the literature. Efficiency over the life of patients under the National Health System perspective was measured as quality-adjusted life years (QALY) and total cost (screening, diagnosis, pharmacological and disease management). A discount rate of 3% was applied to costs and outcomes.

RESULTS

Screening of the adult population would identify a larger number of additional chronic hepatitis C cases (N = 52,694) than screening the highest anti-HCV prevalence population plus high-risk groups (N = 42,027) or screening high-risk groups (N = 26,128). ICUR for the general population vs. high-risk groups was €8914/QALY gained per patient (€18,157 incremental cost and 2.037 QALY). ICUR for the general population vs. population with highest anti-HCV prevalence plus high-risk groups was €7,448/QALY gained per patient (€7,733 incremental cost and 1.038 QALY). These ICUR values are below the accepted efficiency threshold (€22,000-€30,000).

CONCLUSION

HCV screening and treatment of the general adult population is cost-effective compared to screening of high-risk groups or the population with the highest anti-HCV prevalence plus high-risk groups.

Screening of hepatitis C virus infection in adult general population in Spain

PURPOSE

The aim was to estimate seroprevalence and prevalence of hepatitis C virus (HCV) infection in a small health area of the Valencian Community, Spain.

PATIENTS AND METHODS

This is a descriptive cross-sectional study aimed at estimation of HCV infection prevalence in the whole adult population (25-70 years old), that is, a pilot study for an eventual population-based screening program.

RESULTS

A total of 5849 participants aged 25-70 years (51% male) were invited to participate by regular mail. Overall, 143 letters were returned owing to errors in the addresses. Of 5706 participants, 2637 (46.2%) participated in the study. Rapid test of anti-HCV antibody detection was positive in 30 cases (HCV seroprevalence 1.14%, 95% confidence intervals: 0.73-1.55%). Of those, seven were not aware of their condition. Participants who had a positive result in the rapid test of anti-HCV detection were given a confirmatory test by enzyme immune assay, and all had a positive result. RNA-HCV determination by quantitative PCR in positive anti-HCV patients showed positive viremia in 13 (43.3%) cases, of which five were not aware of the disease. Of the 17 patients who had negative viremia, two were unaware of their HCV status, one was a carrier of anti-HCV and was already aware of his condition, and 14 had been previously treated with satisfactory results. Regarding fibrosis, of the seven patients who were unaware of HCV infection, none of them had significant fibrosis. Moreover, 26 (86.7%) anti-HCV positive patients were reported to have one or more risk factors for HCV infection.

CONCLUSION

HCV screening strategies applied to the general population are good means to diagnose and treat patients who are not aware of their infection, avoiding new transmissions as well as disease progression.

Cost-effectiveness of novel treatment of hepatitis C virus in Lebanese patients

Background Limited data is available on Hepatitis C disease prevalence, treatment initiation and its cost-effectiveness in Lebanon and the whole Middle East. Objective The aim of the study is to assess whether initiation of novel Direct Acting Antiviral agents (DAAs) at early stage of hepatitis C is cost-effective in Lebanese patients. Setting Lebanon. Methods This modeling study was conducted from the perspective of Lebanese third party payers, where existing practice is based on international guidelines for the diagnosis and treatment of diseases. The model assessed cost-effectiveness of early versus delayed DAAs treatment in a standard patient upon HCV diagnosis. Medical costs were valued using in-house database. Main outcome measures Incremental Cost-Effectiveness Ratio (ICER) per QALY and per life-year extended. Results Treatment at early HCV disease stage has led to an ICER of 587 euro per QALY gained throughout the course of the disease. Outcomes of early treatment with DAAs upon HCV diagnosis led to an incremental cost of 27,268 euro per QALY gained at first year of treatment, and of 1527 euro per additional life-year extended. Sensitivity analysis showed that a 25% decrease in the cost of dual drug option resulted in a decrease of incremental cost to 16,982 euro per QALY gained at first year of treatment with DAAs upon early HCV diagnosis. Conclusion Decision makers are encouraged to reinforce the need to screen for HCV and initiate novel treatment at early disease stage in the Lebanese healthcare system.

Real life experience with direct-acting antivirals agents against hepatitis C infection in elderly patients

BACKGROUND

New direct-acting antivirals agents (DAAs) are very safe and well tolerated.

OBJECTIVES

The purpose of this study is to analyse the efficacy and safety of DAAs in elderly patients, who have co-morbidities and are on chronic medications.

STUDY DESIGN

All HCV-infected patients over 65 years old in clinical follow-up at two Hospitals in Spain who initiated anti-HCV therapy were included (August 2012-October 2015).

RESULTS

A total of 120 HCV mono-infected patients were recorded. Mean age of patients was 72.6±7.4years. There were 53.3% women and GT1b was the most frequent (83.3%); 64.2% had cirrhosis and 42.5% were treatment experienced. Ombitasvir+Paritaprevir/r±Dasabuvir±Ribavirin (RBV) and sofosbuvir/ledipasvir±RBV were the most frequently used regimens. Weight-adjusted dosing of RBV was included in 61.7% and 43.6% of them required a dose reduction. Most of the patients (86.7%) had concomitant chronic medication and in 35.8% adjustment was necessary. Adverse events (AE) were seen in 65% of the patients; more frequent when a protease inhibitor (PI) was being used. The sustained virological response (SVR12) per ITT was 88.3%. Only 3 patients discontinued treatment and 2 patients died.

CONCLUSIONS

High rates of SVR12 (88.3%) were observed among elderly patients with DAAs-based regimens. The presence of AE was frequent (65%). The majority of these patients (86.7%) had concomitant medication that required adjustment in 1/3 of them. These findings highlight the high rates of response to DAAs in the elderly HCV-population. However, special caution must be taken when using RBV and a PI.

Trends in hospital admissions, re-admissions, and in-hospital mortality among HIV-infected patients between 1993 and 2013: Impact of hepatitis C co-infection

BACKGROUND

New patterns in epidemiological characteristics of people living with HIV infection (PLWH) and the introduction of Highly Active Antiretroviral Therapy (HAART) have changed the profile of hospital admissions in this population. The aim of this study was to evaluate trends in hospital admissions, re-admissions, and mortality rates in HIV patients and to analyze the role of HCV co-infection.

METHODS

A retrospective cohort study conducted on all hospital admissions of HIV patients between 1993 and 2013. The study time was divided in two periods (1993-2002 and 2003-2013) to be compared by conducting a comparative cross-sectional analysis.

RESULTS

A total of 22,901 patient-years were included in the analysis, with 6917 hospital admissions, corresponding to 1937 subjects (75% male, mean age 36±11 years, 37% HIV/HCV co-infected patients). The median length of hospital stay was 8 days (5-16), and the 30-day hospital re-admission rate was 20.1%. A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period (2003-2013), but there was an increase in those related with malignancies, cardiovascular, gastrointestinal, and chronic respiratory diseases. In-hospital mortality remained high (6.8% in the first period vs. 6.3% in the second one), with a progressive increase of non-AIDS-defining illness deaths (37.9% vs. 68.3%, P<.001). The admission rate significantly dropped after 1996 (4.9% yearly), but it was less pronounced in HCV co-infected patients (1.7% yearly).

CONCLUSIONS

Hospital admissions due to infectious and psychiatric disorders have decreased, with a significant increase in non-AIDS-defining malignancies, cardiovascular, and chronic respiratory diseases. In-hospital mortality is currently still high, but mainly because of non-AIDS-defining illnesses. HCV co-infection increased the hospital stay and re-admissions during the study period.