End-stage liver disease deaths due to hepatitis C fall in the United Kingdom and Australia

Deaths from liver failure or liver cancer caused by hepatitis C fell by 20% between 2016 and 2018 in Australia, the Kirby Institute at the University of New South Wales reported in August.

A similar trend was evident in the United Kingdom, Public Health England (PHE) reported.

Deaths from end-stage liver disease and liver cancer caused by hepatitis C in the United Kingdom fell by 11% in 2017, provisional figures from PHE released on 28 July show.

Most of the decline was the result of a reduction in deaths from end-stage liver disease, not liver cancer, PHE says, and took place at the same time as a 19% increase in the number of people who received direct-acting antiviral (DAA) treatment. PHE says that the United Kingdom is on track to achieve the World Health Organization’s target of a 10% reduction in hepatitis C virus-related mortality by 2020.

Just over 14,000 people started DAA treatment from April 2017 to March 2018, an increase of 19% on the previous year and a doubling of the number of people receiving treatment for hepatitis C compared to 2014. PHE warns that the biggest obstacle to further increases in the number of people accessing treatment will be the ability of the NHS, harm reduction and drug treatment services to diagnose and link to care people with undiagnosed hepatitis C.

PHE also reported that nearly two-thirds of those diagnosed with hepatitis C and found to have co-infection with HIV in England between 2008 and 2014 were men who have sex with men. Two-thirds of all those diagnosed as having co-infection had been diagnosed with HIV at least six months before their hepatitis C diagnosis, indicating that they were exposed to hepatitis C after HIV diagnosis. In most of the cases in men who have sex with men, the route of exposure was sexual activity, not injecting drug use.

Supervised drug consumption rooms and hepatitis C testing and treatment

Activists at the Towards Zero Together march in Amsterdam. Photo by Liz Highleyman.

Drug consumption rooms, known in some countries as supervised injection facilities, allow people to use drugs under the watch of trained staff, who can administer naloxone (Narcan) if needed to reverse opioid overdoses. They provide sterile syringes and other equipment, preventing transmission of HIV, hepatitis B virus and hepatitis C virus (HCV). They reduce street-based drug use and improper syringe disposal, as well as offering clients an entry point for seeking addiction treatment and medical care.

Supervised consumption sites tend to serve the most vulnerable people who inject drugs, including those facing mental health issues and homelessness. Research has shown that they reduce risk behaviour and harms associated with drug use including overdose and infectious disease transmission.

There are currently around 100 drug consumption rooms around the world, most of them in Europe. Amsterdam was among the cities that pioneered the concept in the 1980s. Australia has a supervised injecting centre in Sydney and one in Melbourne. Vancouver's Insite, the first North American facility, served more than 7300 clients in 2017.

Most supervised drug consumption facilities offer HCV testing and referrals, but very few offer treatment, indicating that they could potentially play a greater role in curbing transmission and negative health outcomes related to hepatitis C, according to research presented at the 22nd International AIDS Conference in Amsterdam in July.

A survey of 49 supervised drug consumption facilities, conducted in 2016, found that two-thirds offered HCV antibody testing and approximately 80% of clients at these facilities received testing. Just over 60% tested positive for hepatitis C. Liver health monitoring in the form of either blood tests or FibroScan, was offered by around 25% of facilities. Only 4% of facilities offered treatment at the time of the survey.

Development of referral pathways for treatment or an offer of treatment onsite would require an increase in staff capacity, facilities told the researchers. The study concluded that supervised drug consumption facilities have the potential to become low-threshold HCV treatment providers for people who inject drugs if they are supported with funding and training and could reach undiagnosed people with HCV infection not currently engaged in healthcare.

Injecting drug users in South Africa: a high prevalence of HCV

The South African National AIDS Council estimates that around 17,000 South Africans inject drugs, out of a total population of 55 million. Although the prevalence of injecting drug use is low in comparison with some other middle-income countries such as Brazil or Malaysia, a recent national survey has found that around half of people who inject drugs in South Africa already have hepatitis C infection.

The TB/HIV Care Association of South Africa surveyed the prevalence of HIV and viral hepatitis in 3400 people at higher risk of acquiring HIV through unprotected sex or sharing injecting equipment. Overall, 13% of the sample had hepatitis C but half of people who injected drugs had hepatitis C virus (HCV) antibodies.

Harm reduction programmes offering clean needles and injecting equipment and opioid substitution therapy are very limited in South Africa. The report urged scale-up of these services, together with allocation of funds to pay for hepatitis C treatment by South Africa’s provincial governments.

Transplants using organs from donors with HCV

Direct-acting antiviral treatment has the potential to increase the pool of organs available for transplant, a study from Penn Medicine in the United States reports. By taking organs from donors with hepatitis C and treating hepatitis C infection in the recipient as soon as possible after transplantation, it should be possible to eliminate the risk of chronic hepatitis C infection after transplantation – and reduce transplant waiting times. University of Pennsylvania researchers reported this month that kidneys from 20 deceased donors with hepatitis C have now been safely transplanted and hepatitis C has been cured in all cases.

Other research centres have shown similar success with lung transplants. Some experts say that the opioid overdose epidemic in the United States is likely to lead to a greater number of younger hepatitis C virus (HCV)-positive donors, which means that kidneys, hearts and other organs may have less age-related and HCV-related damage. A greater availability of organs would reduce waiting times for transplants.

Although the results of the Penn Medicine and other early studies are promising, the American Society of Transplantation says that more studies are needed to fully understand the risks and benefits. Another issue is that many US patients have no or insufficient health insurance to cover the cost of antiviral treatment, which becomes necessary after the transplant. This means that some of these transplanted patients may have to live with a newly acquired hepatitis C infection, without a guarantee that their infection will be cured, for cost reasons. This raises additional ethical questions, even more so because chronic hepatitis C may take a more aggressive course in immunosuppressed and transplanted patients.

China Gilead patent

Following a patent challenge by I-MAK, Gilead Sciences has withdrawn a patent claim on the base compound for the direct-acting antiviral sofosbuvir. I-MAK says that the decision will allow manufacturers in China to produce generic versions of sofosbuvir from 2019. Sofosbuvir is currently marketed by Gilead in China at a cost of $8939 per treatment course but generic versions of the drug are already available for less than $100. I-MAK says that the decision will permit expansion of hepatitis C treatment in China where approximately 10 million people are estimated to have hepatitis C.

Jessica Burry of the MSF Access campaign said that as well as reducing the price in China, the decision would also allow Chinese manufacturers to supply the drug to other countries where this patent restriction does not apply.

Zepatier price cut

Merck has cut the price of its two-drug hepatitis C combination Zepatier (grazoprevir/elbasvir) by 60%. The decision makes the combination the cheapest option for a 12-week or 8-week course of treatment and the company hopes that the decision will stem declining sales and make Zepatier competitive with AbbVie’s pangenotypic combination product Maviret.

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