Hepatitis C drops among HIV-positive London gay men after direct-acting antiviral scale-up

Lucy Garvey and Daniel Fierer at CROI 2019. Photo by Liz Highleyman.

New cases of hepatitis C virus (HCV) infection among HIV-positive gay and bisexual men receiving HIV care at three clinics in London have declined by nearly 70% since 2015, according to a presentation at the Conference on Retroviruses and Opportunistic Infections (CROI 2019) in Seattle.

The drop is largely attributable to regular HCV screening and a treatment-as-prevention effect resulting from wider use of direct-acting antiviral (DAA) therapy, especially during acute infection.

The British HIV Association aims to cure HCV in everyone with HIV and HCV co-infection by 2021. However, current NHS guidance does not permit DAA treatment for people with acute HCV infection. Three London clinics were able to offer DAA treatment to people with acute HCV infection through clinical trials. They observed a sharp decline in new infections after 2015. The proportion of reinfections relative to all acute infections rose over time, from less than a tenth (9%) in 2013 to nearly half (47%) in 2018.

A study in New York, looking at men who have sex with men who were diagnosed with acute HCV infection and subsequently cured, also found a very high rate of reinfection – 4.4 per 100 person-years of follow-up.

Researchers discussing these studies at the conference said that preventing sexual transmission of HCV among men who have sex with men is proving to be challenging. The high incidence of HCV among men who have sex with men with HIV is partly a consequence of the high prevalence of HCV in this group and the preference for other partners with HIV. A decline in condom use due to greater use of pre-exposure prophylaxis (PrEP) to prevent HIV may be contributing to a higher incidence of hepatitis C among men who have sex with men, but it is not clear whether promotion of condom use would be enough to reduce HCV incidence. Although HCV can be found in semen and rectal fluid, it is not clear to what extent blood exposure during practices such as fisting or sharing of injecting equipment may be contributing to HCV transmission between men who have sex with men. Greater access to DAAs during acute infection is needed to reduce incidence, as well as harm reduction.

HCV reinfection in people who inject drugs a sign of a successful treatment programme, say researchers

High rates of reinfection in people who inject drugs are a sign that access to treatment is improving, not a sign of failure, and should prompt retreatment, not stigmatisation, Australian hepatitis researcher Greg Dore says in the Journal of Viral Hepatitis this month.

He was commenting on a recently published study of hepatitis C treatment and hepatitis C virus (HCV) reinfection among high-frequency injectors in Dundee, Scotland.

Only someone who is cured can get reinfected, so a higher frequency of reinfection in people who inject drugs means that treatment programmes are reaching people who inject drugs and curing them. The high rate of reinfection is a sign that harm reduction interventions such as needle and syringe programmes and opioid substitution therapy are not being offered at sufficient scale or are not engaging people at highest risk of reinfection.

The Eradicate study was designed to evaluate engagement in treatment, cure rates and reinfection rates among active injectors attending needle and syringe programmes in the city.

The study was carried out between 2012 and 2016 when the standard of care was pegylated interferon plus a protease inhibitor for genotype 1 and pegylated interferon and ribavirin for genotypes 2 and 3. The study achieved a high cure rate (82%). There was a high reinfection rate: after 18 months the rate was 21.49 per 100 person-years. The HCV reinfection rate in this study is similar to the community incidence of HCV in Scotland. The investigators say that the high rate of reinfection shows that they are engaging people with a very high risk of HCV infection in care and successfully curing them of hepatitis C.

In an accompanying Comment article, Professor Greg Dore of the Kirby Institute, University of New South Wales, Sydney, said that modelling of treatment uptake in Australia suggests that reinfection rates among people who inject drugs can be expected to rise until 2023 if Australia continues to achieve high rates of treatment among drug users, before beginning to decline as the number of people who inject drugs with chronic HCV infection begins to decline substantially.

“Intensive injecting network exploration and screening could be utilised for those who develop HCV reinfection,” he says, noting that sexual partners are often injecting partners too. Ongoing monitoring of reinfection, point-of-care technologies that can detect HCV RNA – such as fingerprick sampling – and rapid initiation of treatment will all contribute to efforts to reduce reinfection in people who use drugs.

US Department of Veterans Affairs on track to cure 100,000 of hepatitis C

The US Department of Veterans Affairs (VA), which provides medical care for US military veterans, has cured almost 100,000 veterans of hepatitis C using direct-acting antivirals (DAAs). Hepatitis C is approaching elimination among US military veterans, the Department said in a press release last week.

Prior to the introduction of DAAs, approximately 180,000 veterans were living with hepatitis C. Since 2014, 116,000 have started a course of DAAs and so far, 96,654 have completed treatment and been cured.

Aggressive case-finding allowed nearly 2000 people to start treatment every week and the VA expects to have treated 125,000 veterans by October 2019.

The high treatment rate has also been made possible by negotiating low prices for DAAs. The VA estimates that the cost of curing each veteran is approximately $25,000 in 2018 as a result of being able to bring down drug costs.

Hepatitis C treatment reduces risk of diabetes

Treatment of hepatitis C virus (HCV) infection is associated with better glucose control and a lower likelihood of developing diabetes, according to a report at CROI 2019.

People with hepatitis C are at higher risk of developing type 2 diabetes but it has been unclear if curing hepatitis C reduces the risk of developing diabetes. A recently published US study with 384 participants showed that although direct-acting antiviral (DAA) treatment resulted in a short-term improvement in glucose control in people who already had type 2 diabetes, improvement was not sustained.

This month, US researchers reported on the incidence of type 2 diabetes in 52,000 US military veterans with hepatitis C, including 21,279 who had been treated with DAAs.

The study found that DAA treatment was associated with a 52% reduction in the risk of developing diabetes. Further prospective cohort research which includes a larger population of women is needed to validate this finding.

Hepatitis C treatment safe and effective in pregnant women, pilot study shows

Catherine Chappell speaking at CROI 2019. Photo by Liz Highleyman.

Treatment with sofosbuvir/ledipasvir (Harvoni) was well tolerated and likely cured nine out of nine pregnant women with hepatitis C virus (HCV), according to a small study presented at CROI 2019.

While 'baby boomers' have traditionally had the highest rate of hepatitis C in the United States, HCV incidence is rising among younger people, tracking the ongoing opioid epidemic. This means more women of childbearing age are infected with HCV and at risk of transmitting the virus to their babies, but there has been little research on the use of direct-acting antivirals (DAAs) as treatment for this group.

DAAs remain understudied in pregnant women. For example, it is not known how DAAs affect birth outcomes such as the risk of stillbirth, premature delivery or birth weight. As women have rarely been exposed to DAAs at the time of conception or during early pregnancy, there is also a lack of real-world information about how DAAs affect foetal development during the first three months of development, which is the period of greatest risk for birth defects caused by exposure to a drug.

The small phase 1 study tested was designed to test the safety of sofosbuvir/ledipasvir in pregnant women. Nine women were recruited to the study. Eight women were cured and one is still completing SVR follow-up. All nine carried their pregnancies to term and all had undetectable HCV at the time of delivery. All but one of the infants were delivered at term and were of normal weight. None of the infants show evidence of HCV infection, including five who have been followed for a year. No safety concerns were reported in this study population, but larger studies are needed to confirm the safety of DAAs in pregnancy and to test other drugs, especially pangenotypic regimens.

Hepatitis B virus raises the risk of age-related macular degeneration

Macular degeneration is a condition in which the centre of the field of vision becomes blurred or invisible. It is an age-related condition, but its causes are not well understood. Smokers have a higher risk of macular degeneration.

A study in Taiwan has found a strong association between hepatitis B infection and macular degeneration. The researchers looked at the incidence of macular degeneration between 2000 and 2012 in Taiwan and found that people with hepatitis B had a 41% increase in the risk of macular degeneration.

The researchers say that hepatitis B has been associated with eye conditions in studies in other Asian countries and that physicians should be alert for eye problems in people with hepatitis B, especially loss of vision.

EndHep2030 call for proposals

The Fund for Elimination of Viral Hepatitis – EndHep2030 – will launch in April.

The fund will provide grants to speed the elimination of viral hepatitis by supporting the development of sustainable strategic plans at the national and sub-national level to guide effective programme implementation; by showing how countries can optimise their human and financial resources within health budgets; by increasing the availability of country-specific data that inform where and how to intervene most efficiently and effectively; and, by building health system capacity to deliver quality hepatitis prevention and treatment services.

The fund is supported by the Robert Wood Johnson Foundation, the Zeshan Foundation, the CDC Foundation and the John C. Martin Foundation, and also intends to catalyse donor support for viral hepatitis elimination efforts.

The fund is seeking proposals for a first round of funding in 2019. View the call for proposals at: endhep2030.org/grants

World Hepatitis Alliance appoints new CEO and President

The World Hepatitis Alliance (WHA) has announced that, following a comprehensive interview process, Cary James has been selected as CEO and will begin on 8 April. Cary brings decades of experience in public health programmes and health policy at the national and international levels. He is a recognised leader in putting patients and communities at the centre of policy and programmes.

“I am excited for this opportunity to use my skills and experience to champion our members and people affected by viral hepatitis to make viral hepatitis elimination a reality, Cary said.

Cary has worked extensively in hepatitis and HIV response, having developed innovative and successful campaigns and collaborated with numerous civil society organisations during his time as a member of the leadership team at the UK’s Terrence Higgins Trust. He has been a member of international advisory panels and expert groups on diagnostics, digital communications, health equality, HIV, hepatitis, tuberculosis and sexual health.

“Cary has a proven record of working closely with governmental and non-governmental organizations to tailor programmes to unique populations as well as high-level engagement with the WHO and UN, which are important skills in the work of the Alliance,” says Michael Ninburg, president of WHA.

“I am delighted to be passing on the torch to Cary who will be a great fit to the organization and an exciting appointment to drive the Alliance forward,” added Raquel Peck, senior advisor and former CEO of WHA.

Dr Su Wang has been appointed WHA President-Elect, having served on the executive board of the WHA since 2014 as a regional representative for the PAHO region. Su is an internal medicine physician who discovered she had hepatitis B after donating blood in college and has used her own personal experience to advocate for the elimination of hepatitis. She worked for many years in New York City leading outreach and care programmes for hepatitis B patients and now directs a number of hepatitis B and C programmes in her current role as Medical Director for the Center for Asian Health at Saint Barnabas Medical Center in New Jersey.

Next month: News from The International Liver Congress

Next month, infohep will be providing news coverage from The International Liver Congress 2019, organised by the European Association for the Study of the Liver (EASL). The conference is taking place in Vienna, Austria from 10-14 April.

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

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