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Hepatitis C testing and treatment initiations in the United States dropped by 31% at the beginning of the COVID-19 pandemic in 2020 and treatment initiations did not recover to previous levels during 2020, an analysis of testing and treatment data published in the journal Clinical Infectious Diseases shows.

Modelling based on these findings, presented last month at the 2022 Conference on Retroviruses and Opportunistic Infections, indicates that if the reduction in treatment initiation was sustained for at least two years, the number of deaths due to hepatitis C would be almost twice as high than if the reduction in treatment initiation only lasted one year.

The study assessed hepatitis C testing and treatment activity in the United States from a national database that integrates data on laboratory testing and prescriptions.

Antibody tests dropped by 37% from March to April 2020. Test numbers rebounded to pre-COVID levels by the end of 2020.

Hepatitis C treatment initiations fell by 31% during the early months of the pandemic but did not recover to pre-COVID levels by the end of 2020.

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Hepatitis C care located within a needle and syringe programme in New York achieved a three times higher cure rate than referral to a patient navigator and linkage to medical care at a harm reduction programme or clinic, a randomised trial in New York City has found.

Improving the uptake of hepatitis C care among people who inject drugs is essential for achieving the elimination of hepatitis C, especially in countries where the majority of people with hepatitis C are current drug users.

Offering care in services with low barriers to entry, where service users can walk in without an appointment and also obtain methadone maintenance, has been shown to encourage the uptake of treatment among people who inject drugs.

The study, carried out at the Lower East Side Harm Reduction Center in Manhattan, was designed to test whether offering hepatitis C treatment through a ‘low threshold’ drugs service resulted in better cure rates than linking people to existing hepatitis C care in medical facilities.

People in the accessible-care arm were significantly more likely to achieve a sustained virological response (cure) than people in the standard-care arm (67% vs 22%), due to a much higher rate of linkage to care. People in the accessible-care arm were more likely to be referred to a hepatitis C clinician (92% vs 44%), more likely to attend the first clinical visit (86% vs 37%), to complete baseline laboratory testing (86% vs 31%) and start treatment (78% vs 26%).

Depression, anxiety and cognitive performance each improved significantly in people cured of hepatitis C, Indian researchers report in the Journal of Viral Hepatitis.

Anxiety and depression are frequently reported by people with hepatitis C at all stages of liver disease. Neurocognitive impairment – including slowed mental processing speed and reaction times, reduced attention span and verbal fluency, and impaired memory – may affect up to half of people with hepatitis C. The impact on the brain may be twofold in hepatitis C: by a direct impact of the virus, and indirect impact of advanced liver disease. The hepatitis C virus has been found to infect, and replicate, in brain cells. On the other hand, hepatic encephalopathy is a decline in brain function seen in late-stage liver disease when the liver can no longer remove toxins from the blood. Hepatic encephalopathy may appear in any late-stage liver disease, regardless of the course. Its symptoms range from sub-clinical symptoms to severe forms of neurocognitive impairment including confusion and coma.

The Indian state of Punjab provides treatment for hepatitis C and comprehensive health care at 25 decentralised clinics. The Punjab public health treatment model uses a pangenotypic regimen, either sofosbuvir/daclatasvir for people without cirrhosis or sofosbuvir/velpatasvir for people with cirrhosis.

Researchers at Chandigarh University recruited 385 people who started treatment between June 2018 and March 2020, to assess the impact of hepatitis C cure on mental health conditions and neurocognitive functioning.

Study participants exhibited substantial cognitive impairment at baseline, regardless of cirrhosis status, when compared to healthy controls or people with non-alcoholic fatty liver disease.

People who were cured of hepatitis C experienced significant improvements in depression, anxiety and cognitive function, whereas those who were not cured experienced no change or deterioration in various measures. They showed significant improvements in reaction time, visual memory, concentration, attention and processing skills and short-term and working memory. In contrast, scores on these tests deteriorated in people who were not cured.

The study investigators say theirs is the largest prospective cohort study of neurocognitive changes after hepatitis C treatment to date, recruiting almost ten times as many participants as any previous study, and its findings are strengthened by the exclusion of people with a prior history of hepatic encephalopathy.

The prevalence of hepatitis C in England fell by almost 40% between 2015 and 2020 and deaths due to the virus fell by 35% in the same period, the UK Health Security Agency reported earlier this month.

“In England, we are on our way to eliminating hepatitis C as the number of deaths continue to decline and direct acting antiviral drugs are available that will clear the virus in around 95% of people who complete treatment,” said Dr Helen Harris, Chief Scientist at the UK Health Security Agency (UKHSA).

The UKHSA report estimates that hepatitis C prevalence has fallen from around 129,000 in 2015 to around 81,000 in 2020 – a 37% fall in the general population.

The reduction in prevalence has been largely achieved by increased access to treatments, with around 58,850 treatments taking place between April 2015 and the end of March 2021.

The UKHSA modelling estimates that the prevalence of hepatitis C among people who inject drugs in England has fallen from 28% in 2015 to 17% in 2020 – a 40% decline in prevalence.

But despite a doubling in testing activity in drugs services between 2015 and 2020, UKHSA estimates that 60% of people who inject drugs living with hepatitis C in 2020 were unaware of their infection in 2020.

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Liver fibrosis in people with HIV in low- and middle-income countries was more often attributable to metabolic disorders than viral hepatitis, a six-country comparative study has found.

The findings, presented last month at the 2022 Conference on Retroviruses and Opportunistic Infections, suggest that prevention of type 2 diabetes and obesity will be critical for avoiding a growing burden of severe liver disease in people living with HIV as they age.

Screening for liver disease was carried out by Fibroscan transient elastography and showed that 11% had F2-F4 fibrosis, while 31% had steatosis. Prevalence of both conditions was highest in Brazil and India, where over 40% had steatosis and approximately 20% had fibrosis.

The prevalence of viral hepatitis was relatively low compared to cohorts of people with HIV in Europe and Asia: 4.5% had hepatitis B and 3.4% had hepatitis C.

In the multivariable analysis, obesity and type 2 diabetes were each associated with a 2.5-fold increase in the risk of fibrosis, while obesity raised the risk of steatosis fivefold. Type 2 diabetes tripled the risk of steatosis. Dyslipidemia and hypertension did not increase the risk of fibrosis or steatosis.

The researchers calculated what proportion of liver fibrosis in the study population was attributable to the risk factors that proved significant in multivariable analysis (the population attributable fraction). Eighteen per cent of fibrosis was attributable to obesity, 12% to type 2 diabetes, 8% to chronic hepatitis and 3% to hepatitis B.

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Non-alcoholic fatty liver disease or liver fibrosis raised the risk of cardiovascular disease in people with HIV who have either normal body weight or are under 60, Italian and Canadian researchers report in the journal HIV Medicine.

The study investigators say that people with HIV should ideally be screened for non-alcoholic fatty liver disease or referred for screening if they have a raised risk of liver fibrosis on laboratory tests, in order to identify people who may be at higher risk of cardiovascular disease.

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