Availability of hepatitis C diagnostics and therapeutics in European and Eurasia countries

Effect of Direct Acting Antivirals (DAAs) on Myeloid-Derived Suppressor Cells Population in Egyptian Chronic Hepatitis C Virus Patients: A Potential Immunomodulatory Role of DAAs

Chronic hepatitis C is a major health concern with high morbidity and mortality rates. The introduction of direct acting antivirals (DAAs) as a first-line treatment for hepatitis C virus (HCV) has significantly enhanced HCV eradication. However, DAA therapy is facing rising concerns regarding long-term safety, viral resistance, and reinfection. HCV is associated with different immune alteration mechanisms that can evade immunity and establish persistent infection. One of these suggested mechanisms is the accumulation of myeloid-derived suppressor cells (MDSCs), which is known to accumulate in chronic inflammatory conditions. Moreover, the role of DAA in restoring immunity after successful viral eradication is still unclear and needs further investigations. Thus, we aimed to investigate the role of MDSCs in chronic HCV Egyptian patients and its response to DAA in treated compared with untreated patients. Fifty untreated chronic hepatitis C (CHC) patients, 50 DAA-treated CHC patients, and 30 healthy individuals were recruited. We used flow cytometer analysis to measure MDSCs frequency and enzyme-linked immunosorbent assay analysis to evaluate the serum level of interferon (IFN)-γ. We found a significant elevation in MDSC% among the untreated group (34.5 ± 12.4%) compared with the DAA-treated group (18.3 ± 6.7%), while the control group had a mean of (3.8 ± 1.6%). IFN-γ concentration was higher in treated patients compared with untreated. We also found a significant negative correlation (rs -0.662) (p < 0.001) between MDSC% and IFN-γ concentration among treated HCV patients. Our results revealed important evidence of MDSCs accumulation in CHC patients and partial retrieval of the immune system regulatory function after DAA therapy.

A gender lens is needed in hepatitis C elimination research

The World Health Organisation has established a goal of eliminating the hepatitis C virus (HCV) as a public health threat by 2030. Considerable effort is being directed towards research to support and enhance HCV treatment uptake among people who inject drugs, but there is a distinct lack of attention given to gender in this work. We argue that a gender lens is needed to make visible the limitations of current HCV elimination research, and support the development of innovative, inclusive approaches to HCV treatment. Partnerships between researchers and people who inject drugs are essential in this work, particularly in the development and evaluation of programs by and for women who inject drugs. Failure to acknowledge the gendered dimensions of HCV elimination risks entrenching gender disparities in access to treatment and cure.

Barriers to initiation of hepatitis C virus therapy in Germany: A retrospective, case-controlled study

Despite the availability of highly effective and well-tolerated direct-acting antivirals, not all patients with chronic hepatitis C virus infection receive treatment. This retrospective, multi-centre, noninterventional, case-control study identified patients with chronic hepatitis C virus infection initiating (control) or not initiating (case) treatment at 43 sites in Germany from September 2017 to June 2018. It aimed to compare characteristics of the two patient populations and to identify factors involved in patient/physician decision to initiate/not initiate chronic hepatitis C virus treatment, with a particular focus on historical barriers. Overall, 793 patients were identified: 573 (72%) who received treatment and 220 (28%) who did not. In 42% of patients, the reason for not initiating treatment was patient wish, particularly due to fear of treatment (17%) or adverse events (13%). Other frequently observed reasons for not initiating treatment were in accordance with known historical barriers for physicians to initiate therapy, including perceived or expected lack of compliance (14.5%), high patient age (10.9%), comorbidities (15.0%), alcohol abuse (9.1%), hard drug use (7.7%), and opioid substitution therapy (4.5%). Patient wish against therapy was also a frequently reported reason for not initiating treatment in the postponed (35.2%) and not planned (47.0%) subgroups; of note, known historical factors were also common reasons for postponing treatment. Real-world and clinical trial evidence is accumulating, which suggests that such historical barriers do not negatively impact treatment effectiveness. Improved education is key to facilitate progress towards the World Health Organization target of eliminating viral hepatitis as a major public health threat by 2030.

The prevalence of HCV RNA positivity in anti-HCV antibodies-negative hemodialysis patients in Thrace Region. Multicentral study

Introduction

HCV infection in patients under hemodialysis for end stage chronic kidney disease (ESCKD) may exist despite the absence of anti-HCV antibodies. Molecular methods are widely accepted as "gold standard" techniques for the detection of viral RNA. However, the molecular methods are more expensive in comparison to conventional methods and their replacement is not cost-effective. The aim of this study was to estimate the prevalence of HCV RNA positivity in anti-HCV negative hemodialysis patients and evaluate new diagnostic methods for the detection and the monitoring of hepatitis C in ESCKD patients.

Methods

The study was performed in four hospitals of Thrace region of Greece and 233 patients with no history of hepatitis C were enrolled. Measurement of anti-HCV antibodies and HCV core antigen was performed by microparticle chemiluminescence immunoassay. Molecular detection of viral RNA was performed by the real-time RT PCR.

Results

The mean age of the patients was 64.9 ± 23.3 years. HCV-Ag was positive in 2/233 patients (0.86%). Nevertheless, viral RNA was negative in those patients.

Conclusions

The results of the present study showed that the incidence of HCV-RNA in patients with negative anti-HCV Abs, in hemodialysis patients in Thrace region of Greece was negligible (0/233).

Chronic Hepatitis C Virus Infection Modulates the Transcriptional Profiles of CD4+ T Cells

Background

Chronic hepatitis C (CHC) is associated with altered cell-mediated immune response.

Objective

The aim of the study was to characterize functional alterations in CD4⁺ T cell subsets and myeloid-derived suppressor cells (MDSCs) during chronic hepatitis C virus (HCV) infection. Methodology. The expression levels of the lineage-defining transcriptional factors (TFs) T-bet, Gata3, Rorγt, and Foxp3 in circulating CD4⁺ T cells and percentages of MDSCs in peripheral blood were evaluated in 33 patients with CHC, 31 persons, who had spontaneously cleared the HCV infection, and 30 healthy subjects. Analysis. The CD4+ T cells TFs T-bet (T-box expressed in T cells), Foxp3 (Forkhead box P3 transcription factor), Gata3 (Gata-binding protein 3), and Rorγt (retinoic-acid-related orphan receptor gamma) and activation of CD8+ T cells, as well as percentages of MDSCs, were measured by multicolor flow cytometry after intracellular and surface staining of peripheral blood mononuclear cells with fluorescent monoclonal antibodies.

Result

The patients with CHC had significantly lower percentages of CD4⁺ T cells expressing Rorγt and Gata3 and higher percentages of Foxp3-expressing CD4⁺ T cells than healthy controls and persons who spontaneously cleared HCV infection. The ratios of T-bet⁺/Gata3⁺ and Foxp3⁺/Rorγt⁺ CD4⁺ T cells were the highest in the patients with CHC. In the patients with CHC, the percentages of Gata3⁺ and Rorγt⁺ CD4⁺ T cells and the percentages of T-bet⁺ CD4⁺ T cells and CD38⁺/HLA-DR⁺ CD8⁺ T cells demonstrated significant positive correlations. In addition, the percentage of CD38⁺/HLA-DR⁺ CD8⁺ T cells correlated negatively with the percentage of MDSCs.

Conclusion

Chronic HCV infection is associated with downregulation of TFs Gata3 and Rorγt polarizing CD4+ T cells into Th2 and Th17 phenotypes together with upregulation of Foxp3 responsible for induction of regulatory T cells suppressing immune response.

Concordance of non-invasive serology-based scoring indices and transient elastography for liver fibrosis and cirrhosis in chronic hepatitis C

Aim To assess concordance of eight frequently used serology-based scoring indices for liver fibrosis and cirrhosis with transient elastography (TE) in chronic hepatitis C (CHC) patients in order to determine serum indices with the highest concordance and clinical usability in clinical practice. Methods In this prospective study, 63 CHC patients were included and TE results were compared with eight non-invasive indices. The diagnostic performance of these tests was assessed using receiver operating characteristic curves with kappa index calculated for the concordance analysis. Results Median age of 63 patients was 54 years (interquartile range: 42 to 63); 27 (42.9%) were females. According to areas under the Receiver Operating Characteristics (AUROC), the best performing serum markers for significant liver fibrosis (METAVIR ≥F2), advanced liver fibrosis (≥F3) and cirrhosis (F4) determined by TE measurements (≥7.1kPa, ≥9.5kPa and ≥12kPa, respectively) were Fibrotest (AUROC=0.727 for ≥F2) and FIB-4 score (AUROC=0.779 for ≥F3 and AUROC=0.889 for F4). Fibrotest cut-off at >0.50 was concordant with TE for presence of significant fibrosis in 30 (out of 45; 66.7%), FIB-4 cut-off at <1.45 was concordant for absence of significant fibrosis in 13 (out of 18; 72.2%) and Goeteborg University Cirrhosis Index (GUCI) cut-off at >1 was concordant for presence of cirrhosis in 16 (out of 22; 72.7%) patients, but not for exclusion of cirrhosis. Conclusion Serology-based scoring indices had moderate overall concordance with TE. We propose that FIB-4 score, Fibrotest and GUCI be used in routine practice to exclude and diagnose significant fibrosis and diagnose cirrhosis, respectively.

Pegylated interferon and ribavirin gone but not forgotten in the era of direct-acting antivirals

BACKGROUND

Therapy with pegylated interferon and ribavirin (PEG-IFN+RBV) for chronic hepatitis C (CHC) remains the only option available for children in many Eurasian and European countries. Our aim was to evaluate the influence of host and viral factors on response to IFN-based therapy to optimize it for those in whom directly acting antivirals (DAA) are currently unavailable.

METHODS

Seventeen vertically infected, treatment naive children (10 male and 7 female) aged 5-16 years with CHC underwent a course of PEG-IFN+RBV. The end point was sustained virologic response (SVR). Host and virus factors were divided into pre- and on-treatment predictors of response to therapy.

RESULTS

Eleven patients obtained SVR (64%), 4 were non-responders (23%), and 2 were relapsers (12%). Significant relationship was found between HCV RNA elimination and following variables: virus genotype and early virologic response (EVR) (P<0.037, P<0.029 respectively). Higher eradication rate was observed in patients infected with genotype 3 HCV (100% vs. 65% with genotype 1 or 4), and in those with undetectable HCV RNA by week 12 (88% vs. 66% with viremia). EVR was associated with SVR (83% vs. 0% in nonresponders; P<0.004). C allele of IL28B rs12979860 was a predictor of EVR (P<0.043). The SVR rates among CC, CT, and TT carriers were as follows: 75%, 67%, and 33%.

CONCLUSIONS

Detection of favorable HCV and IL28B genotype prior to commencement of PEG-IFN+RBV and continuing it in patients with EVR is of major importance for those in whom DAA are still unavailable.

Progress and Barriers Towards Elimination of Chronic Hepatitis C in Children

Chronic hepatitis C (CHC) is a global health burden. Mother-to-child transmission (MTCT) accounts for most HCV infections in pediatric patients. Spontaneous viral clearance may occur in early childhood but is uncommon thereafter. Infection is usually asymptomatic during childhood, although without an effective treatment, vertically infected children may develop serious liver complications including cirrhosis and hepatocellular carcinoma in adulthood. Despite the lack of vaccine against hepatitis C and effective post-exposure methods of prevention of MTCT, treatment with direct-acting antiviral agents (DAAs) raised the prospect of eliminating HCV on a population level. Highly effective, well-tolerated, oral, and interferon-free regimens of short duration have revolutionized treatment of CHC. However, access to these therapies might be limited because of its high cost. In this review, we provide the current state of knowledge on the epidemiology, testing, monitoring and treating of HCV in children. We outline the remaining gaps in therapy and barriers to disease eradication.

Consensus on management of hepatitis C virus infection in resource-limited Ukraine and Commonwealth of Independent States regions

Globally, 69.6 million individuals were infected with hepatitis C virus (HCV) infection in 2016. Of the six major HCV genotypes (GT), the most predominant one is GT1, worldwide. The prevalence of HCV in Central Asia, which includes most of the Commonwealth of Independent States (CIS), has been estimated to be 5.8% of the total global burden. The predominant genotype in the CIS and Ukraine regions has been reported to be GT1, followed by GT3. Inadequate HCV epidemiological data, multiple socio-economic barriers, and the lack of region-specific guidelines have impeded the optimal management of HCV infection in this region. In this regard, a panel of regional experts in the field of hepatology convened to discuss and provide recommendations on the diagnosis, treatment, and pre-, on-, and posttreatment assessment of chronic HCV infection and to ensure the optimal use of cost-effective antiviral regimens in the region. A comprehensive evaluation of the literature along with expert recommendations for the management of GT1-GT6 HCV infection with the antiviral agents available in the region has been provided in this review. This consensus document will help guide clinical decision-making during the management of HCV infection, further optimizing treatment outcomes in these regions.

Changes in hepatitis C burden and treatment trends in Europe during the era of direct-acting antivirals: a modelling study

OBJECTIVES

Oral direct-acting antivirals (DAAs) for hepatitis C virus (HCV) have dramatically changed the treatment paradigm. Our aim was to project temporal trends in HCV diagnosis, treatment and disease burden in France, Germany, Italy, Spain and the UK.

DESIGN

A mathematical simulation model of natural history of HCV infection.

PARTICIPANTS

HCV-infected patients defined based on country-specific age, fibrosis and genotype distributions.

INTERVENTIONS

HCV screening practice and availability of different waves of DAA treatment in each country.

OUTCOME MEASURES

Temporal trends in the number of patients who achieve sustained virological response (SVR), fail treatment (by drug regimen) and develop advanced sequelae from 2014 to 2030 in each country.

RESULTS

We projected that 1 324 000 individuals would receive treatment from 2014 to 2030 in the five European countries and 12 000-37 000 of them would fail to achieve SVR. By 2021, the number of individuals cured of HCV would supersede the number of actively infected individuals in France, Germany, Spain and the UK. Under status quo, the diagnosis rate would reach between 65% and 75% and treatment coverage between 65% and 74% by 2030 in these countries. The number of patients who fail treatment would decrease over time, with the majority of those who fail treatment having been exposed to non-structural protein 5A inhibitors.

CONCLUSIONS

In the era of DAAs, the number of people with HCV who achieved a cure will exceed the number of viraemic patients, but many patients will remain undiagnosed, untreated, fail multiple treatments and develop advanced sequelae. Scaling-up screening and treatment capacity, and timely and effective retreatment are needed to avail the full benefits of DAAs and to meet HCV elimination targets set by WHO.

Sofosbuvir/velpatasvir for the treatment of HCV: excellent results from a phase-3, open-label study in Russia and Sweden

BACKGROUND

In both Russia and Sweden, the dominant hepatitis C virus (HCV) is genotype 1, but around one-third of patients have genotype 3 infection. For such countries, HCV genotype testing is recommended prior to therapy. An effective pangenotypic therapy may potentially eliminate the need for genotyping. In this study, we evaluated the efficacy and safety of sofosbuvir/velpatasvir for 12 weeks in patients from Russia and Sweden.

METHODS

In an open-label, single-arm phase-3 study, patients could have HCV genotype 1-6 infection and were treatment-naïve or interferon treatment-experienced. All patients received sofosbuvir/velpatasvir, once daily for 12 weeks. The primary endpoint was sustained virologic response 12 weeks post-treatment (SVR12).

RESULTS

Of 122 patients screened, 119 were enrolled and treated. Overall, half (50%) were male, 18% had cirrhosis, and 24% had failed prior interferon-based therapy. In total, 66% of patients were infected with HCV genotype 1 (59% 1b and 7% 1a), 6% with genotype 2, and 29% with genotype 3. The overall SVR12 rate was 99% (118/119, 95% confidence interval 95-100%). One treatment-experienced patient infected with HCV genotype 3 experienced virologic relapse after completing treatment. The most common adverse events were headache (16%) and fatigue (7%). Serious adverse events were observed in four patients, but none were related to treatment. No patients discontinued treatment due to adverse events.

CONCLUSION

Sofosbuvir/velpatasvir as a pangenotypic treatment for 12 weeks was highly effective in patients from Russia and Sweden infected with HCV genotypes 1, 2, or 3. Sofosbuvir/velpatasvir was safe and well-tolerated. Clinical trial number: ClinicalTrials.gov NCT02722837.

Detection of anti-protease inhibitors resistance mutations in HCV strains infecting treatment-naïve chronic patients from Romania

Background: Severe complications of chronic hepatitis C – i.e. cirrhosis and hepatocellular carcinoma – are important causes of morbidity and mortality worldwide. Despite the overwhelming rates of sustained virologic response achieved after therapy with different combinations of direct-acting antiviral drugs (DAAs), treatment failure is still recorded, and is due to the mutations harboured by hepatitis C virus (HCV) resistance associated variants (RAVs) selected during therapy. Baseline RAVs testing was found significant for guiding treatment in the cases of treatment failure and, sometimes, in naïve patients.

Methods: Romanian chronic hepatitis C patients unexposed to DAAs and infected with subtype 1b HCV were studied. Serum samples were used for Sanger population sequencing of a fragment containing NS3 viral protease, known to harbour resistance mutation against protease inhibitors (PIs).

Results: Catalytic triad and zinc-binding site in the studied sequences were conserved. Low-intermediate resistance mutations to first generation PIs were detected either alone or in conjunction with resistance substitutions associated with second generation PIs. Cross-resistance and reduced susceptibility to certain DAAs were observed.

Discussion: This study focused on HCV patients infected with subtype 1b strains, the most prevalent in Romania. The rate of RAVs found in this work is consistent with the results reported by similar studies from other countries. Noticeably, numerous polymorphisms of unknown significance to DAAs resistance, but reflecting the high genetic variability of HCV, were found in the studied sequences. Testing for RAVs can be a useful method for guiding treatment in a cost-efficient manner in developing countries where access to DAAs is limited.

Differences by sex in associations between injection drug risks and drug crime conviction among people who inject drugs in Almaty, Kazakhstan

BACKGROUND

The criminalization of drug use leads to high rates of drug crime convictions for engaging in injection drug use behaviors, introducing barriers to HIV prevention and drug treatment for PWID. Females (FWID) face unique vulnerabilities to HIV compared to males (MWID) in Kazakhstan. This study examined sex differences in associations between HIV/HCV infection, HIV knowledge, injection drug risk behaviors, and conviction for a drug crime in a sample of people who inject drugs (PWID) in Almaty, Kazakhstan.

METHODS

Analyses were performed on baseline data from 510 PWID and stratified by males (MWID) (329) and females (FWID) (181) from Kazakhstan in a couples-focused HIV prevention intervention. Logistic regression analyses using mixed effects (AOR) examined associations between HIV/HCV infection, HIV knowledge, injection drug risk behaviors, drug use severity, drug treatment history and conviction for a drug crime.

RESULTS

About three quarters of PWID reported drug crime conviction (73.92%, n = 377). HCV infection was associated with increased odds of drug crime conviction for FWID (AOR = 4.35, CI95 = 1.83-10.31, p < .01) and MWID (AOR = 3.62, CI95 = 1.09-12.07, p < .01). HIV transmission knowledge was associated with increased odds of conviction for MWID (AOR = 1.19, CI95 = 1.00-1.41, p < .05). Injection drug risk knowledge was associated with lower odds of conviction (AOR = .75, CI95 = .59-.94, p < .05) for FWID. Receptive syringe sharing (AOR = 3.48, CI95 = 1.65-7.31, p < .01), splitting drug solutions (AOR = 4.12, CI95 = 1.86-7.31, p < .05), and injecting with more than two partners (AOR = 1.89, CI95 = 1.06-3.34, p < .05) was associated with increased odds of conviction for FWID. Receptive syringe or equipment sharing with intimate partners was associated with conviction for both MWID (AOR = 1.90, CI95 = 1.03-3.92, p < .05) and FWID (AOR = 1.95, CI95 = 1.02-3.70, p < .05). For FWID, injection drug use in public spaces was associated with conviction (AORME = 3.25, CI95 = 1.31-7.39, p < .01). Drug use severity was associated with increased odds of conviction for FWID (AOR = 1.29, CI95 = 1.09-1.53, p < .001) and MWID (AOR = 1.24, CI95 = 1.09-1.41, p < .001). Ever receiving drug treatment was associated with conviction for MWID (AOR = 2.31, CI95 = 1.32-4.12, p < .01).

CONCLUSION

High-risk behaviors, HCV infection and more severe substance use disorders are associated with drug crime conviction for PWID, particularly FWID. Structural interventions are necessary to increase the engagement of PWID with drug crime convictions in HIV prevention and substance abuse treatment.

Effect of hepatitis C infection on the quality of life

PURPOSE

To assess the quality of life (QoL) of patients with hepatitis C infection (HCI) and its correlations with demographic and clinical variables.

DESIGN AND METHODS

QoL and depressive symptoms were evaluated with the validated rating instruments of the 36-item short form (SF-36) generic health survey and the second version of the self-rated Beck depression inventory (BDI-II) in a cross-sectional design and correlated with basic demographic and clinical variables, including the Fibroscan score, which indicates the severity of liver impairment.

FINDINGS

A cohort of 60 HCI patients who participated in the study scored lower than the general population on all domains of the SF-36. In the multivariate correlation analysis, only the physical functioning domain of the SF-36 showed a significant correlation with age, gender, and BD-II and Fibroscan scores.

IMPLICATIONS FOR CLINICAL PRACTICE

QoL is lower for patients who are older, female, and have depressive symptoms. Progression of hepatic cirrhosis is associated with lower QoL in the physical domain.