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Martinello M, Bhagani S, Shaw D, Orkin C, Cooke G, Gane E, Iser D, Ustianowski A, Kulasegaram R, Stedman C, Tu E, Grebely J, Dore GJ, Nelson M, Matthews GV. Glecaprevir-pibrentasvir for 4 weeks among people with recent HCV infection: The TARGET3D study. JHEP Rep 2023; 5:100867. [PMID: 37771545 PMCID: PMC10522905 DOI: 10.1016/j.jhepr.2023.100867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 09/30/2023] Open
Abstract
Background & Aims Short duration treatment may aid HCV elimination among key populations. This study evaluated the efficacy of glecaprevir-pibrentasvir for 4 weeks among people with recent HCV infection. Methods In this single-arm multicentre international trial, adults with recent HCV (duration of infection <12 months) received glecaprevir-pibrentasvir 300 mg-120 mg daily for 4 weeks. Primary infection was defined as a first positive anti-HCV antibody and/or HCV RNA measurement within 6 months of enrolment and either acute clinical hepatitis within 12 months (symptomatic illness or alanine aminotransferase >10x the upper limit of normal) or antibody seroconversion within 18 months. Reinfection was defined as new positive HCV RNA within 6 months and prior clearance (spontaneous or treatment). The primary endpoint was sustained virological response at 12 weeks post-treatment (SVR12) in the intention-to-treat (ITT) and per-protocol (PP) populations. Results Twenty-three participants (96% men, 70% HIV, 57% ever injected drugs) received treatment, of whom 74% had genotype 1a infection and 35% recent reinfection. At baseline, median duration of infection was 17 weeks (IQR 11-29) and HCV RNA was 5.8 log10IU/ml (IQR 5.2-6.9). SVR12 was achieved by 78% (18/23; 95% CI 56-93%) and 82% (18/22; 95% CI 60-95%) of the ITT and PP populations, respectively, and in 100% (12/12; 95% CI 74-100%) of participants with baseline HCV RNA ≤6 log10. There were four cases of virological failure (relapse); three received retreatment with 12 weeks sofosbuvir-velpatasvir or grazoprevir-elbasvir (SVR, n = 2; loss to follow-up, n = 1). No serious adverse events were reported. Conclusion While most achieved SVR, the efficacy of a 4-week regimen of glecaprevir-pibrentasvir was lower than observed with longer treatment durations (≥6 weeks) among people with recent HCV. Trial Registration Clinicaltrials.gov Identifier: NCT02634008. Impact and implications Short duration treatment may aid HCV elimination among key populations. This investigator-initiated single-arm multicentre international pilot trial demonstrated that efficacy of glecaprevir-pibrentasvir for 4 weeks among people with recent HCV infection was sub-optimal (SVR12 78% ITT, 82% PP). Baseline HCV RNA appeared to impact response, with higher efficacy among participants with lower baseline HCV RNA (≤6 log10; SVR12 100% ITT, 12/12). While most achieved SVR, the efficacy of 4 weeks of glecaprevir-pibrentasvir was below that seen with longer treatment durations (≥6 weeks).
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Affiliation(s)
- Marianne Martinello
- Kirby Institute, UNSW, Sydney, Australia
- Department of Infectious Diseases, Prince of Wales Hospital, Sydney, Australia
| | - Sanjay Bhagani
- Department of Infectious Diseases/HIV Medicine, Royal Free Hospital, London, UK
| | - David Shaw
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, Australia
| | - Chloe Orkin
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Graham Cooke
- Department of Infectious Diseases, Imperial College NHS Trust, St Mary’s Hospital, London, UK
| | - Edward Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - David Iser
- The Alfred Hospital, Melbourne, Australia Burnet Institute, Melbourne, Australia
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
| | | | | | | | - Elise Tu
- Kirby Institute, UNSW, Sydney, Australia
| | | | - Gregory J. Dore
- Kirby Institute, UNSW, Sydney, Australia
- Department of Infectious Diseases, St Vincent’s Hospital, Sydney, Australia
| | - Mark Nelson
- Chelsea and Westminster Hospital, London, UK
| | - Gail V. Matthews
- Kirby Institute, UNSW, Sydney, Australia
- Department of Infectious Diseases, St Vincent’s Hospital, Sydney, Australia
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Grebely J, Dore GJ, Altice FL, Conway B, Litwin AH, Norton BL, Dalgard O, Gane EJ, Shibolet O, Nahass R, Luetkemeyer AF, Peng CY, Iser D, Gendrano IN, Kelly MM, Hwang P, Asante-Appiah E, Haber BA, Barr E, Robertson MN, Platt H. Reinfection and Risk Behaviors After Treatment of Hepatitis C Virus Infection in Persons Receiving Opioid Agonist Therapy : A Cohort Study. Ann Intern Med 2022; 175:1221-1229. [PMID: 35939812 DOI: 10.7326/m21-4119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) reinfection after successful treatment may reduce the benefits of cure among people who inject drugs. OBJECTIVE To evaluate the rate of HCV reinfection for 3 years after successful treatment among people receiving opioid agonist therapy (OAT). DESIGN A 3-year, long-term, extension study of persons enrolled in the CO-STAR (Hepatitis C Patients on Opioid Substitution Therapy Antiviral Response) study (ClinicalTrials.gov: NCT02105688). SETTING 55 clinical trial sites in 13 countries. PATIENTS Aged 18 years and older with chronic HCV infection with genotypes 1, 4, or 6 receiving stable OAT. INTERVENTION No treatments were administered. MEASUREMENTS Serum samples were assessed for HCV reinfection. Urine drug screening was performed. RESULTS Among 296 participants who received treatment, 286 were evaluable for reinfection and 199 were enrolled in the long-term extension study. The rate of HCV reinfection was 1.7 [95% CI, 0.8 to 3.0] per 100 person-years; 604 person-years of follow-up). A higher rate of reinfection was seen among people with recent injecting drug use (1.9 [95% CI, 0.5 to 4.8] per 100 person-years; 212 person-years). Ongoing drug use and injecting drug use were reported by 59% and 21% of participants, respectively, at the 6-month follow-up visit and remained stable during 3 years of follow-up. LIMITATIONS Participants were required to be 80% adherent to OAT at baseline and may represent a population with higher stability and lower risk for HCV reinfection. Rate of reinfection may be underestimated because all participants did not continue in the long-term extension study; whether participants who discontinued were at higher risk for reinfection is unknown. CONCLUSION Reinfection with HCV was low but was highest in the first 24 weeks after treatment completion and among people with ongoing injecting drug use and needle-syringe sharing. PRIMARY FUNDING SOURCE Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia (J.G., G.J.D.)
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia (J.G., G.J.D.)
| | | | - Brian Conway
- Vancouver Infectious Diseases Centre, Vancouver, British Columbia, Canada (B.C.)
| | - Alain H Litwin
- Prisma Health/University of South Carolina School of Medicine Greenville, and Clemson University, Greenville, South Carolina (A.H.L., B.L.N.)
| | - Brianna L Norton
- Prisma Health/University of South Carolina School of Medicine Greenville, and Clemson University, Greenville, South Carolina (A.H.L., B.L.N.)
| | - Olav Dalgard
- Institute of Clinical Medicine, Akershus University, Oslo, Norway (O.D.)
| | - Edward J Gane
- Auckland City Hospital, Auckland, New Zealand (E.J.G.)
| | - Oren Shibolet
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and Tel Aviv University, Tel Aviv, Israel (O.S.)
| | | | - Anne F Luetkemeyer
- University of California San Francisco, San Francisco, California (A.F.L.)
| | - Cheng-Yuan Peng
- China Medical University Hospital, Taichung, Taiwan (C.Y.P.)
| | - David Iser
- The Alfred Hospital, Melbourne, Victoria, Australia (D.I.)
| | - Isaias Noel Gendrano
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Michelle M Kelly
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Peggy Hwang
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Ernest Asante-Appiah
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Barbara A Haber
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Eliav Barr
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Michael N Robertson
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
| | - Heather Platt
- Merck & Co., Inc., Rahway, New Jersey (I.N.G., M.M.K., P.H., E.A.A., B.A.H., E.B., M.N.R., H.P.)
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Dalgard O, Litwin AH, Shibolet O, Grebely J, Nahass R, Altice FL, Conway B, Gane EJ, Luetkemeyer AF, Peng CY, Iser D, Gendrano IN, Kelly MM, Haber BA, Platt H, Puenpatom A. Health-related quality of life in people receiving opioid agonist treatment and treatment for hepatitis C virus infection. J Addict Dis 2022:1-12. [PMID: 35920743 DOI: 10.1080/10550887.2022.2088978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND In people with chronic hepatitis C virus (HCV) infection, viral eradication is associated with improved health-related quality of life (HRQOL). OBJECTIVE To assess changes in HRQOL among participants receiving opioid agonist therapy undergoing treatment for HCV infection. METHODS COSTAR (NCT02251990) was a randomized, double-blind, placebo-controlled study. Adults with HCV infection on opioid agonist therapy received elbasvir (50 mg)/grazoprevir (100 mg) or placebo for 12 weeks. HRQOL was evaluated using the Medical Outcomes Study 36-Item Short Form Health Survey version 2 (SF-36v2) Acute Form. Participants remained blinded until 4 weeks after end of treatment. RESULTS Overall, 201 participants received elbasvir/grazoprevir and 100 participants received placebo. Treatment difference mean change from baseline scores (elbasvir/grazoprevir minus placebo) indicated an improvement in HRQOL at 4 weeks after end of treatment in participants receiving elbasvir/grazoprevir versus those receiving placebo, driven by declining HRQOL in those receiving placebo and improved HRQOL in certain domains among participants receiving elbasvir/grazoprevir. Notable differences in SF-36v2 scores were evident in the general health (mean treatment difference [MTD], 6.00; 95% CI, 1.37-10.63), vitality (MTD, 6.81; 95% CI, 1.88-11.75), and mental health (MTD, 5.17; 95% CI, 0.52-9.82) domains and in the mental component summary score (mean, 2.83; 95% CI, 0.29-5.37). No notable between-treatment differences were evident at treatment weeks 4 or 12. CONCLUSION HRQOL in patients receiving medication for opioid dependence was improved following treatment for HCV infection with elbasvir/grazoprevir, suggesting that eradication of HCV infection with direct-acting antivirals is associated with improved HRQOL. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT02251990.
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Affiliation(s)
- Olav Dalgard
- Institute of Clinical Medicine, Akershus University, Oslo, Norway
| | - Alain H Litwin
- Prisma Health/University of South Carolina School of Medicine Greenville, Clemson University, Greenville, SC, USA
| | - Oren Shibolet
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | | | - Brian Conway
- Vancouver Infectious Diseases Centre, Vancouver, BC, Canada
| | | | | | | | - David Iser
- The Alfred Hospital, Melbourne, VIC, Australia
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Papaluca T, Craigie A, McDonald L, Edwards A, Winter R, Hoang A, Pappas A, Waldron A, McCoy K, Stoove M, Doyle J, Hellard M, Holmes J, MacIsaac M, Desmond P, Iser D, Thompson A. Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study. Open Forum Infect Dis 2022; 9:ofac350. [PMID: 35949401 PMCID: PMC9356682 DOI: 10.1093/ofid/ofac350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited. Methods We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release. Results Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049). Conclusions Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.
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Affiliation(s)
- T Papaluca
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - A Craigie
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - L McDonald
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - A Edwards
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - R Winter
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
- Burnet Institute , Melbourne, Victoria , Australia
| | - A Hoang
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - A Pappas
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - A Waldron
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - K McCoy
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - M Stoove
- Burnet Institute , Melbourne, Victoria , Australia
- Department of Epidemiology and Preventative Medicine, Monash University , Victoria , Australia
| | - J Doyle
- Burnet Institute , Melbourne, Victoria , Australia
- Department of Epidemiology and Preventative Medicine, Monash University , Victoria , Australia
- Department of Infectious Diseases, The Alfred and Monash University , Melbourne, Victoria , Australia
| | - M Hellard
- Burnet Institute , Melbourne, Victoria , Australia
- Department of Epidemiology and Preventative Medicine, Monash University , Victoria , Australia
- Department of Infectious Diseases, The Alfred and Monash University , Melbourne, Victoria , Australia
| | - J Holmes
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - M MacIsaac
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - P Desmond
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - D Iser
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
| | - A Thompson
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne , Victoria , Australia
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5
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Carson JM, Hajarizadeh B, Hanson J, O'Beirne J, Iser D, Read P, Balcomb A, Davies J, Doyle JS, Yee J, Martinello M, Marks P, Matthews GV, Dore GJ. Retreatment for hepatitis C virus direct acting antiviral therapy virological failure in primary and tertiary settings: the REACH-C cohort. J Viral Hepat 2022; 29:661-676. [PMID: 35583922 PMCID: PMC9542502 DOI: 10.1111/jvh.13705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 12/12/2022]
Abstract
Virological failure occurs in a small proportion of people treated for hepatitis C virus (HCV) with direct-acting antiviral (DAA) therapies. This study assessed retreatment for virological failure in a large real-world cohort. REACH-C is an Australian observational study (n=10843) evaluating treatment outcomes of sequential DAA initiations across 33 health services between March 2016 to June 2019. Virological failure retreatment data were collected until October 2020. Of 408 people with virological failure (81% male; median age 53; 38% cirrhosis; 56% genotype 3), 213 (54%) were retreated once; 15 were retreated twice. A range of genotype specific and pangenotypic DAAs were used to retreat virological failure in primary (n=56) and tertiary (n=157) settings. Following sofosbuvir/velpatasvir/voxilaprevir availability in 2019, the proportion retreated in primary care increased from 21% to 40% and median time to retreatment initiation declined from 294 to 152 days. Per-protocol (PP) sustained virological response (SVR12) was similar for people retreated in primary and tertiary settings (80% vs 81%; p=1.000). In regression analysis, sofosbuvir/velpatasvir/voxilaprevir (vs. other regimens) significantly decreased likelihood of second virological failure (PP SVR12 88% vs. 77%; adjusted odds ratio [AOR] 0.29; 95%CI 0.11-0.81); cirrhosis increased likelihood (PP SVR12 69% vs. 91%; AOR 4.26; 95%CI 1.64-11.09). Indigenous Australians had lower likelihood of retreatment initiation (AOR 0.36; 95%CI 0.15-0.81). Treatment setting and prescriber type were not associated with retreatment initiation or outcome. Virological failure can be effectively retreated in primary care. Expanded access to simplified retreatment regimens through decentralised models may increase retreatment uptake and reduce HCV-related mortality.
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Affiliation(s)
| | | | - Josh Hanson
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- Cairns and Hinterland Hospital and Health ServiceCairnsQueenslandAustralia
| | - James O'Beirne
- Sunshine Coast Hospital and Health ServiceSunshine CoastQueenslandAustralia
- University of the Sunshine CoastSunshine CoastQueenslandAustralia
| | - David Iser
- Scope GastroenterologyMelbourneVictoriaAustralia
| | - Phillip Read
- Kirketon Road CentreSydneyNew South WalesAustralia
| | - Anne Balcomb
- Prince Street MedicalOrangeNew South WalesAustralia
| | - Jane Davies
- Menzies School of Health ResearchDarwinNorthern TerritoryAustralia
- Royal Darwin HospitalDarwinNorthern TerritoryAustralia
| | - Joseph S. Doyle
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Infectious DiseasesThe Alfred and Monash UniversityMelbourneVictoriaAustralia
| | - Jasmine Yee
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | | | - Philippa Marks
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | - Gail V. Matthews
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- St Vincent's HospitalSydneyNew South WalesAustralia
| | - Gregory J. Dore
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- St Vincent's HospitalSydneyNew South WalesAustralia
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Lubel JS, Strasser SI, Thompson AJ, Cowie BC, MacLachlan J, Allard NL, Holmes J, Kemp WW, Majumdar A, Iser D, Howell J, Matthews GV. Australian consensus recommendations for the management of hepatitis B. Med J Aust 2022; 216:478-486. [PMID: 35249220 DOI: 10.5694/mja2.51430] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The prevalence of hepatitis B virus (HBV) infection in Australia is nearly 1%. In certain well defined groups the prevalence is far greater, yet an estimated 27% of people living with HBV infection remain undiagnosed. Appropriate screening improves detection, increases opportunity for treatment, and ultimately reduces the significant morbidity and mortality associated with the development of liver fibrosis and hepatocellular carcinoma (HCC). MAIN RECOMMENDATIONS This statement highlights important aspects of HBV infection management in Australia. There have been recent changes in nomenclature and understanding of natural history, as well as a newly defined upper limit of normal for liver tests that determine phase classification and threshold for antiviral treatment. As the main burden of hepatitis B in Australia is within migrant and Indigenous communities, early identification and management of people living with hepatitis B is essential to prevent adverse outcomes including liver cancer and cirrhosis. CHANGE IN MANAGEMENT AS A RESULT OF THIS GUIDELINE These recommendations aim to raise awareness of the current management of hepatitis B in Australia. Critically, the timely identification of individuals living with hepatitis B, and where appropriate, commencement of antiviral therapy, can prevent the development of cirrhosis, HCC and mother-to-child transmission as well as hepatitis B reactivation in immunocompromised individuals. Recognising patient and viral factors that predispose to the development of cirrhosis and HCC will enable clinicians to risk-stratify and appropriately implement surveillance strategies to prevent these complications of hepatitis B.
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Affiliation(s)
- John S Lubel
- Alfred Health, Melbourne, VIC
- Monash University, Melbourne, VIC
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Alexander J Thompson
- St Vincent's Hospital Melbourne, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
| | - Benjamin C Cowie
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
- Royal Melbourne Hospital, Melbourne, VIC
| | - Jennifer MacLachlan
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
| | - Nicole L Allard
- University of Melbourne, Melbourne, VIC
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
| | - Jacinta Holmes
- St Vincent's Hospital Melbourne, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
| | | | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW
| | - David Iser
- St Vincent's Hospital Melbourne, Melbourne, VIC
| | - Jess Howell
- Monash University, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
- Burnet Institute, Melbourne, VIC
| | - Gail V Matthews
- Kirby Institute, University of New South Wales, Sydney, NSW
- St Vincent's Hospital Sydney, Sydney, NSW
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Marukutira T, Moore KP, Hellard M, Richmond J, Turner K, Pedrana AE, Melody S, Johnston FH, Owen L, Van Den Boom W, Scott N, Thompson A, Iser D, Spelman T, Veitch M, Stoové MA, Doyle J. Randomised controlled trial of active case management to link hepatitis C notifications to treatment in Tasmania, Australia: a study protocol. BMJ Open 2022; 12:e056120. [PMID: 35338062 PMCID: PMC8961121 DOI: 10.1136/bmjopen-2021-056120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION By subsidising access to direct acting antivirals (DAAs) for all people living with hepatitis C (HCV) in 2016, Australia is positioned to eliminate HCV as a public health threat. However, uptake of DAAs has declined over recent years and new initiatives are needed to engage people living with HCV in care. Active follow-up of HCV notifications by the health department to the notifying general practitioner (GP) may increase treatment uptake. In this study, we explore the impact of using hepatitis C notifications systems to engage diagnosing GPs and improve patient access to treatment. METHODS AND ANALYSIS This study is a randomised controlled trial comparing enhanced case management of HCV notifications with standard of care. The intervention includes phone calls from a department of health (DoH) specialist HCV nurse to notifying GPs and offering HCV management support. The level of support requested by the GP was graded in complexity: level 1: HCV information only; level 2: follow-up testing advice; level 3: prescription support including linkage to specialist clinicians and level 4: direct patient contact. The study population includes all GPs in Tasmania who notified HCV diagnosis to the DoH between September 2020 and December 2021. The primary outcome is proportion of HCV cases who initiate DAAs after 12 weeks of HCV notification to the health department. Secondary outcomes are proportion of HCV notifications that complete HCV RNA testing, treatment workup and treatment completion. Multiple logistic regression modelling will explore factors associated with the primary and secondary outcomes. The sample size required to detect a significant difference for the primary outcome is 85 GPs in each arm with a two-sided alpha of 0.05% and 80% power. ETHICS AND DISSEMINATION The study was approved by University of Tasmania's Human Research Ethics Committee (Protocol ID: 18418) on 17 December 2019. Results of the project will be presented in scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04510246. TRIAL PROGRESSION The study commenced recruitment in September 2020 and end of study expected December 2021.
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Affiliation(s)
- Tafireyi Marukutira
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiuology, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Karen P Moore
- Department of Health and Human Services, Hobart, Tasmania, Australia
| | | | - Jacqui Richmond
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Kate Turner
- Department of Health and Human Services, Hobart, Tasmania, Australia
| | - A E Pedrana
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Shannon Melody
- Department of Health and Human Services, Hobart, Tasmania, Australia
| | - Fay H Johnston
- Department of Health and Human Services, Hobart, Tasmania, Australia
| | - Louise Owen
- Department of Health and Human Services, Hobart, Tasmania, Australia
| | | | - N Scott
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Alexander Thompson
- Department of Gastroenterology, St Vincent's Hospital Melbourne Pvt Ltd, Fitzroy, Victoria, Australia
| | - David Iser
- Department of Gastroenterology, St Vincent's Hospital Melbourne Pvt Ltd, Fitzroy, Victoria, Australia
| | - Tim Spelman
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Mark Veitch
- Department of Health and Human Services, Hobart, Tasmania, Australia
| | - Mark A Stoové
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Joseph Doyle
- Public Health, Burnet Institute, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
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Harney BL, Whitton B, Paige E, Brereton R, Weiss R, Membrey D, Wade AJ, Iser D, Kemp W, Roberts SK, Spelman T, Sacks-Davis R, Hellard ME, Doyle JS. A multi-site, nurse-coordinated hepatitis C model of care in primary care and community services in Melbourne, Australia. Liver Int 2022; 42:522-531. [PMID: 34821021 DOI: 10.1111/liv.15107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) treatment through primary care and community-based services will be a critical component of HCV elimination. We evaluated a nurse-coordinated programme providing care across eight sites and analysed progression through the HCV care cascade. METHODS People-accessing services from six primary care clinics, a homeless crisis accommodation provider and a mental health service were directly referred to nurses or engaged by nurses during regular clinic visits. Nurses supported HCV testing, treatment and follow-up. The prescription was provided by affiliated clinicians. Logistic regression was used to examine factors associated with treatment commencement and sustained virological response (SVR) testing. RESULTS Of 640 people referred to and/or engaged by the nurses from January 2017 to July 2019, 518 had an HCV RNA test of whom 381 (74%) were HCV RNA positive. Treatment was commenced by 281 (74%) people of whom 161 had an SVR test, 157 (97.5%) were cured. Opioid agonist therapy was associated with treatment commencement (aOR 2.68, 95% CI 1.48-4.88). People who were homeless/unstably housed were less likely to commence treatment (aOR 0.45, 95% CI 0.23-0.87). Treatment prescription from a specialist (aOR 2.39, 95% CI 1.20-4.74) and recent injection drug use (<6 months) (aOR 2.15, 95% CI 1.07-4.31) was associated with SVR testing. CONCLUSION A nurse-coordinated model of care led to high levels of HCV treatment uptake and cure amongst people attending primary care and community services. More tailored models of care may be beneficial for people who are homeless or have unstable housing. These results support primary care and community-based hepatitis C treatment.
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Affiliation(s)
- Brendan L Harney
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Bradley Whitton
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia
| | - Rebecca Brereton
- St Kilda Road Clinic & South City Clinic, Alfred Community Mental & Addiction Health, Melbourne, Australia
| | | | | | - Amanda J Wade
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,Department of Infectious Diseases, Barwon Health, Geelong, Australia
| | - David Iser
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - Tim Spelman
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - Rachel Sacks-Davis
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Margaret E Hellard
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Doherty Institute and School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Australia
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9
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Yee J, Carson JM, Hajarizadeh B, Hanson J, O'Beirne J, Iser D, Read P, Balcomb A, Doyle JS, Davies J, Martinello M, Marks P, Dore GJ, Matthews GV. High Effectiveness of Broad Access Direct-Acting Antiviral Therapy for Hepatitis C in an Australian Real-World Cohort: The REACH-C Study. Hepatol Commun 2022; 6:496-512. [PMID: 34729957 PMCID: PMC8870316 DOI: 10.1002/hep4.1826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/29/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022] Open
Abstract
Australia was one of the first countries with unrestricted access to government subsidized direct-acting antiviral (DAA) therapy for adults with chronic hepatitis C virus. This study assessed real-world DAA treatment outcomes across a diverse range of Australian clinical services and evaluated factors associated with successful treatment and loss to follow-up. Real-world Effectiveness of Antiviral therapy in Chronic Hepatitis C (REACH-C) consisted a national observational cohort of 96 clinical services including specialist clinics and less traditional settings such as general practice. Data were obtained on consecutive individuals who commenced DAAs from March 2016 to June 2019. Effectiveness was assessed by sustained virological response ≥12 weeks following treatment (SVR) using intention-to-treat (ITT) and per-protocol (PP) analyses. Within REACH-C, 10,843 individuals initiated DAAs (male 69%; ≥50 years 52%; cirrhosis 22%). SVR data were available in 85% (9,174 of 10,843). SVR was 81% (8,750 of 10,843) by ITT and 95% (8,750 of 9,174) by PP. High SVR (≥92%) was observed across all service types and participant characteristics. Male gender (adjusted odds ratio [aOR] 0.56, 95% confidence interval [CI] 0.43-0.72), cirrhosis (aOR 0.52, 95% CI 0.41-0.64), recent injecting drug use (IDU; aOR 0.64, 95% CI 0.46-0.91) and previous DAA treatment (aOR 0.50, 95% CI 0.28-0.90) decreased the likelihood of achieving SVR. Multiple factors modified the likelihood of loss to follow-up including IDU ± opioid agonist therapy (OAT; IDU only: aOR 1.75, 95% CI 1.44-2.11; IDU + OAT: aOR 1.39, 95% CI 1.11-1.74; OAT only, aOR 1.36; 95% CI 1.13-1.68) and age (aOR 0.97, 95% CI 0.97-0.98). Conclusion: Treatment response was high in a diverse population and through a broad range of services following universal access to DAA therapy. Loss to follow-up presents a real-world challenge. Younger people who inject drugs were more likely to disengage from care, requiring innovative strategies to retain them in follow-up.
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Affiliation(s)
- Jasmine Yee
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia
| | | | | | - Joshua Hanson
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,Cairns HospitalCairnsQLDAustralia
| | - James O'Beirne
- Sunshine Coast University HospitalSunshine CoastQLDAustralia
| | - David Iser
- Scope GastroenterologyMelbourneVICAustralia
| | | | | | - Joseph S Doyle
- Burnet InstituteMelbourneVICAustralia.,The Alfred and Monash UniversityDepartment of Infectious DiseasesMelbourneVICAustralia
| | - Jane Davies
- Royal Darwin HospitalDarwinAustralia.,Menzies School of Health ResearchDarwinAustralia
| | - Marianne Martinello
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,Blacktown Mount Druitt HospitalBlacktownNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
| | | | - Gregory J Dore
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
| | - Gail V Matthews
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
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10
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Xiao Y, Wallace J, Thompson A, Hellard M, van Gemert C, Holmes JA, Croagh C, Richmond J, Papaluca T, Hall S, Hong T, Demediuk B, Iser D, Ryan M, Desmond P, Visvanathan K, Howell J. A qualitative exploration of enablers for hepatitis B clinical management among ethnic Chinese in Australia. J Viral Hepat 2021; 28:925-933. [PMID: 33662159 DOI: 10.1111/jvh.13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 12/09/2022]
Abstract
An estimated 18% of people living with chronic hepatitis B (CHB) in Australia were born in China. While guideline-based care, including regular clinical monitoring and timely treatment, prevent CHB-related cirrhosis, cancer and deaths, over three-quarters of people with CHB do not receive guideline-based care in Australia. This qualitative study aimed to identify enablers to engagement in CHB clinical management among ethnic Chinese people attending specialist care. Participants self-identified as of Chinese ethnicity and who attended specialist care for CHB clinical management were interviewed in Melbourne in 2019 (n = 30). Semi-structured interviews covered experiences of diagnosis and engagement in clinical management services, and advice for people living with CHB. Interviews were recorded with consent; data were transcribed verbatim and thematically analysed. Receiving clear information about the availability of treatment and/or the necessity of long-term clinical management were the main enablers for participants to engage in CHB clinical management. Additional enablers identified to maintain regular clinical monitoring included understanding CHB increases risks of cirrhosis and liver cancer, using viral load indicators to visualize disease status in patient-doctor communication; expectations from family, peer group and medical professionals; use of a patient recall system; availability of interpreters or multilingual doctors; and largely subsidized healthcare services. In conclusion, to support people attending clinical management for CHB, a holistic response from community, healthcare providers and the public health sector is required. There are needs for public health programmes directed to communicate (i) CHB-related complications; (ii) availability of effective and cheap treatment; and that (iii) long-term engagement with clinical management and its benefits.
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Affiliation(s)
- Yinzong Xiao
- Burnet Institute, Melbourne, VIC, Australia.,Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Jack Wallace
- Burnet Institute, Melbourne, VIC, Australia.,La Trobe University, Bundoora, VIC, Australia
| | - Alex Thompson
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Margaret Hellard
- Burnet Institute, Melbourne, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia.,The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Caroline van Gemert
- Burnet Institute, Melbourne, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Jacinta A Holmes
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Catherine Croagh
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | | | - Tim Papaluca
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Samuel Hall
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Thai Hong
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Barbara Demediuk
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - David Iser
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Marno Ryan
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Paul Desmond
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Kumar Visvanathan
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Jess Howell
- Burnet Institute, Melbourne, VIC, Australia.,Department of Gastroenterology, St Vincent's Hospital, Fitzroy, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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11
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Tambakis G, Lee T, Shah R, Wright E, Connell W, Miller A, Demediuk B, Ryan M, Howell J, Tsoi E, Lust M, Basnayake C, Ding N, Croagh C, Hong T, Kamm M, Farrell A, Papaluca T, MacIsaac M, Iser D, Mahady S, Holt B, Thompson A, Holmes J. Low failure to attend rates and increased clinic capacity with Telehealth: A highly effective outpatient model that should continue beyond the COVID-19 pandemic. J Gastroenterol Hepatol 2021; 36:1136-1137. [PMID: 33338284 DOI: 10.1111/jgh.15379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/09/2022]
Affiliation(s)
- G Tambakis
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - T Lee
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - R Shah
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - E Wright
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - W Connell
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - A Miller
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - B Demediuk
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - M Ryan
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - J Howell
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - E Tsoi
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - M Lust
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - C Basnayake
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - N Ding
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - C Croagh
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - T Hong
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - M Kamm
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - A Farrell
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - T Papaluca
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - M MacIsaac
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - D Iser
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - S Mahady
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - B Holt
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - A Thompson
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - J Holmes
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
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12
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Wade AJ, Doyle JS, Draper B, Howell J, Iser D, Roberts SK, Kemp W, Thompson AJ, Hellard ME. In support of community-based hepatitis C treatment with triage of people at risk of cirrhosis to specialist care. J Viral Hepat 2021; 28:217-218. [PMID: 32860312 DOI: 10.1111/jvh.13391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/02/2020] [Indexed: 12/09/2022]
Affiliation(s)
- Amanda J Wade
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Infectious Diseases, Barwon Health, Geelong, Vic., Australia
| | - Joseph S Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Vic., Australia
| | - Bridget Draper
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia
| | - Jessica Howell
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia
| | - David Iser
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia
| | - Stuart K Roberts
- Department of Gastroenterology, The Alfred, Melbourne, Vic., Australia.,Department of Medicine, Monash University, Melbourne, Vic., Australia
| | - William Kemp
- Department of Gastroenterology, The Alfred, Melbourne, Vic., Australia.,Department of Medicine, Monash University, Melbourne, Vic., Australia
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Margaret E Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Infectious Diseases, Barwon Health, Geelong, Vic., Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
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13
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Papaluca T, Craigie A, McDonald L, Edwards A, MacIsaac M, Holmes JA, Jarman M, Lee T, Huang H, Chan A, Lai M, Sundararajan V, Doyle JS, Hellard M, Stoove M, Howell J, Desmond P, Iser D, Thompson AJ. Non-invasive fibrosis algorithms are clinically useful for excluding cirrhosis in prisoners living with hepatitis C. PLoS One 2020; 15:e0242101. [PMID: 33206696 PMCID: PMC7673506 DOI: 10.1371/journal.pone.0242101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/26/2020] [Indexed: 01/01/2023] Open
Abstract
Background and aims Prison-based HCV treatment rates remain low due to multiple barriers, including accessing transient elastography for cirrhosis determination. The AST-to-platelet ratio index (APRI) and FIB-4 scores have excellent negative predictive value (NPV) in hospital cohorts to exclude cirrhosis. We investigated their performance in a large cohort of prisoners with HCV infection. Methods This was a retrospective cohort study of participants assessed by a prison-based hepatitis program. The sensitivity, specificity, NPV and positive predictive value (PPV) of APRI and FIB-4 for cirrhosis were then analysed, with transient elastography as the reference standard. The utility of age thresholds as a trigger for transient elastography was also explored. Results Data from 1007 prisoners were included. The median age was 41, 89% were male, and 12% had cirrhosis. An APRI cut-off of 1.0 and FIB-4 cut-off of 1.45 had NPVs for cirrhosis of 96.1% and 96.6%, respectively, and if used to triage prisoners for transient elastography, could reduce the need for this investigation by 71%. The PPVs of APRI and FIB-4 for cirrhosis at these cut-offs were low. Age ≤35 years alone had a NPV for cirrhosis of 96.5%. In those >35 years, the APRI cut-off of 1.0 alone had a high NPV >95%. Conclusion APRI and FIB-4 scores can reliably exclude cirrhosis in prisoners and reduce requirement for transient elastography. This finding will simplify the cascade of care for prisoners living with hepatitis C.
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Affiliation(s)
- Timothy Papaluca
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Anne Craigie
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Lucy McDonald
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Amy Edwards
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Michael MacIsaac
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Jacinta A. Holmes
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Matthew Jarman
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Tanya Lee
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Hannah Huang
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Andrew Chan
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Mark Lai
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Public Health, La Trobe University, Melbourne, Australia
| | - Joseph S. Doyle
- Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
| | - Margaret Hellard
- Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
| | - Mark Stoove
- Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Jessica Howell
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
- Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Paul Desmond
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - David Iser
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
| | - Alexander J. Thompson
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, Australia
- * E-mail:
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14
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Doyle JS, van Santen DK, Iser D, Sasadeusz J, O'Reilly M, Harney B, Traeger MW, Roney J, Cutts JC, Bowring AL, Winter R, Medland N, Fairley CK, Moore R, Tee B, Asselin J, El-Hayek C, Hoy JF, Matthews GV, Prins M, Stoové MA, Hellard ME. Micro-elimination of hepatitis C among people with HIV coinfection: declining incidence and prevalence accompanying a multi-center treatment scale-up trial. Clin Infect Dis 2020; 73:e2164-e2172. [PMID: 33010149 DOI: 10.1093/cid/ciaa1500] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Gay and bisexual men (GBM) are a key population affected by HIV and hepatitis C (HCV) co-infection. Providing HCV treatment scale-up across specialist and non-hepatitis specialist settings may eliminate HCV in this population. We aimed to (1) deliver and measure HCV treatment effectiveness, and (2) determine the population impact of treatment on HCV prevalence and incidence longitudinally. METHODS The co-EC Study (Enhancing care and treatment among HCV/HIV co-infected individuals to Eliminate Hepatitis C transmission) was an implementation trial providing HCV direct-acting antiviral treatment in Melbourne, Australia, from 2016-2018. Individuals with HCV/HIV co-infection were prospectively enrolled from primary and tertiary-care services providing care for 85% of GBM with HIV in our jurisdiction. HCV-viraemic prevalence and HCV-antibody/viraemic incidence were measured using a state-wide, individually-linked, electronic surveillance system. RESULTS Among 200 participants recruited, 186 initiated treatment during the study period. Sustained virological response among primary care participants (98%, 95%CI:93-100%) was not different to tertiary care (98%, 95%CI:86-100%). From 2012-2019, between 2434 and 3476 GBM with HIV-infection attended our primary-care sites annually providing 13,801 person-years of follow-up; 50-60% received an HCV test annually, 10-14% were anti-HCV positive. Among those anti-HCV positive, viraemic prevalence declined 83% during the study (54% to 9%; 2016 to 2019). HCV incidence decreased 25% annually from 1.7/100 person-years in 2012 to 0.5/100 person-years in 2019 (incidence rate ratio 0.75; CI:0.68-0.83;p<0.001). CONCLUSION High treatment effectiveness by non-specialists demonstrates the feasibility of treatment scale-up in this population. Substantial declines in HCV incidence and prevalence among GBM with HIV-infection provides proof-of-concept for HCV micro-elimination. REGISTRATION ClinicalTrials.gov (Identifier: NCT02786758).
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Affiliation(s)
- J S Doyle
- Burnet Institute, Melbourne, VIC, Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
| | - D K van Santen
- Burnet Institute, Melbourne, VIC, Australia.,School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - D Iser
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - J Sasadeusz
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia.,Victorian Infectious Diseases Service at the Doherty Institute, Melbourne, VIC, Australia
| | - M O'Reilly
- Prahran Market Clinic, Melbourne, VIC, Australia
| | - B Harney
- Burnet Institute, Melbourne, VIC, Australia
| | | | - J Roney
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
| | - J C Cutts
- Burnet Institute, Melbourne, VIC, Australia
| | | | - R Winter
- Burnet Institute, Melbourne, VIC, Australia
| | - N Medland
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - C K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - R Moore
- Northside Clinic, Fitzroy North, VIC, Australia
| | - B Tee
- Centre Clinic, Melbourne, VIC, Australia
| | - J Asselin
- Burnet Institute, Melbourne, VIC, Australia
| | - C El-Hayek
- Burnet Institute, Melbourne, VIC, Australia
| | - J F Hoy
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
| | - G V Matthews
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - M Prins
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Infection and Immunity Institute Amsterdam, the Netherlands.,Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - M A Stoové
- Burnet Institute, Melbourne, VIC, Australia.,School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - M E Hellard
- Burnet Institute, Melbourne, VIC, Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia.,School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Doherty Institute and Melbourne School of Population and Global Health, University of Melbourne
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15
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Papaluca T, Sinclair M, Gow P, Pianko S, Sievert W, Arachchi N, Cameron K, Bowden S, O'Keefe J, Doyle J, Stoove M, Hellard M, Iser D, Thompson A. Retreatment with elbasvir, grazoprevir, sofosbuvir ± ribavirin is effective for GT3 and GT1/4/6 HCV infection after relapse. Liver Int 2019; 39:2285-2290. [PMID: 31355968 DOI: 10.1111/liv.14201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/31/2019] [Accepted: 07/04/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Despite highly effective direct-acting antiviral (DAA) therapies for chronic hepatitis C virus (HCV) infection, some patients experience virological relapse. Salvage regimens should include multiple agents to suppress emergence of resistance-associated substitutions (RAS) and minimise treatment failure. The combination of sofosbuvir (SOF) and elbasvir/grazoprevir (ELB/GZR) ±ribavirin (RBV) is an effective retreatment strategy for HCV genotype (GT)1 and 4 infection. We hypothesised that SOF and ELB/GZR (±RBV) would also be an effective salvage regimen for DAA-experienced GT3 patients. METHODS We evaluated the efficacy and safety of SOF/ELB/GZR ± RBV in DAA-experienced participants with chronic HCV infection who had prior relapse. Participants were treated at four hospitals between December 2016 and March 2018 for either 12- or 16-weeks. The primary endpoint was sustained virological response at week 12 post-treatment (SVR12) using intention-to-treat analysis. RESULTS There were 40 participants included in the analysis. The mean age was 53 years, 53% had GT3, 33% had GT1 infection and 63% had cirrhosis. Fifty-eight percent were treated for 12 weeks, 42% were treated for 16 weeks and 90% received RBV. The SVR12 rate was 98% overall, 100% in non-GT3 participants and 95% in GT3 participants. One GT3 cirrhotic participant relapsed. ELB/GZR was stopped at week 6 in one GT3 cirrhotic participant who switched to SOF/velpatasvir/RBV for a further 12 weeks and achieved SVR12. RBV dose reduction was required in two participants. Treatment was otherwise well tolerated. DISCUSSION The combination of SOF/ELB/GZR ± RBV is effective and safe for difficult-to-cure patients who relapse after first-line DAA, including those with cirrhosis and GT3 infection.
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Affiliation(s)
- Timothy Papaluca
- St Vincent's Hospital and the University of Melbourne, Fitzroy, Vic., Australia
| | | | - Paul Gow
- The Austin Hospital, Melbourne, Vic., Australia
| | - Stephen Pianko
- Monash Health and Monash University, Melbourne, Vic., Australia
| | - William Sievert
- Monash Health and Monash University, Melbourne, Vic., Australia
| | | | | | - Scott Bowden
- Victorian Infectious Disease Reference Laboratory, Melbourne, Vic., Australia
| | - Jacinta O'Keefe
- Victorian Infectious Disease Reference Laboratory, Melbourne, Vic., Australia
| | - Joseph Doyle
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Vic., Australia.,Burnet Institute, Melbourne, Vic., Australia
| | - Mark Stoove
- Burnet Institute, Melbourne, Vic., Australia
| | | | - David Iser
- St Vincent's Hospital and the University of Melbourne, Fitzroy, Vic., Australia
| | - Alexander Thompson
- St Vincent's Hospital and the University of Melbourne, Fitzroy, Vic., Australia
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Papaluca TJ, Tambakis G, Iser D, Thompson AJ. Effective prison-based treatment and linkage to care after release. Lancet Infect Dis 2019; 19:1171. [PMID: 31657780 DOI: 10.1016/s1473-3099(19)30536-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Timothy J Papaluca
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Fitzroy, VIC 3065, Australia
| | - George Tambakis
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Fitzroy, VIC 3065, Australia
| | - David Iser
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Fitzroy, VIC 3065, Australia
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Fitzroy, VIC 3065, Australia.
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Wade AJ, Doyle JS, Gane E, Stedman C, Draper B, Iser D, Roberts SK, Kemp W, Petrie D, Scott N, Higgs P, Agius PA, Roney J, Stothers L, Thompson AJ, Hellard ME. Outcomes of Treatment for Hepatitis C in Primary Care, Compared to Hospital-based Care: A Randomized, Controlled Trial in People Who Inject Drugs. Clin Infect Dis 2019; 70:1900-1906. [DOI: 10.1093/cid/ciz546] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/20/2019] [Indexed: 12/18/2022] Open
Abstract
Abstract
Background
To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to direct-acting antivirals (DAAs), especially among people who inject drugs (PWID). We aimed to determine the effectiveness of providing DAAs in primary care, compared with hospital-based specialist care.
Methods
We randomized PWID with HCV attending primary care sites in Australia or New Zealand to receive DAAs at their primary care site or local hospital (standard of care [SOC]). The primary outcome was to determine whether people treated in primary care had a noninferior rate of sustained virologic response at Week 12 (SVR12), compared to historical controls (consistent with DAA trials at the time of the study design); secondary outcomes included comparisons of treatment initiation, SVR12 rates, and the care cascade by study arm.
Results
We recruited 140 participants and randomized 136: 70 to the primary care arm and 66 to the SOC arm. The SVR12 rate (100%, 95% confidence interval [CI] 87.7–100) of people treated in primary care was noninferior when compared to historical controls (85% assumed). An intention-to-treat analysis revealed that the proportion of participants commencing treatment in the primary care arm (75%, 43/57) was significantly higher than in the SOC arm (34%, 18/53; P < .001; relative risk [RR] 2.48, 95% CI 1.54–3.95), and the proportion of participants with SVR12 was significantly higher in the primary care arm, compared to in the SOC arm (49% [28/57] and 30% [16/53], respectively; P = .043; RR 1.63, 95% CI 1.0–2.65).
Conclusions
Providing HCV treatment in primary care increases treatment uptake and cure rates. Approaches that increase treatment uptake among PWID will accelerate elimination strategies.
Clinical Trials Registration
NCT02555475.
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Affiliation(s)
- Amanda J Wade
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - Joseph S Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, The Alfred, Melbourne, Australia
| | - Edward Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Christchurch, New Zealand
| | - Catherine Stedman
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
- University of Otago, Christchurch, New Zealand
| | - Bridget Draper
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - David Iser
- Department of Infectious Diseases, The Alfred, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, The Alfred
- Department of Medicine, Monash University
| | - William Kemp
- Department of Gastroenterology, The Alfred
- Department of Medicine, Monash University
| | | | - Nick Scott
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne
- Department of Public Health, La Trobe University, Bundoora
| | - Paul A Agius
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne
- Judith Lumley Centre, La Trobe University
| | - Janine Roney
- Department of Infectious Diseases, The Alfred, Melbourne, Australia
| | - Lisa Stothers
- Department of Gastroenterology, St Vincent’s Hospital
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent’s Hospital
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Margaret E Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, The Alfred, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne
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Papaluca T, McDonald L, Craigie A, Gibson A, Desmond P, Wong D, Winter R, Scott N, Howell J, Doyle J, Pedrana A, Lloyd A, Stoove M, Hellard M, Iser D, Thompson A. Outcomes of treatment for hepatitis C in prisoners using a nurse-led, statewide model of care. J Hepatol 2019; 70:839-846. [PMID: 30654067 DOI: 10.1016/j.jhep.2019.01.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/26/2018] [Accepted: 01/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Treatment programs for people who inject drugs (PWID), including prisoners, are important for achieving hepatitis C elimination targets. There are multiple barriers to treatment of hepatitis C in prisons, including access to specialist physicians, testing and antiviral therapy, short prison sentences, and frequent inter-prison transfer. We aimed to assess the effectiveness of a nurse-led model of care for the treatment of prisoners with hepatitis C. METHODS A statewide program for assessment and management of hepatitis C was developed in Victoria, Australia to improve access to care for prisoners. This nurse-led model of care is supported by telemedicine to provide decentralized care within all prisons in the state. We prospectively evaluated the feasibility and efficacy of this nurse-led model of care for hepatitis C within the 14 adult prisons over a 13-month period. The primary endpoint was sustained virological response at post-treatment week 12 (SVR12) using per protocol analysis. RESULTS There were 416 prisoners included in the analysis. The median age was 41 years, 90% were male, 50% had genotype 3 and 44% genotype 1 hepatitis C and 21% had cirrhosis. Injecting drug use was reported by 68% in the month prior to prison entry, 54% were receiving opioid substitution therapy, and 86% reported never previously engaging with specialist HCV care. Treatment duration was 8 weeks in 24%, 12 weeks in 59%, and 24 weeks in 17% of treatment courses. The SVR12 rate was 96% (301/313) per protocol. Inter-prison transfer occurred during 26% of treatment courses but was not associated with lower SVR12 rates. No treatment-related serious adverse events occurred. CONCLUSION Hepatitis C treatment using a decentralized, nurse-led model of care is highly effective and can reach large numbers of prisoners. Large scale prison treatment programs should be considered to support hepatitis C elimination efforts. LAY SUMMARY There is a high burden of hepatitis C infection among prisoners worldwide. Prisoners who continue to inject drugs are also at risk of developing new infections. For this reason, the prison setting provides an opportunity to treat those people at greatest risk of infection and to stop transmission to others. We developed a new method of providing hepatitis C treatment to prisoners, in which nurses rather than doctors assessed prisoners locally at each prison site. Treatment was safe and most prisoners were cured. Such programs will contribute greatly to achieving the World Health Organization's hepatitis C elimination goals.
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Affiliation(s)
- Timothy Papaluca
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia
| | - Lucy McDonald
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia
| | - Anne Craigie
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia
| | - Annabelle Gibson
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia
| | - Paul Desmond
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia
| | - Darren Wong
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia
| | | | - Nick Scott
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, Monash University, Australia
| | - Jessica Howell
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia; Burnet Institute, Melbourne, Australia
| | - Joseph Doyle
- Burnet Institute, Melbourne, Australia; Department of Infectious Diseases, The Alfred and Monash University, Melbourne Australia
| | | | - Andrew Lloyd
- Kirby Institute, University of New South Wales, Australia
| | - Mark Stoove
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, Monash University, Australia
| | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, Monash University, Australia
| | - David Iser
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia; Department of Infectious Diseases, The Alfred and Monash University, Melbourne Australia
| | - Alexander Thompson
- Department of Gastroenterology, St Vincent's Hospital and the University of Melbourne, Australia.
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Wade AJ, Doyle JS, Gane E, Stedman C, Draper B, Iser D, Roberts SK, Kemp W, Petrie D, Scott N, Higgs P, Agius PA, Roney J, Stothers L, Thompson AJ, Hellard ME. Community-based provision of direct-acting antiviral therapy for hepatitis C: study protocol and challenges of a randomized controlled trial. Trials 2018; 19:383. [PMID: 30012192 PMCID: PMC6048874 DOI: 10.1186/s13063-018-2768-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 06/27/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to treatment. Direct-acting antiviral (DAA) treatment can be provided in primary healthcare services (PHCS), improving accessibility, and, potentially, retention in care. Here, we describe our protocol for assessing the effectiveness of providing DAAs in PHCS, and the impact on the HCV care cascade. In addition, we reflect on the challenges of conducting a model of care study during a period of unprecedented change in HCV care and treatment. METHODS Consenting patients with HCV infection attending 13 PHCS in Australia or New Zealand are randomized to receive DAA treatment at the local tertiary institution (standard care arm), or their PHCS (intervention arm). The primary endpoint is the proportion commenced on DAAs and cured. Treatment providers at the PHCS include: hepatology nurses, primary care practitioners, or, in two sites, a specialist physician. All PHCS offer opioid substitution therapy. DISCUSSION The Prime Study is the first real-world, randomized, model of care study exploring the impact of community provision of DAA therapy on HCV-treatment uptake and cure. Although the study has faced challenges unique to this period of time characterized by changing treatment and service delivery, the data gained will be of critical importance in shaping health service policy that enables the elimination of HCV. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT02555475 . Registered on 15 September 2015.
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Affiliation(s)
- A. J. Wade
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - J. S. Doyle
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
| | - E. Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - C. Stedman
- Department of Gastroenterology, Christchurch Hospital, and University of Otago, Christchurch, New Zealand
| | - B. Draper
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
| | - D. Iser
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
| | - S. K. Roberts
- Department of Gastroenterology, The Alfred, Melbourne, VIC Australia
- Department of Medicine, Monash University, Melbourne, VIC Australia
| | - W. Kemp
- Department of Gastroenterology, The Alfred, Melbourne, VIC Australia
- Department of Medicine, Monash University, Melbourne, VIC Australia
| | - D. Petrie
- Centre for Health Economics, Monash University, Melbourne, VIC Australia
| | - N. Scott
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
| | - P. Higgs
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
- Department of Public Health, La Trobe University, Bundoora, VIC Australia
| | - P. A. Agius
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
- Judith Lumley Centre, La Trobe University, Melbourne, VIC Australia
| | - J. Roney
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
| | - L. Stothers
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC Australia
| | - A. J. Thompson
- Department of Medicine, University of Melbourne, Melbourne, VIC Australia
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC Australia
| | - M. E. Hellard
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
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Chen Yi Mei SLG, Thompson AJ, Christensen B, Cunningham G, McDonald L, Bell S, Iser D, Nguyen T, Desmond PV. Sustained virological response halts fibrosis progression: A long-term follow-up study of people with chronic hepatitis C infection. PLoS One 2017; 12:e0185609. [PMID: 29065124 PMCID: PMC5655473 DOI: 10.1371/journal.pone.0185609] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Long-term follow-up studies validating the clinical benefit of sustained virological response (SVR) in people with chronic hepatitis C (CHC) infection are lacking. Our aim was to identify rates and predictors of liver fibrosis progression in a large, well characterized cohort of CHC patients in whom paired liver fibrosis assessments were performed more than 10 years apart. METHODS CHC patients who had undergone a baseline liver biopsy pre-2004 and a follow up liver fibrosis assessment more than 10 years later (biopsy or liver stiffness measurement (LSM) using transient elastography [FibroScan]) were identified. Subjects who had undergone a baseline liver biopsy but had no follow up fibrosis assessment were recalled for LSM. Fibrosis was categorised as mild-moderate (METAVIR F0-2 / LSM result of ≤ 9.5 kPa) or advanced (METAVIR F3-4/ LSM >9.5 kPa). The primary objective was to assess the association between SVR and the rate of liver fibrosis progression over at least 10 years, defined as an increase from mild-moderate fibrosis at baseline liver biopsy (METAVIR F0-2) to advanced fibrosis at follow-up liver fibrosis assessment. RESULTS 131 subjects were included in this analysis: 69% male, 82% Caucasian, 60% G1 HCV, 25% G3 HCV. The median age at F/U fibrosis staging was 57 (IQR 54-62) years with median estimated duration of infection 33-years (IQR 29-38). At F/U, liver fibrosis assessment was performed by LSM in 86% and liver biopsy in 14%. The median period between fibrosis assessments was 14-years (IQR 12-17). 109 (83%) participants had received interferon-based antiviral therapy. 40% attained SVR. At F/U, there was a significant increase in the proportion of subjects with advanced liver fibrosis: 27% at baseline vs. 46% at F/U (p = 0.002). The prevalence of advanced fibrosis did not change among subjects who attained SVR, 30% at B/L vs 25% at F/U (p = 0.343). However, advanced fibrosis became more common at F/U among subjects with persistent viremia: 10% at B/L vs 31% at F/U (p = 0.0001). SVR was independently associated with protection from liver fibrosis progression after adjustment for other variables including baseline ALT (p = 0.011), duration of HCV infection and mode of acquisition. CONCLUSION HCV eradication is associated with lower rates of liver fibrosis progression. The data support early treatment to prevent long-term liver complications of HCV infection.
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Affiliation(s)
- Swee Lin G. Chen Yi Mei
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- * E-mail:
| | - Alexander J. Thompson
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Britt Christensen
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
| | | | - Lucy McDonald
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
| | - Sally Bell
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - David Iser
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
| | - Tin Nguyen
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
| | - Paul V. Desmond
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
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Wallace DF, McDonald CJ, Ostini L, Iser D, Tuckfield A, Subramaniam VN. The dynamics of hepcidin-ferroportin internalization and consequences of a novel ferroportin disease mutation. Am J Hematol 2017; 92:1052-1061. [PMID: 28681497 DOI: 10.1002/ajh.24844] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 12/31/2022]
Abstract
The hepcidin-ferroportin axis underlies the pathophysiology of many iron-associated disorders and is a key target for the development of therapeutics for treating iron-associated disorders. The aims of this study were to investigate the dynamics of hepcidin-mediated ferroportin internalization and the consequences of a novel disease-causing mutation on ferroportin function. Specific reagents for ferroportin are limited; we developed and characterized antibodies against the largest extracellular loop of ferroportin and developed a novel cell-based assay for studying hepcidin-ferroportin function. We show that hepcidin-mediated ferroportin internalization is a rapid process and could be induced using low concentrations of hepcidin. Targeted next-generation sequencing utilizing an iron metabolism gene panel developed in our group identified a novel ferroportin p.D84E variant in a patient with iron overload. Wild-type and mutant ferroportin constructs were generated, transfected into HEK293 cells and analysed using an all-in-one flow-cytometry-based assay to study the effects on hepcidin-mediated internalization and iron transport. Consistent with the classical phenotype of ferroportin disease, the p.D84E mutation results in an inability to transport iron and hepcidin insensitivity. These results validate a recently proposed 3D-structural model of ferroportin and highlight the significance of this variant in the structure and function of ferroportin. Our novel ferroportin antibody and assay will be valuable tools for investigating the regulation of hepcidin/ferroportin function and the development of novel approaches for the therapeutic modulation of iron homeostasis.
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Affiliation(s)
- Daniel F. Wallace
- Institute of Health and Biomedical Innovation and School of Biomedical Sciences. Queensland University of Technology (QUT); Brisbane Queensland Australia
- Membrane Transport Laboratory; QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
| | - Cameron J. McDonald
- Membrane Transport Laboratory; QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
| | - Lesa Ostini
- Membrane Transport Laboratory; QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
| | - David Iser
- Department of Gastroenterology; St Vincent's Hospital; Fitzroy Victoria Australia
| | | | - V. Nathan Subramaniam
- Institute of Health and Biomedical Innovation and School of Biomedical Sciences. Queensland University of Technology (QUT); Brisbane Queensland Australia
- Membrane Transport Laboratory; QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
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Papaluca T, McDonald L, Craigie A, Scarmozzino J, Jarman M, Shulberg J, Stoove M, Hellard M, Howell J, Doyle J, Iser D, Thompson A. O4 Outcomes of treatment for hepatitis C virus infection in the prison setting. J Virus Erad 2017. [DOI: 10.1016/s2055-6640(20)30887-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Lubel J, Strasser S, Stuart KA, Dore G, Thompson A, Pianko S, Bollipo S, Mitchell JL, Fragomeli V, Jones T, Chivers S, Gow P, Iser D, Levy M, Tse E, Gazzola A, Cheng W, Nazareth S, Galhenage S, Wade A, Weltman M, Wigg A, MacQuillan G, Sasadeusz J, George J, Zekry A, Roberts SK. Real-world efficacy and safety of ritonavir-boosted paritaprevir, ombitasvir, dasabuvir ± ribavirin for hepatitis C genotype 1 – final results of the REV1TAL study. Antivir Ther 2017; 22:699-710. [DOI: 10.3851/imp3168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
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Martinello M, Hellard M, Shaw D, Petoumenos K, Applegate T, Grebely J, Yeung B, Maire L, Iser D, Lloyd A, Thompson A, Sasadeusz J, Haber P, Dore GJ, Matthews GV. Short duration response-guided treatment is effective for most individuals with recent hepatitis C infection: the ATAHC II and DARE-C I studies. Antivir Ther 2016; 21:465. [PMID: 27509356 DOI: 10.3851/imp3073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Marianne Martinello
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Australia, Sydney, NSW, Australia.
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Audsley J, Robson C, Aitchison S, Matthews GV, Iser D, Sasadeusz J, Lewin SR. Liver Fibrosis Regression Measured by Transient Elastography in Human Immunodeficiency Virus (HIV)-Hepatitis B Virus (HBV)-Coinfected Individuals on Long-Term HBV-Active Combination Antiretroviral Therapy. Open Forum Infect Dis 2016; 3:ofw035. [PMID: 27006960 PMCID: PMC4800457 DOI: 10.1093/ofid/ofw035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 02/09/2016] [Indexed: 12/21/2022] Open
Abstract
Transient elastography (TE) data in HIV-HBV co-infection are lacking. The majority of this cohort had mild-moderate fibrosis, however over 28% of those with >1 TE showed liver fibrosis regression and the prevalence of advanced fibrosis (≥F3) decreased 12.3% (32.7 to 20.4%) over a median 31 months Background. Advanced fibrosis occurs more commonly in human immunodeficiency virus (HIV)-hepatitis B virus (HBV) coinfected individuals; therefore, fibrosis monitoring is important in this population. However, transient elastography (TE) data in HIV-HBV coinfection are lacking. We aimed to assess liver fibrosis using TE in a cross-sectional study of HIV-HBV coinfected individuals receiving combination HBV-active (lamivudine and/or tenofovir/tenofovir-emtricitabine) antiretroviral therapy, identify factors associated with advanced fibrosis, and examine change in fibrosis in those with >1 TE assessment. Methods. We assessed liver fibrosis in 70 HIV-HBV coinfected individuals on HBV-active combination antiretroviral therapy (cART). Change in fibrosis over time was examined in a subset with more than 1 TE result (n = 49). Clinical and laboratory variables at the time of the first TE were collected, and associations with advanced fibrosis (≥F3, Metavir scoring system) and fibrosis regression (of least 1 stage) were examined. Results. The majority of the cohort (64%) had mild to moderate fibrosis at the time of the first TE, and we identified alanine transaminase, platelets, and detectable HIV ribonucleic acid as associated with advanced liver fibrosis. Alanine transaminase and platelets remained independently advanced in multivariate modeling. More than 28% of those with >1 TE subsequently showed liver fibrosis regression, and higher baseline HBV deoxyribonucleic acid was associated with regression. Prevalence of advanced fibrosis (≥F3) decreased 12.3% (32.7%–20.4%) over a median of 31 months. Conclusions. The observed fibrosis regression in this group supports the beneficial effects of cART on liver stiffness. It would be important to study a larger group of individuals with more advanced fibrosis to more definitively assess factors associated with liver fibrosis regression.
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Affiliation(s)
- Jennifer Audsley
- Department of Infectious Diseases, Monash University; Department of Infectious Diseases, The Alfred Hospital; The Peter Doherty Institute for Infection and Immunity, Melbourne
| | | | | | | | - David Iser
- St Vincent's Hospital , Melbourne , Australia
| | - Joe Sasadeusz
- Department of Infectious Diseases , The Alfred Hospital
| | - Sharon R Lewin
- Department of Infectious Diseases, Monash University; Department of Infectious Diseases, The Alfred Hospital; The Peter Doherty Institute for Infection and Immunity, Melbourne
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Martinello M, Hellard M, Shaw D, Petoumenos K, Applegate T, Grebely J, Yeung B, Maire L, Iser D, Lloyd A, Thompson A, Sasadeusz J, Haber P, Dore GJ, Matthews GV. Short duration response-guided treatment is effective for most individuals with recent hepatitis C infection: the ATAHC II and DARE-C I studies. Antivir Ther 2016; 21:425-34. [PMID: 26867206 DOI: 10.3851/imp3035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Individuals with recent HCV infection may benefit from shortened duration therapy. These studies evaluated the efficacy and safety of response-guided regimens with pegylated interferon-α2a and ribavirin for people with recent HCV infection. METHODS Participants with recent hepatitis C (duration of infection ≤18 months) enrolled in the ATAHC II (pegylated interferon-α2a ± ribavirin) and DARE-C I (pegylated interferon-α2a, ribavirin and telaprevir) studies were included for analysis. Treatment duration was response-guided (ATAHC II: 8, 16, 24 or 48 weeks; DARE-C I: 8, 12 or 24 weeks) and dependent on time to first undetectable HCV RNA using Roche Taqman HCV RNA testing. The primary efficacy end point was sustained virological response at 12 weeks (SVR12) by intention-to-treat. Logistic regression analyses were used to identify predictors of SVR. RESULTS A total of 82 participants (62% HIV-positive) were enrolled in ATAHC II (treated, n=52) and 14 (79% HIV-positive) in DARE-C I. The predominant modes of HCV acquisition were injecting drug use (ATAHC II 55%, DARE-C I 36%) and sexual intercourse with a partner of the same sex (ATAHC II 39%, DARE-C I 64%). SVR12 was 71% in both ATAHC II (37/52) and DARE-C I (10/14) with 56% in ATAHC II receiving shortened therapy (8 or 16 weeks). SVR was associated with a rapid virological response (odds ratio 10.80; P=0.001). CONCLUSIONS The majority of participants were able to receive short duration response-guided therapy with pegylated interferon-α2a and ribavirin. Response-guided therapy for recent hepatitis C infection could be considered in the absence of available interferon-free therapies. ClinicalTrials.gov registry (ATAHC II: NCT01336010; DARE-C I: NCT01743521).
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Affiliation(s)
- Marianne Martinello
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Australia, Sydney, NSW, Australia.
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Crane M, Avihingsanon A, Rajasuriar R, Velayudham P, Iser D, Solomon A, Sebolao B, Tran A, Spelman T, Matthews G, Cameron P, Tangkijvanich P, Dore GJ, Ruxrungtham K, Lewin SR. Lipopolysaccharide, immune activation, and liver abnormalities in HIV/hepatitis B virus (HBV)-coinfected individuals receiving HBV-active combination antiretroviral therapy. J Infect Dis 2014; 210:745-51. [PMID: 24585898 DOI: 10.1093/infdis/jiu119] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We investigated the relationship between microbial translocation, immune activation, and liver disease in human immunodeficiency virus (HIV)/hepatitis B virus (HBV) coinfection. Lipopolysaccharide (LPS), soluble CD14, CXCL10, and CCL-2 levels were elevated in patients with HIV/HBV coinfection. Levels of LPS, soluble CD14, and CCL-2 declined following receipt of HBV-active combination antiretroviral therapy (cART), but the CXCL10 level remained elevated. No markers were associated with liver disease severity on liver biopsy (n = 96), but CXCL10, interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor α, and interferon γ (IFN-γ) were all associated with elevated liver enzyme levels during receipt of HBV-active cART. Stimulation of hepatocyte cell lines in vitro with IFN-γ and LPS induced a profound synergistic increase in the production of CXCL10. LPS may contribute to liver disease via stimulating persistent production of CXCL10.
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Affiliation(s)
| | | | - Reena Rajasuriar
- Monash University Burnet Institute University of Malaya, Kuala Lumpur, Malaysia
| | | | - David Iser
- Monash University St. Vincent's Hospital
| | | | | | | | | | - Gail Matthews
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Paul Cameron
- Monash University Burnet Institute Alfred Hospital, Melbourne
| | | | - Gregory J Dore
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Sharon R Lewin
- Monash University Burnet Institute Alfred Hospital, Melbourne
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Iser D, Ryan M. Fatty liver disease--a practical guide for GPs. Aust Fam Physician 2013; 42:444-447. [PMID: 23826593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD), encompassing both simple steatosis and non-alcoholic steato-hepatitis (NASH), is the most common cause of liver disease in Australia. Non-alcoholic fatty liver disease needs to be considered in the context of the metabolic syndrome, as cardiovascular disease will account for much of the mortality associated with NAFLD. OBJECTIVE To provide an approach to the identification of NAFLD in general practice, the distinction between simple steatosis and NASH, and the management of these two conditions. DISCUSSION Non-alcoholic steato-hepatitis is more common in the presence of diabetes, obesity, older age and increased inflammation, and is more likely to progress to cirrhosis. Cirrhosis may be complicated by hepatocellular carcinoma or liver failure. Hepatocellular carcinoma has also been described in NASH without cirrhosis. Assessment and treatment of features of the metabolic syndrome may reduce associated cardiovascular mortality. Numerous agents have been evaluated, but weight loss remains the only effective treatment for NAFLD.
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Affiliation(s)
- David Iser
- Department of Gastroenterology, St Vincent's Hospital, Melbourne and Infectious Diseases Unit, The Alfred Hospital, Melbourne, Victoria, Australia.
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Holmes JA, Nguyen T, Ratnam D, Heerasing NM, Tehan JV, Bonanzinga S, Dev A, Bell S, Pianko S, Chen R, Visvanathan K, Hammond R, Iser D, Rusli F, Sievert W, Desmond PV, Bowden DS, Thompson AJ. IL28B genotype is not useful for predicting treatment outcome in Asian chronic hepatitis B patients treated with pegylated interferon-α. J Gastroenterol Hepatol 2013; 28:861-6. [PMID: 23301835 DOI: 10.1111/jgh.12110] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM IL28B genotype predicts response to pegylated interferon (peg-IFN)-based therapy in chronic hepatitis C. However, the utility of IL28B genotyping in chronic hepatitis B (CHB) cohorts treated with peg-IFN is unclear. It was investigated whether IL28B genotype is associated with peg-IFN treatment outcomes in a predominantly Asian CHB cohort. METHODS This was a retrospective analysis of CHB patients treated with 48 weeks of peg-IFN monotherapy. IL28B genotype (rs12979860) was determined (TaqMan allelic discrimination kit). Baseline hepatitis B virus (HBV)-DNA, alanine aminotransferase, and liver histology were available. The primary end-points were HBV e antigen (HBeAg) seroconversion with HBV-DNA < 2000 IU/mL 24 weeks post-therapy (HBeAg-positive patients) and HBV-DNA < 2000 IU/mL 24 weeks after peg-IFN (HBeAg-negative patients). The association between IL28B genotype and peg-IFN outcomes was analyzed. RESULTS IL28B genotype was determined for 96 patients. Eighty-eight percent were Asian, 62% were HBeAg positive, and 13% were METAVIR stage F3-4. Median follow-up time was 39.3 months. The majority of patients carried the CC IL28B genotype (84%). IL28B genotype did not differ according to HBeAg status. The primary end-points were achieved in 27% of HBeAg-positive and 61% of HBeAg-negative patients. There was no association between IL28B genotype and the primary end-point in either group. Furthermore, there was no difference in HBeAg loss alone, HBV surface antigen, alanine aminotransferase normalization, or on-treatment HBV-DNA levels according to IL28B genotype. CONCLUSIONS In the context of a small possible effect size and high frequency in Asian populations, IL28B genotyping is likely to have, at best, limited clinical utility for predicting peg-IFN treatment outcome for CHB patients in the Asia-Pacific region.
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Affiliation(s)
- Jacinta A Holmes
- Department of Gastroenterology, St Vincent's Hospital, University of Melbourne, Melbourne, Australia.
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Abstract
Liver disease in human immunodeficiency virus (HIV)-infected individuals encompasses the spectrum from abnormal liver function tests, liver decompensation, with and without evidence of cirrhosis on biopsy, to non-alcoholic liver disease and its more severe form, non-alcoholic steatohepatitis and hepatocellular cancer. HIV can infect multiple cells in the liver, leading to enhanced intrahepatic apoptosis, activation and fibrosis. HIV can also alter gastro-intestinal tract permeability, leading to increased levels of circulating lipopolysaccharide that may have an impact on liver function. This review focuses on recent changes in the epidemiology, pathogenesis and clinical presentation of liver disease in HIV-infected patients, in the absence of co-infection with hepatitis B virus or hepatitis C virus, with a specific focus on issues relevant to low and middle income countries.
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Affiliation(s)
- Megan Crane
- Megan Crane, Sharon R Lewin, Department of Medicine, Monash University, Melbourne 3004, Australia
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Thompson AJV, Nguyen T, Iser D, Ayres A, Jackson K, Littlejohn M, Slavin J, Bowden S, Gane EJ, Abbott W, Lau GKK, Lewin SR, Visvanathan K, Desmond PV, Locarnini SA. Serum hepatitis B surface antigen and hepatitis B e antigen titers: disease phase influences correlation with viral load and intrahepatic hepatitis B virus markers. Hepatology 2010; 51:1933-44. [PMID: 20512987 DOI: 10.1002/hep.23571] [Citation(s) in RCA: 323] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
UNLABELLED Although threshold levels for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) titers have recently been proposed to guide therapy for chronic hepatitis B (CHB), their relationship to circulating hepatitis B virus (HBV) DNA and intrahepatic HBV replicative intermediates, and the significance of emerging viral variants, remains unclear. We therefore tested the hypothesis that HBsAg and HBeAg titers may vary independently of viral replication in vivo. In all, 149 treatment-naïve CHB patients were recruited (HBeAg-positive, n = 71; HBeAg-negative, n = 78). Quantification of HBeAg and HBsAg was performed by enzyme immunoassay. Virological characterization included serum HBV DNA load, HBV genotype, basal core promoter (BCP)/precore (PC) sequence, and, in a subset (n = 44), measurement of intrahepatic covalently closed circular DNA (cccDNA) and total HBV DNA, as well as quantitative immunohistochemical (IHC) staining for HBsAg. In HBeAg-positive CHB, HBsAg was positively correlated with serum HBV DNA and intrahepatic cccDNA and total HBV DNA (r = 0.69, 0.71, 0.76, P < 0.01). HBeAg correlated with serum HBV DNA (r = 0.60, P < 0.0001), although emerging BCP/PC variants reduced HBeAg titer independent of viral replication. In HBeAg-negative CHB, HBsAg correlated poorly with serum HBV DNA (r = 0.28, P = 0.01) and did not correlate with intrahepatic cccDNA nor total HBV DNA. Quantitative IHC for hepatocyte HBsAg confirmed a relationship with viral replication only in HBeAg-positive patients. CONCLUSION The correlation between quantitative HBsAg titer and serum and intrahepatic markers of HBV replication differs between patients with HBeAg-positive and HBeAg-negative CHB. HBeAg titers may fall independent of viral replication as HBeAg-defective variants emerge prior to HBeAg seroconversion. These findings provide new insights into viral pathogenesis and have practical implications for the use of quantitative serology as a clinical biomarker.
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Affiliation(s)
- Alexander J V Thompson
- Department of Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria, Australia
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Affiliation(s)
- D Iser
- Department of Gastroenterology, St. Vincent's Hospital, Fitzroy, Victoria 3065, Australia
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Affiliation(s)
- K K Sia
- Department of Gastroenterology, Western Hospital, Footscray, Victoria, Australia
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