New hepatitis C antiviral treatments eliminate the virus

Chronic hepatitis C virus infections in Switzerland in 2020: Lower than expected and suggesting achievement of WHO elimination targets

In this multi-method study, we investigated the prevalence of chronic infections with the hepatitis C virus (HCV) in Switzerland in 2020, and assessed Switzerland's progress in eliminating HCV as a public health problem by 2030 with regard to the World Health Organization (WHO) criteria targeting infections acquired during the preceding year ('new transmissions') and HCV-associated mortality. Based on a systematic literature review, the reappraisal of a 2015 prevalence analysis assuming 0.5% prevalence among the Swiss population and data from many additional sources, we estimated the prevalence among subpopulations at increased risk and the general population. For new transmissions, we evaluated mandatory HCV notification data and estimated unreported new transmissions based on subpopulation characteristics. For the mortality estimate, we re-evaluated a previous mortality estimate 1995-2014 based on new data on comorbidities and age. We found a prevalence of ≤0.1% among the Swiss population. Discrepancies to the 2015 estimate were explained by previous (i) underestimation of sustained virologic response numbers, (ii) overestimation of HCV prevalence among PWID following bias towards subgroups at highest risk, (iii) overestimation of HCV prevalence among the general population from inclusion of high-risk persons and (iv) underestimation of spontaneous clearance and mortality. Our results suggest that the WHO elimination targets have been met 10 years earlier than previously foreseen. These advancements were made possible by Switzerland's outstanding role in harm-reduction programmes, the longstanding micro-elimination efforts concerning HIV-infected MSM and nosocomial transmissions, little immigration from high-prevalence countries except Italian-born persons born before 1953, and wealth of data and funding.

The Prison and Transition Health (PATH) cohort study: Prevalence of health, social, and crime characteristics after release from prison for men reporting a history of injecting drug use in Victoria, Australia

BACKGROUND

People who inject drugs are overrepresented in prison and have diverse and complex health needs. However, outcomes after release from prison are poorly understood, limiting effective interventions supporting community reintegration. We describe the prevalence of socio-demographics, physical and mental health, alcohol and other drug use, and crime characteristics of men with histories of injecting drug use after their release from prison in Victoria, Australia.

METHODS

Data come from the Prison and Transition Health (PATH) prospective cohort study. Interviews were undertaken approximately three, 12, and 24 months after release from their index prison episode and were completed in the community, or in prison for those reimprisoned during the study. We present cross-sectional descriptive statistics for each follow-up wave of the PATH study.

RESULTS

Among 400 men recruited into PATH, 85 % (n = 336) completed at least one follow-up interview; 162 (42 %) completed all three interviews. Participants reported social disadvantage and health inequity, including high rates of unemployment, homelessness, and physical and mental health morbidities at each follow-up time point. Rapid return to illicit substance use was common, as was overdose (ranging 9 %-13 %), receptive syringe sharing (ranging 20 %-29 %), involvement in crime-related activities (ranging 49 %-58 %), and reimprisonment (ranging 22 %-50 %) over the duration of follow-up.

CONCLUSION

Men in this study experienced substantial health and social challenges across a 24-month prospective follow-up period. Improved understanding of characteristics and experiences of this group after release from prison can inform more coordinated and continued care between prison and the community.

The Last Year Before Graft Failure Negatively Impacts Economic Outcomes and is Associated With Greater Healthcare Resource Utilization Compared With Previous Years in the United Kingdom: Results of a Retrospective Observational Study

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Background.

Kidney and liver transplantation is the standard of care for end-stage renal or liver disease. However, long-term survival of kidney and liver grafts remain suboptimal. Our study aimed to understand the healthcare resources utilized and their associated costs in the years before graft failure.

Methods.

Two noninterventional, retrospective, observational studies were conducted in cohorts of kidney or liver transplant patients. Once identified, patients were followed using the UK Clinical Practice Research Datalink linked to the Hospital Episode Statistics databases from the date of transplantation to the date of the first graft failure. Total healthcare costs in the year before graft failure (primary endpoint) and during years 2–5 before graft failure (secondary endpoint) were collected.

Results.

A total of 269 kidney and 81 liver transplant patients were analyzed. The mean total costs were highest for all resource components in the last year before graft failure, except for mean costs of immunosuppressive therapy per patient, which decreased slightly by index date (ie, graft failure). The mean total healthcare costs in the last year before graft failure were £8115 for kidney and £9988 for liver transplant patients and were significantly (P < 0.05) higher than years 2–5 before graft failure. Mean healthcare costs for years 2, 3, 4, and 5 before graft failure were £5925, £5575, £5469, and £5468, respectively, for kidney, and £6763, £7042, £6020, and £5651, respectively, for liver transplant patients.

Conclusions.

Total healthcare costs in the last year before graft failure are substantial and statistically significantly higher than years 2–5 before graft failure, in both kidney and liver transplant patients. Our findings show the economic burden placed on healthcare services in the years before graft failure.

Pathways to ensure universal and affordable access to hepatitis C treatment

Direct-acting antivirals (DAAs) have dramatically changed the landscape of hepatitis C treatment and prevention. The World Health Organization has called for the elimination of hepatitis C as a public health threat by 2030. However, the discrepancy in DAA prices across low-, middle- and high-income countries is considerable, ranging from less than US$ 100 to approximately US$ 40,000 per course, thus representing a major barrier for the scale-up of treatment and elimination. This article describes DAA pricing and pathways to accessing affordable treatment, providing case studies from Australia, Egypt and Portugal. Pathways to accessing DAAs include developing comprehensive viral hepatitis plans to facilitate price negotiations, voluntary and compulsory licenses, patent opposition, joint procurement, and personal importation schemes. While multiple factors influence the price of DAAs, a key driver is a country's capacity and willingness to negotiate with pharmaceutical companies. If negotiations do not lead to a reasonable price, governments have the option to utilise flexibilities outlined in the Agreement on Trade-Related Aspects of Intellectual Property Rights. Affordable access to DAAs is underpinned by collaboration between government, civil society, global organisations and pharmaceutical companies to ensure that all patients can access treatment. Promoting these pathways is critical for influencing policy, improving access to affordable DAAs and achieving hepatitis C elimination.

Decreased CD4+CD25+CD127dim/- Regulatory T Cells and T Helper 17 Cell Responsiveness to Toll-Like Receptor 2 in Chronic Hepatitis C Patients with Daclatasvir Plus Asunaprevir Therapy

Direct-acting antivirals (DAAs) not only rapidly inhibited hepatitis C virus (HCV) replication but also modulated innate and adaptive immune response in chronic hepatitis C patients. However, the regulatory activity of DAAs to Toll-like receptor 2 (TLR2) stimulation on CD4⁺CD25⁺CD127^dim/- regulatory T cells (Tregs) and T helper (Th) 17 cells was not completely understood. In the present study, a total of 23 patients with chronic HCV genotype 1b infection were enrolled, and blood samples were collected at baseline (treatment naive), end of therapy (EOT), and 12 weeks after EOT (SVR12) with daclatasvir plus asunaprevir therapy. TLR2 expression on Tregs and Th17 cells was measured by flow cytometry. Cellular proliferation, cytokine production, and suppressive activity were also tested in purified CD4⁺CD25⁺CD127^dim/- Tregs in response to the stimulation of Pam3Csk4, an agonist of TLR2. Inhibition of HCV RNA by daclatasvir and asunaprevir did not affect either percentage of Tregs/Th17 cells or TLR2 expression on Tregs/Th17 cells. Pam3Csk4 stimulation also did not influence either cellular proliferation or Tregs/Th17 proportion at each time point. Stimulation with Pam3Csk4 only enhanced the suppressive function and interleukin (IL)-35 production by Tregs purified from baseline, but not those from EOT or SVR12. Similarly, Pam3Csk4 stimulation only elevated Th17 cell frequency of CD4⁺ T cells from baseline, but not those from EOT or SVR12. Moreover, daclatasvir and asunaprevir therapy did not promote TLR2-induced shift of Tregs toward Th17-like phenotype and function. These data suggested that daclatasvir plus asunaprevir therapy resulted in the decreased responsiveness of Tregs/Th17 cells to TLR2 stimulation in chronic hepatitis C patients, which might provide a novel mechanism underlying DAA-induced immunoregulation.