12 good practices that should be part of the hepatitis C standard of care

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Hepatitis C programmes and health services should review whether they are using best practices in diagnosis, treatment and care of people with hepatitis C, and update service models to improve hepatitis C elimination efforts, according to a review published this month.

The review, carried out by a team at the Barcelona Institute for Global Health and colleagues at universities in Denmark, Italy, Sweden and the United Kingdom, identified 12 good practices that should be scaled up in order to improve diagnosis of hepatitis C, uptake of treatment and retention in care.

Reflex testing, the practice of automatically testing hepatitis C antibody-positive blood samples for hepatitis C virus (RNA testing), eliminates the need for a person who tests positive for antibodies to be recalled for further testing. Reflex testing increases the rate of diagnosis of chronic hepatitis C infection. Reflex testing is practiced widely in Spain.

Alternative diagnostic methods to help people move from hepatitis diagnosis to cure are also needed, especially point-of-care tests that can give results within 20 minutes or an hour. Again, these can eliminate the need for multiple visits and blood draws, for example through siting the Gene Xpert RNA testing platform in drugs services. Testing for hepatitis C core antigen can eliminate the need for confirmatory RNA testing, while dried blood spot sampling allows screening in people with poor venous access or where trained personnel are not available to carry out blood draws. Dried blood spot sampling has been used extensively for hepatitis C screening in the United Kingdom, France and the Netherlands.

Electronic medical record reminders to screen for hepatitis C can improve screening rates, using age cohort reminders to screen older patients in the United States or risk-based reminders to screen people with hepatitis C risk factors.

Decentralised and community-based testing in drugs services not only improves diagnosis but leads to increased engagement in treatment, the review found. Similarly, offering testing in migrant facilities and internment centres can enable engagement in treatment, Italian and Australian models show. Very large-scale community-based testing in Egypt resulted in testing of almost 80% of the population in 2018 and 2019, the reviewers note.

Testing in community pharmacies using dried blood spot testing has achieved high testing uptake among people who inject drugs in London and Scotland and was more likely to result in hepatitis C screening compared to the conventional testing pathway in a Scottish study in people receiving opioid substitution therapy. Mobile testing services, for example through vans which go to locations where they can reach homeless people, drug users and sex workers, have proved successful in Australia, Denmark, Spain and the United States.

Providing treatment in non-clinical locations, such as prisons and harm reduction facilities has the potential to increase the numbers treated and engage people who would otherwise be missed by conventional service patterns. Co-ordination between existing health services such as mental health services providing treatment for substance users and hepatitis C programmes can also increase treatment uptake, US research shows. Screening for hepatitis C in tuberculosis treatment programmes resulted in high rates of diagnosis and referral for treatment in Georgia, a country with a high burden of TB.

Task-shifting, when medical tasks are devolved to nurses or community health workers, increases capacity to screen for hepatitis C and start people on treatment. A US study found no difference in cure rates according to the medical personnel who were responsible for supervising treatment, showing that a broad range of healthcare workers can provide high-quality hepatitis C care.

Telemedicine can support primary care physicians to provide hepatitis C treatment, linking physicians to specialist support in hepatology, addiction medicine and psychiatry, as they manage hepatitis C patients with complex needs.

Loss to follow-up prior to treatment or during treatment is a major obstacle to hepatitis C elimination. Strategies to promote re-engagement in care are essential. Some studies find a high proportion of those screened for hepatitis C have a previous diagnosis. Re-engaging these people in care by identifying their current and previous barriers to care can result in high cure rates, research in the Netherlands shows.

Stigmatising attitudes among healthcare workers are often cited as the reason for avoidance of hepatitis C care. Stigma education programmes for healthcare workers have the potential to improve engagement in care. Peer support in healthcare settings, drugs services and the community is critical for engaging people from marginalised groups in care and overcoming stigma. Peer outreach proved successful in promoting engagement in care in a UK trial, for example.

The study authors say that without political will to eliminate hepatitis C and investment in elimination efforts, good practices will not be sufficient to drive the elimination of hepatitis C. Research into the implementation of a combination of good practices, such as point-of-care testing, nurse-led treatment initiation and peer support, all delivered in non-clinical services, is needed to demonstrate how good practices can be combined to best effect.

People with HIV and hepatitis B should have ongoing monitoring for liver cancer

Dr H. Nina Kim (centre right) presenting to CROI 2021.

People with HIV and hepatitis B co-infection remain at risk for developing hepatocellular carcinoma (HCC) despite antiviral treatment and should undergo regular monitoring for liver cancer, according to research presented this month at the virtual Conference on Retroviruses and Opportunistic Infections (CROI).

The study looked at 8354 people with HIV and hepatitis B in 22 North American HIV cohort studies. About a quarter were hepatitis B 'e' antigen (HBeAg) positive and 76% were taking antiretrovirals for HIV that were also active against hepatitis B virus (HBV).

The study found that older age, heavy alcohol use and chronic hepatitis C were independent risk factors for liver cancer. However, there was no significant association with HIV viral load or CD4 percentage.

Detectable HBV DNA raised the risk of liver cancer but suppression for at least four years reduced the risk by 66%.

"To gain maximal protective benefit from antiviral therapy for HCC prevention, sustained and ideally uninterrupted suppression of HBV may be necessary over years," said investigator Dr H. Nina Kim of the University of Washington in Seattle.

Pancreatic and colorectal cancer risk raised in people with hepatitis C

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Pancreatic cancer occurred more often in people with hepatitis C or HIV in Canada’s British Columbia Hepatitis Testers Cohort, and colorectal cancer was more likely to occur in people diagnosed with hepatitis B or C, or HIV, cohort investigators report in the journal Therapeutic Advances in Medical Oncology.

The British Columbia Hepatitis Testers Cohort records data on almost everyone tested for hepatitis or HIV in the Canadian province of British Columbia since 1990. Test results can be linked with the provincial cancer registry, allowing investigators to assess the incidence of cancers in people diagnosed with hepatitis B and C or HIV, and compare them to people with similar risk factors for these infections who tested negative for the viruses.

The study found that people with HIV and people with hepatitis C virus (HCV) were at 2.8 times higher risk of developing pancreatic cancer compared to people who tested negative for these viruses, while people with hepatitis B virus (HBV)/HCV co-infection were at 2.9 times higher risk of developing pancreatic cancer.

People with viral hepatitis or HIV were between 2.3 and three times more likely to be diagnosed with colorectal cancer, and people co-infected with HIV and HCV were 2.38 times more likely to be diagnosed with colorectal cancer, compared to people testing negative for these viruses.

Any infection with viral hepatitis greatly increased the risk of liver cancer. People with hepatitis B were at 85 times higher risk of developing liver cancer, people with hepatitis C at 121 times higher risk and people co-infected with hepatitis B and C at 106 times higher risk, compared to people who tested negative. People with HIV did not have a raised risk of liver cancer unless they were co-infected with hepatitis B or C. The higher risk of liver cancer in people diagnosed with hepatitis C was reduced, but not eliminated, in those cured of hepatitis C.

Curing hepatitis C did not reduce the risk of colorectal or pancreatic cancer.

Although some previous studies have found a higher risk of pancreatic cancer in people with hepatitis C and people with HIV, this is the largest population study to find an association. The investigators say that the association persisted after controlling for diabetes, which may be a complication of hepatitis C or antiretroviral treatment for HIV.

Outreach to homeless in England achieved large-scale testing for hepatitis C during the COVID-19 lockdown

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Outreach to homeless people in England housed in temporary accommodation during the COVID-19 pandemic led to over 1200 to be tested for hepatitis C, one in ten to test positive for active infection and at least 83 to begin direct-acting antiviral treatment during 2020, researchers from the University of Southampton and Public Health England report in Clinical Liver Disease.

A similar number were tested and diagnosed in London in the same period, according to a report by the London Joint Working Group on Substance Use and Hepatitis C.

Catch up on the EASL Digital Liver Cancer Summit

Professor Jordi Bruix reported on the breakthroughs in systemic therapy for hepatocellular carcinoma (HCC) and their overall implications for clinical management, with a particular focus on the results of the IMbrave study.

Professor Chiara Braconi discussed recent advances in cholangiocarcinoma, from clinical to translational research and the relative lack of progress in immunotherapy for this condition.

Dr Jean-Charles Nault reviewed pre-clinical models related to HCC, including the identification of subtype-specific treatment.

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