Microelimination of HCV in people with co-infection

Microelimination of hepatitis C means breaking down targets for the elimination of hepatitis C into smaller population targets. Different populations have different needs and characteristics. For example, achieving elimination of hepatitis C in people who use drugs or in people with hepatitis C and HIV co-infection will require different approaches. Whereas people who use drugs are most likely to be reached for diagnosis and treatment through drug treatment and harm reduction services, people with HIV and hepatitis C co-infection are most likely to be reached through clinical services providing HIV treatment.

In the United Kingdom, the British HIV Association (BHIVA) has set a target of eliminating hepatitis C in people with HIV and hepatitis C virus (HCV) co-infection by 2021. BHIVA says that this target is feasible because some regions of the country have already achieved very high levels of treatment and cure. However, reaching the last 20% of patients is likely to prove more challenging because these people are likely to need more support to begin treatment and because they may have complex needs including housing, addiction treatment and co-morbidities.

Public Health England estimated that approximately 3300 people with HIV were also living with hepatitis C in England at the beginning of 2016. People with co-infection form a small proportion of the entire population of people with hepatitis C in the UK but a high proportion of those becoming newly infected with HCV. The incidence of hepatitis C in HIV-positive men who have sex with men has risen over the past ten years.

BHIVA says that it wants to see every person living with HIV and hepatitis C assessed for direct-acting antiviral treatment by April 2019 and 80% cured by that point. By April 2020 BHIVA wants to see 90% of hepatitis C infections cured in people living with HIV and complete elimination the following year.

Testing for hepatitis C

Slide from Rachel Epstein's presentation at IDWeek 2018.

Only about a third of adolescents and young adults diagnosed with opioid use disorder in the United States are screened for hepatitis C virus (HCV) or HIV, even though injection drug use is one of the main risk factors for transmission, according to a study presented at IDWeek 2018 in October in San Francisco.

Traditionally baby boomers born between 1945 and 1965 have had the highest rate of hepatitis C in the US, but the incidence of acute HCV infection has been rising among younger age groups in conjunction with the ongoing opioid epidemic. HCV infection rates have also risen among pregnant women and their babies.

The study looked at just over 269,000 young people who attended clinics between 2012 and 2017 in 19 states. Nine per cent had been diagnosed with a 'substance use disorder', predominantly cannabis use, and 0.3% had been diagnosed with an opioid use disorder. Thirty-six per cent of those with an opioid use disorder had been tested for HCV and only 11% of youth tested for HCV were also tested for HIV. Eleven per cent of opioid users, 3% of cocaine users and 6% of amphetamine users tested HCV positive. Opioid use was associated with a 20-fold higher risk and amphetamine with a ninefold higher risk of having HCV. The only other significant risk factor was older age.

What support do people with liver cirrhosis and their families need?

People with liver cirrhosis and their families need more information about their condition and prognosis and greater access to palliative care, a systematic review of studies on the needs of people with cirrhosis of the liver has concluded.

Patients consistently drew attention to several information gaps:

  • A lack of understanding of their disease, its progression or prognosis.
  • A lack of understanding of the need for hepatocellular carcinoma screening.
  • A lack of understanding of the connection between cirrhosis and symptoms they experienced.
  • A lack of awareness of palliative care.
  • Dissatisfaction with communication from healthcare professionals.

Patients wanted information about home-based care, how to manage their symptoms and what would happen if they needed to be admitted to hospital.

They wanted practical advice and support in stopping alcohol or drug use, and more information about hepatic encephalopathy and how to manage it.

Healthcare professionals were aware of the desire for more information and recognised that patients often did not understand the severity of their liver disease.

They recognised that they often provided suboptimal care for people with cirrhosis and needed to be more active in addressing quality of life issues.

Liver specialists said they lacked the skills and training to talk to patients about prognosis and end-of-life issues or about the need for screening for liver cancer. Both liver specialists and primary healthcare practitioners said that they experienced resistance from patients and families to talking about palliative care, due to a perception that it meant end-of-life care.

In fact, as well as end-of life care, palliative care outside the hospital setting might consist of any of the following:

  • Large-volume paracentesis (drainage of a build-up of fluid from the abdomen); has the potential to reduce hospital admissions in people with ascites.
  • Pain relief that is sensitive to the potential renal toxicity of NSAIDs in people with cirrhosis and to the impact of opioid side-effects on the symptoms of hepatic encephalopathy.
  • Symptom management.
  • Caregiver support.

The review concluded that better communication would be supported by:

  • Development of lists of recommended questions to be provided to patients and their families before consultation, to encourage discussion.
  • Training to reduce stigma of cirrhosis among healthcare workers.

Improved access to palliative care would be supported by:

  • Screening tools that can help identify patients with a need for early referral to palliative care.
  • Improved care co-ordination between specialist liver teams, general practitioners and palliative care teams.

What are the barriers to hepatitis C treatment in prisons?

Lack of privacy, lack of peer support and lack of harm reduction are perceived as the biggest barriers to improving the uptake of direct-acting antiviral treatment for hepatitis C among prisoners, a qualitative study among prisoners in Australia has found.

The findings, published in the Journal of Viral Hepatitis, underline the need for messaging from prison authorities which emphasises the opportunity for treatment, say the authors of the study, who are associated with the STOP-C study of hepatitis C elimination in prisons in the state of New South Wales.

Hepatitis C is highly prevalent among prisoners, as many incarcerated people have a history of injecting drug use. Where hepatitis C treatment is provided through prison medical services, promotion of treatment availability needs to take into account barriers within the prison environment. The Australian research found that lack of harm reduction in the prison was perceived a major barrier, as prisoners were concerned about the risk of reinfection after being cured if they subsequently shared needles and syringes.

The investigators suggest that prison health services seeking to encourage the uptake of treatment should emphasise the following messages to prison inmates with hepatitis C:

  • Ease of access to treatment in the prison.
  • Accessing hepatitis C treatment in prison is an opportunity for self-improvement prior to release, a 'new start'.
  • Treatment is free.

Prisons should also focus on bringing injecting networks into treatment together rather than penalising injecting. Treating entire injecting networks at the same time would also reduce the risk of reinfection in the absence of needle and syringe programmes in prisons.

Lack of harm reduction measures in prisons was highlighted as a major barrier to hepatitis C elimination in prisoners in a European survey by the European Liver Patients Association earlier this year. The survey also found that hepatitis C treatment was available to all prisoners in only five European countries.

Low dead-space syringes associated with lower HCV prevalence

Low dead-space syringes (LDSS) are syringes with needles attached. They retain far less blood after injecting than syringes with detachable needles. By retaining less blood, LDSS may reduce the risk of hepatitis C transmission by sharing of injecting equipment.

LDSS are distributed by needle and syringe programmes and are recommended by the World Health Organization as a means of reducing the transmission of blood-borne infections. However, evidence is still lacking on the extent to which LDSS reduce the transmission of hepatitis C.

Exclusive use of LDSS is associated with a lower prevalence of hepatitis C virus (HCV) in people who inject drugs, especially in people who began injecting drugs recently, a study in the United Kingdom has found. The study is published in the journal Drug and Alcohol Dependence.

Need for liver transplants due to hepatitis C drops in the United Kingdom

Registrations for liver transplants due to complications of hepatitis C infection in the United Kingdom fell sharply between 2013 and 2016, coinciding with the gradual increase in availability of direct-acting antiviral treatment, researchers from seven of the country’s leading liver clinics reported in the Journal of Viral Hepatitis in October.

The decline in need matches a pattern also reported in Italy and the United States in recent years.

News coverage of The Liver Meeting 2018

In November, infohep will be providing news coverage from The Liver Meeting 2018, organised by the American Association for the Study of Liver Diseases (AASLD). The conference is taking place in San Francisco, USA from 9-13 November.

We will be publishing news online and the November infohep bulletin will be dedicated to news from the conference.

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