Patient acceptability of, and attitudes towards, hepatitis B cure research - A scoping review and identification of knowledge gaps

Functional cure, defined as durable loss of hepatitis B surface antigen (HBsAg) and hepatitis B virus (HBV) DNA suppression off therapy, is an increasingly important goal in the treatment of chronic hepatitis B. Although novel treatments aimed at achieving functional cure are being developed and tested in clinical trials, it is important to assess the perspectives of people living with HBV towards these potential treatments and their participation in HBV functional cure research. We have performed a scoping review that revealed that there is limited knowledge regarding patient perspectives of HBV functional cure research and then identified gaps in knowledge for further investigation. Our work highlights the need for further studies in patient perspectives in HBV functional cure research.

Comparison of Antiretroviral Therapies in Pregnant Women Living With Human Immunodeficiency Virus and Hepatitis B Virus: A Randomized Controlled Trial

OBJECTIVE

To describe the anti-hepatitis B virus (HBV) efficacy, HBeAg serologic changes, HBV perinatal transmission, and safety in pregnant women who are living with human immunodeficiency virus (HIV) and HBV co-infection who were randomized to various antiretroviral therapy (ART) regimens.

METHODS

The PROMISE (Promoting Maternal and Infant Survival Everywhere) trial was a multicenter randomized trial for ART-naive pregnant women with HIV infection. Women with HIV and HBV co-infection at 14 or more weeks of gestation were randomized to one of three ART arms: one without HBV treatment (group 1) and two HBV treatment arms with single (group 2) or dual anti-HBV activity (group 3). The primary HBV outcome was HBV viral load antepartum change from baseline (enrollment) to 8 weeks; safety assessments included alanine aminotransferase (ALT) level, aspartate aminotransferase (AST) level, and anemia (hemoglobin less than 10 g/dL). Primary comparison was for the HBV-active treatment arms. Pairwise comparisons applied t test and the Fisher exact tests.

RESULTS

Of 3,543 women, 3.9% were HBsAg-positive; 42 were randomized to group 1, 48 to group 2, and 48 to group 3. Median gestational age at enrollment was 27 weeks. Among HBV-viremic women, mean antepartum HBV viral load change at week 8 was -0.26 log 10 international units/mL in group 1, -1.86 in group 2, and -1.89 in group 3. In those who were HBeAg-positive, HBeAg loss occurred in 44.4% at delivery. Two perinatal HBV transmissions occurred in group 2. During the antepartum period, one woman (2.4%) in group 1 had grade 3 or 4 ALT or AST elevations, two women (4.2%) in group 2, and three women (6.3%) in group 3.

CONCLUSION

Over a short period of time, HBV DNA suppression was not different with one or two HBV-active agents. HbeAg loss occurred in a substantial proportion of participants. Perinatal transmission of HBV infection was low. Hepatitis B virus-active ART was well-tolerated in pregnancy, with few grade 3 or 4 ALT or AST elevations.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT01061151.

1247. Primary Care Teams in Veterans Health Administration Have High Knowledge of Universal HCV Screening But Favor System-Level Interventions to Close Care Gaps

Background

In 2020, the United States Preventive Services Taskforce recommended one-time Hepatitis C virus (HCV) screening for all adults aged 18-79. As the largest provider of HCV treatment in the US the Veterans Health Administration (VA) is committed to implementing these recommendations; thus, understanding perspectives of primary care teams towards this is critical.

Methods

We disseminated a 24-item online survey to PCPs at the VA Greater Los Angeles Healthcare System (VAGLAHCS), serving 1.5 million Veterans within an area that spans five counties. Our sample included physicians, pharmacists, nurse practitioners, and physician assistants on primary care teams. Our survey contained questions on demographics, provider knowledge of HCV testing, practice patterns and beliefs, and preferences for new screening tools. Descriptive statistics were completed and we compared item responses across demographics. Hypothesis testing was performed using Wilcoxon rank sum test for continuous variables and Fisher’s exact or Chi-square tests for categorical variables.

Results

In total, 107 PCPs responded to the survey (107/385=28% response rate), with 100 complete responses. Most respondents were women (63%) with median age of 42 years, physicians (53%), Internal Medicine-trained (47%), and of Asian descent (45%). A majority (59%) were aware of new screening recommendations. Most PCPs reported confidence (71%), intent (77%), and commitment towards (82%) HCV screening. Only 38% reported remembering to screen Veterans regularly. Physicians were most aware of new recommendations (73%), compared to pharmacists (55%) and nurse practitioners (42%). The most strongly preferred strategies to enhance screening included automatic test orders during physician visits (71%), automatic electronic-consults (68%), clinician reminders for HCV screening (57%), and opt-out phlebotomy (48%).

Conclusion

In a sample of providers within a large and diverse VA, 3 in 5 PCPs were aware of new universal HCV screening recommendations. There is high motivation among PCPs to perform screening, but forgetting to screen is still common. Several strategies to augment universal HCV screening were acceptable towards PCPs.

Disclosures

Debika Bhattacharya, MD, MSc, Gilead: Grant/Research Support|Regeneron: Grant/Research Support.

1234. Analysis of an Automated Letter HCV Screening Program within a Veterans Affairs Health System: Implications for Universal HCV Screening

Background

Although universal Hepatitis C Virus (HCV) Screening in the US was recommended in 2020, the optimal implementation method is unknown. We characterized the efficacy of an automated letter HCV screening program at the Veteran’s Affairs (VA) Greater Los Angeles Healthcare System (VAGLAHS) and evaluated associations with linkage to care.

Methods

From January 2017 to May 2020, 14,804 Veterans born between 1945-1965 who did not have an HCV antibody (Ab) test result within the last 10 years and who were within the VAGLAHS catchment area were identified. Veterans were mailed a letter recommending HCV screening via a centralized process. Veterans then used the letter to present to a VA laboratory for HCV Ab testing, which included reflex HCV viral load. Those who were HCV viremic were referred to Hepatology/Infectious Diseases clinics for initiation of HCV treatment. Baseline characteristics of those with subsequent HCV viremia were collected. To determine associations with the first HCV visit (linkage to care), we performed independent chi-squared tests.

Flowchart of Automated Letter HCV Screening for Veterans

Results

A total of 12,875 Veterans were identified, 4,011 (31%) Veterans presented for HCV Ab testing, 167/4011 were HCV Ab + (4.2%), and 69/167 (41.3%) had HCV viremia. Of those viremic, 94 % were male, 26% were African-American, 62% had stable housing, 24% lived >90 miles from the nearest VA clinic, and 17% had cirrhosis. Fifty-five Veterans (80%) were evaluated in a viral hepatitis clinic and 84 % (46/55) initiated HCV treatment (Figure 1). Patients’ housing status (p = 0.02), cirrhosis (p< 0.0001), and distance to clinic (p=0.063) were associated with non-linkage to an initial HCV appointment.

Conclusion

One third of Veterans approached via mail participated in HCV Ab testing. Overall HCV Ab positivity rates were 4% and nearly half had HCV viremia. The majority of Veterans were linked to care but housing status, cirrhosis, and distance to clinic were associated with non-linkage to care. Automated letter screening is a promising approach to HCV screening, including universal screening. Future research should include investigations of telehealth and e-consults for linkage to care, especially for those who have marginalized housing status and live far from clinic.

Disclosures

Debika Bhattacharya, MD, MSc, Gilead: Grant/Research Support|Regeneron: Grant/Research Support.

Brief Report: Impact of Antiretroviral Regimen on Pregnancy and Infant Outcomes in Women With HIV/ HBV Coinfection

BACKGROUND

There are limited data on the impact of antenatal antiretroviral regimens (ARV) on pregnancy and infant outcomes in HIV/HBV coinfection. We compared outcomes among 3 antenatal antiretroviral regimens for pregnant women with HIV/HBV.

METHODS

The PROMISE study enrolled ARV-naive pregnant women with HIV. Women with HBV were randomized to (no anti-HBV)-zidovudine (ZDV) + intrapartum nevirapine and 1 week of tenofovir disoproxil fumarate and emtricitabine (TDF-FTC); (3TC)-3TC + ZDV + LPV/r; or (FTC-TDF)-FTC + TDF + LPV/r. Pairwise group comparisons were performed with Fisher exact, t , or log rank tests. Adverse pregnancy outcome (APO) was a composite of low birth weight, preterm delivery, spontaneous abortion, stillbirth, or congenital anomaly.

RESULTS

Of 138 women with HIV/HBV, 42, 48, and 48 were analyzed in the no anti-HBV, 3TC, and FTC-TDF arms. Median age was 27 years. APOs trended lower in the no anti-HBV (26%) vs 3TC (38%), and FTC-TDF arms (35%), P ≥ 0.25). More infant deaths occurred among the FTC-TDF [6 (13%)] vs no anti-HBV [2 (5%)] and 3TC [3 (7%)] arms. There were no differences in time-to-death, HIV-free survival, birth or one-year WHO Z-score length-for-age, and head circumference. Hepatitis B e antigen (HBeAg) was associated with an increased risk of APO, 48% vs 27% (odds ratio 2.79, 95% confidence interval: 1.19 to 6.67, post hoc ).

CONCLUSION

With HBV/HIV coinfection, the risk of an APO was increased with maternal ARV compared with ZDV alone, although the differences were not statistically significant. Maternal HBeAg was associated with a significantly increased risk of APO. Infant mortality was highest with FTC + TDF + LPV/r. Early assessment of HBeAg could assist in identifying high-risk pregnancies for close monitoring.

Hepatotoxicity and Liver-Related Mortality in Women of Childbearing Potential Living With Human Immunodeficiency Virus and High CD4 Cell Counts Initiating Efavirenz-Containing Regimens

BACKGROUND

Severe hepatotoxicity in people with human immunodeficiency virus (HIV) receiving efavirenz (EFV) has been reported. We assessed the incidence and risk factors of hepatotoxicity in women of childbearing age initiating EFV-containing regimens.

METHODS

In the Promoting Maternal and Infant Survival Everywhere (PROMISE) trial, ART-naive pregnant women with HIV and CD4 count ≥ 350 cells/μL and alanine aminotransferase ≤ 2.5 the upper limit of normal were randomized during the antepartum and postpartum periods to antiretroviral therapy (ART) strategies to assess HIV vertical transmission, safety, and maternal disease progression. Hepatotoxicity was defined per the Division of AIDS Toxicity Tables. Cox proportional hazards models were constructed with covariates including participant characteristics, ART regimens, and timing of EFV initiation.

RESULTS

Among 3576 women, 2435 (68%) initiated EFV at a median 121.1 weeks post delivery. After EFV initiation, 2.5% (61/2435) had severe (grade 3 or higher) hepatotoxicity with an incidence of 2.3 (95% confidence interval [CI], 2.0-2.6) per 100 person-years. Events occurred between 1 and 132 weeks postpartum. Of those with severe hepatotoxicity, 8.2% (5/61) were symptomatic, and 3.3% (2/61) of those with severe hepatotoxicity died from EFV-related hepatotoxicity, 1 of whom was symptomatic. The incidence of liver-related mortality was 0.07 (95% CI, .06-.08) per 100 person-years. In multivariable analysis, older age was associated with severe hepatotoxicity (adjusted hazard ratio per 5 years, 1.35 [95% CI, 1.06-1.70]).

CONCLUSIONS

Severe hepatotoxicity after EFV initiation occurred in 2.5% of women and liver-related mortality occurred in 3% of those with severe hepatotoxicity. The occurrence of fatal events underscores the need for safer treatments for women of childbearing age.

Significance and Management of Isolated Hepatitis B Core Antibody (Anti-HBc) in HIV and HCV: Strategies in the DAA Era

PURPOSE OF REVIEW

The purpose of this review is to summarize the prevalence and clinical implications of the isolated anti-HBc serologic profile in HIV-infected individuals. We highlight the rare but important issue of HBV reactivation in the setting of HCV therapy and describe an approach to management.

RECENT FINDINGS

The isolated anti-HBc pattern, a profile that most often indicates past exposure to HBV with waning anti-HBs immunity, is found commonly in HIV-infected individuals, particularly those with HCV. Some large cohort studies demonstrate an association with advanced liver disease, while others do not. Conversely, meta-analyses have found an association between occult HBV infection (a component of the isolated anti-HBc pattern) and advanced liver disease and hepatocellular carcinoma in HIV-uninfected individuals. In HIV-uninfected individuals with anti-HBc positivity, HBV reactivation has been reported in patients receiving HCV therapy. This phenomenon is likely the result of disinhibition of HBV with HCV eradication. In HIV-infected patients, the long-term liver outcomes associated with the isolated anti-HBc pattern remain to be fully elucidated, supporting the need for large cohort studies with longitudinal follow-up. HBV reactivation during HCV DAA therapy has been well-described in HIV-uninfected cohorts and can inform algorithms for the screening and management of the isolated anti-HBc pattern in this population.