Hepatology, medicine and policy最新文献

The treatment of hepatitis C has entered a new era since the advent of curative pharmaceuticals. As policy, government and civil society assemble in response, there are still gaps to be addressed. The Manifesto on Hepatitis C and Drug Use, launched in Berlin during the Correlation Hepatitis C Initiative conference in October 2014, was formulated and endorsed by many key organizations in the hepatitis field. The Manifesto takes strides to pinpoint shortcomings in hepatitis action oriented towards the population most affected by the hepatitis C virus (HCV): active drug users. Despite a considerable amount of evidence that active drug users are disproportionately affected by HCV, barriers to care remain. Engagement with representatives of communities of people who inject drugs (PWID) is imperative in order to effectively create guidelines which reflect reality. Unfortunately, widespread systemic stigmatization and lack of trust between affected communities, decision-makers and healthcare professionals have reproduced this divide. The Berlin Manifesto has identified a disconnect between evidence and action which must be answered. In this roundtable discussion, experts from diverse parts of the hepatitis community have contributed their perspectives and experience on access to prevention, testing, and treatment for HCV in PWID. The authors discuss relevant topics such as realities of access to HCV treatment in the United Kingdom, interventions of a regional network of active drug users in Europe and lack of PWID involvement in government policy in Catalonia. Collectively they challenge the neglect of HCV in PWID by many decision-makers and health care professionals and promote a scale-up of integrated prevention and treatment strategies focusing on this population. The authors' conclusions aim to clarify the discourse on hepatitis in order to prevent disease, save lives and work towards eventual hepatitis elimination.

The inaugural World Hepatitis Summit was jointly convened by the World Health Organization (WHO) and the World Hepatitis Alliance and hosted by the Scottish Government and supported by Glasgow Caledonian University and Health Protection Scotland in September 2015. The three day event convened a broad range of stakeholders to meet and share ideas, experience and best practice in addressing the many facets of viral hepatitis prevention, diagnosis and treatment. With the next World Hepatitis Summit scheduled to take place from 1 to 3 November 2017, the World Hepatitis Alliance asked Hepatology, Medicine and Policy to commission a roundtable discussion article in order to encourage reflection on how the 2015 Summit was significant for stakeholders' efforts and why it is important to keep the momentum going ahead of the World Hepatitis Summit 2017 and in the light of the newly adopted first-ever Global Health Sector Strategy on Viral Hepatitis.

After introduction of new direct acting antivirals (DAAs) against hepatitis C, the cure rate has increased substantially especially in patients with liver cirrhosis. Decreased but remaining risk for hepatocellular carcinoma (HCC) has been shown in patients with liver cirrhosis after cure, in previous studies with interferon (IFN)-based treatments. This risk for HCCs is expected to become the next hurdle in the management of hepatitis C patients, as the number of treated and cured patients with liver cirrhosis is increasing dramatically. At the recent International Liver Congress 2016, Barcelona, Spain, a potentially alarming report was presented by Buonfiglioli F et al., among otherwise positive reports, for patients with prior HCC being treated with DAAs. This preliminary report showed a high early recurrence rate of 29 % for HCC after initiation of DAA treatment in patients with treated HCC, at follow-ups 12-24 weeks post-treatment. Another study was published just prior to this report by Reig M et al. showing similarly high recurrence rate for HCC. In this study, patients who have been treated for HCC with ablation, resection or transarterial chemoembolization, and no sign of remaining HCC at treatment start, were analysed for the risk of HCC recurrence after DAA treatment initiation. After a median follow-up time of 5.7 months, recurrence rate of HCC was seen in 28 %. The disadvantage of these studies was the lack of any control group, but these figures were unexpectedly high compared to figures in previous studies. These findings need to be further explored and eventually confirmed in other studies before making any firm conclusions and change of the routine practice. Until we have more data, the eventual risks for early HCC recurrence and other risks must be weighed against other benefits of these DAAs, halting liver disease progression, on an individual basis.

Background: People who inject drugs (PWID) are disproportionately affected by both HIV and hepatitis C infection (HCV). Awareness of infection status is essential to ensure linkage to appropriate healthcare for those infected, who need treatment and regular follow-up, as well as for uninfected individuals, who need access to targeted testing and counselling services. In this paper we compare self-reported HIV and HCV status with serological markers of infection among PWID recruited through respondent driven sampling.

Methods: From 2011 through 2014, biological and behavioural data was collected from 2,077 PWID in Germany. Dried blood spots from capillary blood samples were collected and screened for HCV antibodies, HCV RNA and HIV-1/-2 antibodies. HIV reactive samples were confirmed by Western blot.

Results: Laboratory testing revealed that 5 % were infected with HIV and 81 % were aware of being infected. Chronic HCV infection was detected in 41 % of the participants, 2 % had an acute HCV infection, 22 % had a cleared infection, and 34 % were unexposed to HCV. The concordance between self-reported and measured HCV status was lower than for HIV, with 73 % of those with chronic HCV infection being aware of their infection.

Conclusions: We found a relatively high awareness of HIV and HCV infection status among PWID. Nevertheless, access to appropriate testing, counselling and care services targeted to the needs of PWID should be further improved, particularly concerning HCV.

Trial registration: Ethical approval was received from the ethics committee at the medical university of Charité, Berlin, Germany in May 2011 and with an amendment approved retrospectively on 19/11/2012 (No EA4/036/11). The German Federal Commissioner for Data Protection and Freedom of Information approved the study protocol retrospectively on 29/11/2012 (III-401/008#0035).

Background: HCV/HIV coinfection in people who inject drugs is a public health issue, which presents a variety of challenges to healthcare providers. The determinants of HCV/HIV coinfection in this population are nonetheless not well known. The aim of the present study is to identify the factors associated with HCV/HIV coinfection in people who inject drugs and enter drug-related treatment.

Methods: Linked serological and behavioral data were collected from people who entered 38 opioid substitution treatment clinics in central and southern Greece between January and December 2013. Three mutually exclusive groups were defined based on the presence of HCV and HIV antibodies. Group 1 clients had neither infection, Group 2 had HCV but not HIV, and Group 3 had HCV/HIV coinfection. Multinomial logistic regression analyses identified differences between groups according to socio-demographic, drug use and higher-risk behavioral characteristics.

Results: Our study population consisted of 580 people who injected drugs in the past 12 months (79.8 % males, with median age 36 years).79.4 % were HCV and 15.7 % HIV infected. Of those with complete serological data in both HCV and HIV indicators, 20.4 % were uninfected, 64.0 % HCV monoinfected, and 14.9 % HCV/HIV coinfected. HCV infection with or without HIV coinfection was positively associated with living alone or with a spouse/partner without children, prior incarceration, drug injecting histories of ≥10 years, and syringe sharing in the past 12 months, and negatively associated with never having previously been tested for HCV. HCV/HIV coinfection, but not HCV infection alone, was positively associated with residence in urban areas (relative risk ratio [RRR] = 4.8, 95 % confidence interval [CI]: 1.7-13.7, p = 0.004) and averaging >3 injections a day in the past 30 days (RRR = 4.5, 95 % CI: 1.6-12.8, p = 0.005), and negatively associated with using a condom in the last sexual intercourse.

Conclusions: People who inject drugs and live in urban areas and inject frequently have higher risk of coinfection. Findings highlight the need for scaling-up needle and syringe programs in inner city areas and promoting access of this population to screening and treatment, especially in prisons. The protective role of living with parents and children could inform the implementation of indicated interventions.

Background: HIV co-infection exacerbates hepatitis C disease, increasing the risk of cirrhosis and hepatitis C-related mortality. Combination antiretroviral therapy (cART) is the current standard treatment for co-infected individuals, but the impact of cART and antiretroviral (ARV) monotherapy on liver disease in this population is unclear. We aimed to assess the effect of cART and ARV monotherapy on liver disease progression and liver-related mortality in individuals co-infected with HIV and chronic hepatitis C.

Methods: A systematic review with meta-analyses was conducted. MEDLINE and EMBASE bibliographic databases were searched up to September 2015. Study quality was assessed using a modified Newcastle-Ottawa scale. Results were synthesised narratively and by meta-analysis.

Results: Fourteen observational studies were included. In analyses that adjusted for potential confounders, risk of liver-related mortality was significantly lower in patients receiving cART (hazard ratio/odds ratio 0.31, 95 % CI 0.14 to 0.70). Results were similar in unadjusted analyses (relative risk 0.40, 95 % CI 0.29 to 0.55). For outcomes where meta-analysis could not be performed, results were less consistent. Some studies found cART was associated with lower incidence of, or slower progression of liver disease, fibrosis and cirrhosis, while others showed no evidence of benefit. We found no evidence of liver-related harm from cART or ARV monotherapy compared with no HIV therapy.

Conclusions: cART was associated with significantly lower liver-related mortality in patients co-infected with HIV and HCV. Evidence of a positive association between cART and/or ARV monotherapy and liver-disease progression was less clear, but there was no evidence to suggest that the absence of antiretroviral therapy was preferable.