African hepatitis summit

Uganda hosted the first African Hepatitis Summit in June. According to the World Health Organization (WHO), approximately 200,000 people die from complications due to viral hepatitis in Africa each year and 60 million people are living with hepatitis B in Africa.

Despite the high burden of viral hepatitis, only three of the 47 countries in sub-Saharan Africa are on track to eliminate viral hepatitis by 2030, a scorecard released by WHO ahead of the meeting showed.

The analysis shows that 28 countries have developed a national hepatitis strategic plan for viral hepatitis; however, most are still in draft form with only 13 officially published and disseminated.

Only 15% (7/47) countries are leading prevention efforts with national coverage of both hepatitis B birth dose and childhood vaccination exceeding 90%. There are major gaps in hepatitis testing and treatment with less than eight countries providing subsidised testing and treatment for viral hepatitis. Uganda has started free nationwide hepatitis B treatment, and Rwanda is providing free treatment for both hepatitis B and C. These two countries are championing the regional response and are on track to reach the 2020 Framework targets for testing and community awareness.

With investments of around US$ 3 million a year, Uganda embarked on a massive, free hepatitis B screening programme in 2015, along with widespread community mobilisation and awareness-raising actions. More than four million people have been screened.

Egypt to provide hepatitis C testing, treatment for 14 countries

Although hepatitis C is less prevalent than hepatitis B in sub-Saharan Africa, approximately 10 million people are estimated to have chronic hepatitis C infection. The most frequent route of transmission is unsafe injection practices in health facilities, according to the World Health Organization.

Treatment of hepatitis C using direct-acting antivirals (DAAs) is extremely limited in the region except in Rwanda, where a 5-year national elimination programme has won support from the Clinton Health Access Initiative and Partners in Health. Rwanda’s Ministry of Health aims to screen four million people for hepatitis C over the next three years. Ten thousand people have already been treated in a pilot programme and DAA treatment is now being provided through all hospitals in Rwanda.

Egypt’s large-scale testing and treatment programme is the only national programme in North Africa and the Middle East. The Egyptian Ministry of Health announced that it will share its expertise in community screening and treatment with 14 countries in sub-Saharan Africa and provide free treatment with generic DAAs manufactured in Egypt for 1 million people.

The 14 countries are Burundi, Chad, the Democratic Republic of Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Kenya, Mali, Somalia, South Sudan, Sudan, Tanzania and Uganda.

Opioid substitution prescribers and DAA treatment

Across the world, only 30% of physicians who prescribe opioid substitution therapy to people who inject drugs have also prescribed direct-acting antivirals (DAAs), despite being ideally placed to offer testing and treatment for hepatitis C, an international survey has found.

Opioid substitution therapy consists of prescribing medical opioids to reduce dependence on injected heroin. People who use drugs are enabled to avoid the harms associated with injecting illicit drugs, such as bacterial infections, arrest and imprisonment, and may stabilise their daily routines.

Pangenotypic treatment in France

French health authorities have recommended that everyone diagnosed with hepatitis C should be treated with a pangenotypic direct-acting antiviral combination by a general practitioner unless they have severe liver disease, co-infection or kidney disease and need to be referred to a liver specialist.

The new guidance is intended to simplify testing and treatment initiation and speed progress towards the target of eliminating hepatitis C in France by 2030. The guidance has been issued by the Haute Autorité de Santé, the French national authority for health technology assessment and development of healthcare guidelines.

The guidance recommends that everyone who has been at risk of hepatitis C exposure should be tested for hepatitis C. The new guidance cuts down on testing in people with chronic hepatitis C infection: no genotyping will be needed owing to the use of pangenotypic treatment, and only two viral load tests will be carried out, one at the time of diagnosis and another test 12 weeks after the completion of treatment to check for sustained virologic response.

How much can 'Netflix'-style pricing for hepatitis C drugs save?

A 'Netflix'-style pricing agreement that allows the Australian government to treat an unlimited number of people with hepatitis C for AU$1 billion may result in savings close to US$5 billion, according to an analysis published recently in the New England Journal of Medicine.

The so-called 'Netflix' model, also being explored by the US state of Louisiana, allows treatment for an unlimited number of people during a fixed period, just as subscription to the streaming entertainment channel Netflix allows unlimited viewing.

Parkinson’s disease risk in people treated for hepatitis C

People with hepatitis C who received interferon-based treatment were less likely to develop Parkinson’s disease, a large study from Taiwan has concluded. The results, published in JAMA Neurology, add to the evidence that hepatitis C is a risk factor for developing Parkinson’s disease and that antiviral treatment may reduce this risk, say the study authors.

Parkinson’s disease is a degenerative neurological condition that leads to tremors, slowed movement and eventually to difficulties in walking, standing and swallowing. The risk of developing Parkinson’s disease increases with age and several epidemiological studies have shown that hepatitis C infection increases the risk of developing Parkinson’s disease.

The Taiwan study looked at everyone treated for hepatitis C with interferon-based treatment between 2003 and 2013 and matched them by age, sex and co-morbidities with the same number of people with hepatitis C who remained untreated.

Although there was no difference in the risk of developing Parkinson’s disease after one year or three years of follow-up, a significant difference in risk was evident after five years of follow-up. Treated people were around 25% less likely to have developed Parkinson’s disease by this point.

The study could not distinguish between people cured of hepatitis C and those who did not respond to treatment. Nor does it provide any information about the impact of the new direct-acting antivirals on the risk of developing Parkinson’s disease.

Hepatitis C stigma

Qualitative research with HIV-positive gay and bisexual men in Australia who had been cured of hepatitis C infection revealed that having hepatitis C was more stigmatising than HIV infection. While being a member of certain social and sexual networks increased the chances of reinfection with hepatitis C, leaving these networks and abstinence from drug use could lead to social isolation.

Engagement with treatment services for hepatitis C often led to a better understanding of hepatitis C infection risks and an improvement in strategies to avoid reinfection. Participants also reported that engagement in hepatitis C care encouraged a reduction in sexualised drug use (often called 'chemsex' or 'party 'n' play'). This was reported in the Journal of the International AIDS Society by Sophia Schroeder and colleagues at the Burnet Institute in Melbourne.

Liver cancer screening

There is a “strikingly low adherence” to clinical guidelines for ultrasound screening for hepatocellular carcinoma in western Europe, researchers report in the Journal of Viral Hepatitis.

Over years or decades, chronic hepatitis B or C can cause serious liver disease including both cirrhosis and liver cancer (hepatocellular carcinoma, HCC). The risk of HCC is elevated in people with cirrhosis and in people with hepatitis/HIV co-infection.

HCC treatment is more likely to be successful if the cancer is diagnosed promptly. Clinical guidelines from the European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD) and European AIDS Clinical Society (EACS) therefore all recommend that adults with cirrhosis should be screened with ultrasound scans for HCC every six months.

Hepatitis C vaccine not effective

An early-stage test of an experimental hepatitis C vaccine has shown that the vaccine did not prevent infection.

The study tested a prime-boost vaccine, consisting of a first vaccine to prime the immune system to recognise hepatitis C, followed by a second vaccination with a vaccine designed to expand and boost the immune response to hepatitis C.

The study recruited 548 people with a recent history of injecting drugs and followed them for approximately three years after vaccination. There was no significant difference in the rate of infection between people who received the experimental vaccine and people who received a dummy vaccine.

The results are disappointing but not surprising. Spontaneous clearance of prior infection with hepatitis C does not confer immunity against subsequent infection. Antibodies to hepatitis C are not protective and the immune profile that is required to protect against hepatitis C infection is unknown.

Despite these challenges – some of which are also faced by developers of experimental HIV vaccines – a vaccine against hepatitis C remains a priority if elimination of hepatitis C is to be achieved.

The study sponsor, the United States National Institute of Allergy and Infectious Diseases (NIAID), says that it will continue to support research into a hepatitis C vaccine.

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