Hepatitis C testing and treatment in prisons

Prisoners have a higher prevalence of hepatitis C than the general population, both because of risk factors prior to imprisonment and risk factors in the prison environment, including sharing of injecting equipment and tattooing using unsterilised equipment.

The incidence of hepatitis C in prisoners who inject drugs while in prison is very high; a systematic review of studies of hepatitis C virus (HCV) infection in prison found that among people with a history of injecting drug use, 16 out of 100 prisoners would become infected for each year they spent in prison.

Governments in the European region have agreed to work towards the elimination of hepatitis C by 2030. To achieve this target, prevention and treatment of hepatitis C in prisoners must be a priority owing to the high prevalence of hepatitis C among prisoners. The prevalence of hepatitis C in prisoners is above the average for the general population in all countries where it has been measured.

However, two reports published in May show the serious shortcomings of hepatitis C prevention, testing and treatment in prisons in the European region.

A survey of prison prevention and harm reduction policy and practice in European countries was carried out by the European Liver Patients Association as part of the Hep-CORE study. Hep-CORE is a cross-sectional study of viral hepatitis policy implementation in Europe, using responses from hepatitis patient groups in 25 countries gathered in 2016 and 2017.

The Hep-CORE study found that 16 countries reported no HCV screening policy for prisoners. Only nine European countries had identified prisoners as a population at high risk of HCV infection and a priority group for screening. Just one country, the United Kingdom, operates a universal opt-out screening programme for all prison entrants.

Access to HCV treatment in prisons is limited. Although 21 countries provide treatment to some prisoners, only five countries (Slovakia, Slovenia, Spain, Sweden and the United Kingdom) provide HCV treatment in all prisons. In other countries, treatment is not available in all prisons or information is unavailable about which prisons provide treatment, the survey found.

Needle and syringe programmes in prisons are permitted only in Romania and Spain but eleven countries offer opioid substitution therapy (OST) to prisoners, the survey found. However, in four out of eleven countries OST is provided only to those people already enrolled in OST programmes at the time of imprisonment, while regional variations to access exist in other countries.

The European AIDS Treatment Group collated available evidence on HCV prevalence and services for prison populations in Europe and developed in-depth case studies of six European countries to inform the development of recommendations on best practice from a community perspective.

Major recommendations of the report include:

  • HCV-related services in prisons should fall under the jurisdiction of the Ministry of Health rather than the justice ministry.
  • NGOs should be contracted to deliver services in prisons and funding for services should be sufficient to ensure consistent and sustainable services.
  • National surveillance mechanisms for hepatitis C and key populations affected by hepatitis C should be established to monitor the prevalence of HCV and progress towards achieving treatment and prevention goals.
  • Comprehensive harm reduction services should be provided in prisons.
  • Voluntary and confidential testing for viral hepatitis should be provided.
  • Ensure that a positive HCV or HIV diagnosis does not result in discrimination within the prison setting.
  • Make direct-acting antivirals available for all prisoners according to European Association for the Study of the Liver and European AIDS Clinical Society treatment guidelines and train prison doctors in the monitoring and treatment of hepatitis C.
  • Ensure that treatment is free and not dependent on health insurance status.
  • Introduce incentives for medical professionals to provide services in prisons.
  • Improve follow-up after release to ensure continuity of care.

Scotland and harm reduction

The reduction in new hepatitis C virus (HCV) infections that has taken place in Scotland since 2008 is most likely due to increased provision of needle and syringe programmes (NSP) and opioid substitution therapy (OST), rather than a reduction in the number of people with hepatitis C as a result of increased treatment of HCV infection, a modelling study published in the journal Addiction reports.

Scotland launched a national action plan for HCV and a national drug and alcohol strategy in 2008, which led to expanded coverage of NSP and OST. The vast majority of new infections in Scotland occur as a result of sharing injecting equipment, so researchers modelled the impact of these interventions.

Modelling the Scottish HCV epidemic and interventions introduced after 2008 led the researchers to estimate that HCV incidence among current drug injectors fell by 61% between 2008 and 2015.

The model examined the effect of scaling up OST and NSP after 2008 by looking at what would have happened without the increased scale of activity. The model found that even without these interventions, the incidence would still have declined by 27%. But the interventions reduced HCV incidence further, and averted an estimated 1492 infections. Two-thirds of the infections were averted as a result of the increased provision of NSP and OST. Most of the remainder were likely to have been averted by a reduction in the number of high-risk injectors – those injecting stimulants or homeless – and less than 5% by treatment of HCV.

"The study illustrates how a country-level HCV action plan incorporating the scale-up of a range of HCV prevention interventions can markedly reduce HCV incidence," the authors conclude. "However, even with high OST and NSP coverage, the impact achieved in Scotland still falls short of the World Health Organization’s strategy for reducing HCV incidence by 90%."

Hepatitis C treatment and payer coverage in US

Just over half of US patients with commercial insurance had prescriptions for direct-acting antivirals refused for reimbursement by insurers in 2016 and early 2017, a study of over 9000 people in 45 states has found. Thirty-five per cent of people insured by Medicaid and 15% of people insured by Medicare also suffered a refusal.

The study found that refusal rates were higher in 2017 than in 2016 for all types of insurance coverage.

Another study, looking at people with hepatitis C in care, found that by 2016 at least 300,000 people with hepatitis C were awaiting treatment in the United States. The study was able to assess the treatment status of the majority of people with diagnosed hepatitis C in the US by using records from the two largest laboratory chains in the US. The study found that a growing number of those awaiting treatment are younger and have early-stage fibrosis, indicating recent infection. However, the study also found that at least 23% of those awaiting treatment already had stage F3 or F4 fibrosis.

Birth cohort testing in Canada

The Canadian Association for the Study of the Liver has recommended that all Canadians born between 1945 and 1975 should be tested for hepatitis C. Dr Jordan Feld of Toronto’s University Health Network told the National Post that between two-thirds and three-quarters of people with chronic hepatitis C virus (HCV) infection in Canada were born between 1945 and 1975. Up to 70% of HCV infections in Canada may still be undiagnosed. The Canadian recommendation follows a US recommendation for screening of everyone born between 1945 and 1965. In Canada, screening people born up to 1975 was found to be cost-effective.

Hepatitis C testing in community pharmacies

Expanding the opportunities for people to obtain a hepatitis C virus (HCV) antibody test will be essential for achieving targets for diagnosis and treatment of hepatitis C. A recent pilot study in London shows that community pharmacies can successfully offer testing, reaching people at higher risk of HCV infection and achieving a high yield of positive diagnoses.

The pilot scheme offered HCV antibody testing at pharmacies with needle exchange facilities. The testing scheme was designed to reach people not engaged with drug treatment services who are active drug injectors. Two hundred and sixteen people were tested during the six-month pilot and 53% tested positive for HCV antibodies.

Although the pilot achieved a high yield of positive diagnoses, subsequent engagement in care was disappointing; 23 out of 84 people referred to secondary care subsequently attended. The report concluded that education on the availability of direct-acting antiviral (DAA) treatment needs to take place in pharmacies alongside testing, and ways of delivering DAA treatment through pharmacies should be evaluated.

Hepatitis C drugs to be discontinued

Two hepatitis C virus combination treatments, Technivie (ombitasvir, paritaprevir, ritonavir) and Viekira XR (dasabuvir sodium, ombitasvir, paritaprevir, ritonavir), have been discontinued by AbbVie, the US Food and Drug Administration announced last month. Technivie’s European equivalent, Viekirax, is still available.

Janssen has already discontinued Olysio (simeprevir) due to lack of demand in the United States and European Union.

Treatment for NASH

Non-alcoholic fatty liver disease (NAFLD) and its more severe form, non-alcoholic steatohepatitis (NASH) are often associated with obesity and the metabolic syndrome. The build-up of fat in the liver triggers inflammation and development of scar tissue (fibrosis), which over time can lead to cirrhosis, liver cancer and the need for a liver transplant.

Now that direct-acting antivirals can cure more than 95% of people with hepatitis C and experts in some countries are discussing its elimination as a public health threat, fatty liver disease is responsible for a growing share of advanced liver disease – and is getting a rising amount of attention at liver conferences. NASH is estimated to affect between 3 and 12% of American adults and might be the number one cause of liver transplant by 2020.

At The International Liver Congress in April, results of studies investigating drug treatments for NASH showed that some promising treatments are in mid-stage studies.

Cenicriviroc, a drug that blocks both CCR5 and CCR2 receptors on immune cells, continued to show an anti-fibrotic effect in people with NASH after two years of follow-up.

MGL-3196, a selective thyroid hormone receptor-beta (THR-beta) agonist, increases levels of thyroid hormone, leading to lower levels of liver fat. A 12-week dose comparison study found that treatment with the drug reduced liver fat in a dose-dependent manner. There was preliminary evidence of an improvement in liver fibrosis too.

The conference also heard results of a study of NGM282, an engineered analogue of human fibroblast growth factor 19 (FGF19). NGM282 targets multiple processes involved in the development of NASH, leading to improvements in steatohepatitis and fibrosis. The study of this agent also observed a reduction in liver fat, and fibrosis improved in just under half of participants in this small study.

Gilead is developing a combination of agents to target different processes in the development of NASH. The conference heard findings from a proof-of-concept study evaluating combinations of three experimental drugs from Gilead Sciences: the apoptosis signal-regulating kinase 1 (ASK1) inhibitor selonsertib (formerly GS-4997), the acetyl-CoA carboxylase (ACC) inhibitor GS-0976 and the selective non-steroidal farnesoid X receptor (FXR) agonist GS-9674. ASK1 promotes inflammation and fibrosis, ACC is involved in de novo lipogenesis (conversion of carbohydrates into fatty acids in the liver) and FXR regulates bile acid synthesis and plays a role in lipid metabolism.

Participants with NASH and F2/F3 fibrosis were randomly assigned to receive either selonsertib, GS-0976, GS-9674, selonsertib plus GS-0976, or selonsertib plus GS-9674, all once daily for 12 weeks. The greatest reductions in liver fat were seen in those who received selonsertib plus GS-0976.

7th International Symposium on Hepatitis Care in Substance Users

The 7th International Symposium on Hepatitis Care in Substance Users is being held from 19-21 September in Cascais, Portugal.

The symposium is the leading international conference focused on the management of hepatitis among substance users. It is organised by the International Network for Hepatitis in Substance Users (INHSU).

This year’s programme will include:

  • Day 1: Policy, Epidemiology and Public Health
  • Day 2: Hepatitis C virus (HCV) Diagnosis, Linkage to Care and Treatment
  • Day 3: HCV Treatment and Access.

National and international speakers will provide both a global perspective and a national perspective throughout the sessions, with several state-of-the-art lectures in their areas of expertise. The symposium will include proffered papers, invited speaker presentations and educational workshops.

The earlybird registration deadline is Friday 29 June.

2nd HEP-C Community Summit

The 2nd HEP-C Community Summit is being held on 18 September in Lisbon, Portugal. It is organised by Correlation Network and will bring together people from the affected communities, advocates, researchers, healthcare providers, harm reduction practitioners, and policymakers to discuss and to develop an enduring co-operation for building the road to hepatitis C virus (HCV) elimination.

The summit is organised in close co-operation with the International Network of Hepatitis in Substance Users (INHSU).

The HEP-C Community Summit will highlight the needs, current gaps and opportunities to make HCV treatment available for all people. The summit will also present and discuss community approaches for testing and treatment for HCV (and other diseases), and discuss and agree on further community action and advocacy steps.

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