WHO hepatitis C elimination targets: the global equity challenge

Patient and physician preferences for treatment of hepatitis C virus infection in Japan: a discrete choice experiment

AIMS

This study was performed to evaluate patients' and physicians' preferences regarding hepatitis C virus (HCV) treatment in Japan, particularly focusing on direct-acting antivirals. Understanding these preferences is important for maintaining adherence to treatment necessary for achieving HCV elimination.

METHODS

A discrete choice experiment was conducted to identify patients' and physicians' preferences for HCV treatment in Japan. Eligible participants completed a preference survey via an online questionnaire. Eight attributes and their respective levels - pertaining to dosing regimen/schedule, safety, and out-of-pocket costs - were identified. The primary and secondary endpoints were the relative attribute importance (RAI) and utility value of attribute levels, which were compared between patients and physicians to highlight differences.

RESULTS

Both patients (n = 95) and physicians (n = 118) showed the greatest concern for total out-of-pocket treatment costs, followed by safety risks. While patients and physicians generally shared similar treatment preferences, patients placed a higher RAI on total out-of-pocket costs than did physicians (50.4% vs. 39.4%). Conversely, patients assigned lower RAI values to the risks of nasopharyngitis and pruritus (15.2% vs. 17.9% and 11.7% vs. 16.2%, respectively). The RAI for the number of tablets taken daily was higher than that for treatment duration among patients (11.6% vs. 0.2%), but nearly equal among physicians.

LIMITATIONS

The study had potential non-response bias, physicians not being actual care providers for surveyed patients, a small sample size, reliance on predefined DCE attributes, and limited participant diversity from online panels.

CONCLUSIONS

This study highlights the importance of patient-centered care in HCV treatment and the need to raise awareness of the public subsidy for hepatitis, and to ensure an effective access scheme for the patients. Simplifying regimens like once-daily pills and minimal monitoring may enhance treatment convenience. Improved patient-physician communication supports optimized strategies, aiding Japan's goal of HCV elimination by 2030.

Impact of a minimal monitoring HCV treatment approach on Health-Related Quality of Life

BACKGROUND

Direct-acting antivirals (DAA) are highly effective for the management of HCV disease. This study aims to evaluate changes in health-related quality of life (HQoL) among people with HCV who were treated with DAAs using a minimal monitoring (MINMON) approach.

METHODS

ACTG A5360 was a multicenter, international (Brazil, South Africa, Thailand, Uganda, and USA) trial to assess the feasibility and efficacy of MINMON approach in people with HCV. We measured HQoL using EQ-5D-3L at baseline, sustained virological evaluation visit, week 48 and week 72, and described using EQ-5D summary index (ranges:0-1) and visual analog scale (VAS) score (ranges 0-100). We used paired T-tests to evaluate the change in EQ-5D summary and multivariable linear regression for changes in VAS scores.

RESULTS

Overall, 394 individuals were included; most did not have cirrhosis (360; 91%) or problematic alcohol use (278; 71%). We found HQoL improvements for participants from Brazil and Thailand, but not for the USA. Participants reported high rates of pain/discomfort and anxiety/depression, with decreases over time only for Brazil. Factors associated with larger improvements in VAS scores included: cirrhosis at baseline, and non-use or problematic use of other substances (apart from tobacco/marijuana) compared to non-problematic use.

CONCLUSION

We found HQoL improvements among people with HCV following DAA treatment with variability across countries. Our findings reinforce the importance of DAA treatment, especially among those with advanced HCV disease. Continuous mental health care including depression and substance use support should be offered to individuals after HCV treatment.

TRIAL REGISTRATION NUMBER

NCT03512210 (22-Oct-2018) Direct-acting antivirals are highly effective for the management of hepatitis C disease. Recent studies have shown that hepatitis C treatment with direct-acting antivirals has a positive impact on quality of life. However, no studies have assessed quality of life among individuals starting direct-acting antivirals treatment across multiple countries representing high-, middle- and low-income settings. In this study, we evaluated changes in health-related quality of life among people with hepatitis C who were treated with direct-acting antivirals using a simplified treatment delivery and offering minimal in-person monitoring. We found quality of life improvements among persons with hepatitis C after direct-acting antivirals treatment, with differences across countries. Although direct-acting antivirals treatment works well and should be available to all persons with hepatitis C, we found that participants with cirrhosis (liver damage) had higher improvements in quality of life, reinforcing the importance of starting treatment among people with advanced hepatitis C. We also found high rates of anxiety and depression, pointing to the importance of adding mental health care and support to infectious diseases services.

Association between hepatitis C virus infection and rheumatoid arthritis: a nationwide cross-sectional study

BACKGROUND

Patients infected with Hepatitis C Virus (HCV) often present with rheumatic symptoms, but its link to rheumatoid arthritis (RA) remains unclear. The purpose of this cross-sectional study was to investigate whether HCV infection is related to the risk for RA in adults.

METHODS

We analyzed data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES). HCV infection and RA status were determined through questionnaires. Covariates included gender, age, race, marital status, body mass index (BMI), high-sensitivity C-reactive protein (hs-CRP), and diabetes status. Multivariate logistic regression and subgroup analyses were used to assess the relationship between HCV infection and RA risk.

RESULTS

In this population-based study involving 5,825 participants aged 18-80 years (including 485 RA patients), we observed a significantly higher prevalence of HCV infection in the RA group compared with non-RA controls. After adjusting for covariates, multivariate logistic regression showed that HCV infection was associated with an increased risk of RA (OR = 1.93; 95%CI = 1.07-3.50, p < 0.05).

CONCLUSION

This study demonstrates that HCV infection is associated with the risk of RA in adults, underscoring the potential value of HCV screening in RA patients for improved disease management. However, causal interpretation is limited by the cross-sectional design and reliance on self-reported data.

Cost-Effectiveness of Screening and Treating Chronic Hepatitis C Virus Infection in Zimbabwe

BACKGROUND

The aim of this study was to assess the cost effectiveness of a screening and treatment intervention approach for chronic HCV infection in Zimbabwe.

METHODS

Using a decision tree and a validated Markov model, we estimated the lifetime costs and health effects of screening for and treating HCV infections from a healthcare perspective. We evaluated three screening strategies, namely the following: i. no screening; ii. screening among the general population; and iii. screening among high-risk groups. Incremental cost effectiveness ratios were calculated for the strategies that were not dominated. We used deterministic and probabilistic sensitivity analyses to explore the impacts of parameter uncertainty on cost effectiveness outcomes.

RESULTS

The strategy of screening among high-risk groups and treating with sofosbuvir/velpatasvir had an incremental cost of USD 1201 and incremental quality-adjusted life years (QALY) of 2.01, yielding an incremental cost effectiveness ratio (ICER) of USD 604 per QALY gained as compared to no screening. The ICER was below the 0.5 times the gross domestic product per capita parameter (USD 796), making the intervention potentially cost effective. The strategy to screen among the general population was dominated, because it costed more and resulted in fewer QALYs than its comparators.

CONCLUSIONS

Screening for HCV among high-risk populations followed by treatment using sofosbuvir/velpatasvir is cost effective under the assumptions made in this study.

Targeting cGAS-STING: modulating the immune landscape of hepatic diseases

Liver diseases, including viral hepatitis, alcoholic liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and hepatocellular carcinoma (HCC), represent a significant threat to global health due to their high mortality rates. The cGAS-STING pathway, a critical part of the innate immune system, plays a crucial role in detecting cytoplasmic DNA and initiating immune responses, including autoimmune inflammation and antitumor immunity. Genomic instability during cancer progression can trigger this pathway by releasing DNA into the cytoplasm. Emerging research indicates that cGAS-STING signaling is intricately involved in maintaining liver homeostasis and contributes to the pathogenesis of various liver diseases. This review outlines the cGAS-STING pathway, with a particular focus on its activation mechanism and its roles in several notable liver conditions. Specifically, we explore the complex interplay of cGAS-STING signaling in viral hepatitis, ALD, MASLD, and HCC, and discuss its potential as a therapeutic target. For example, in HCC, strategies targeting cGAS-STING include using nanomaterials to deliver STING agonists, combining radiofrequency ablation (RFA) with cGAS-STING activation, and leveraging radiotherapy to enhance pathway activation. Furthermore, modulating cGAS-STING activity may offer therapeutic avenues for viral hepatitis and chronic liver diseases like MASLD and ALD, either by boosting antiviral responses or mitigating inflammation. This review highlights the complex role of cGAS-STING signaling in these specific liver diseases and underscores the need for further research to fully realize its therapeutic potential.

The Changing Demographics and Epidemiology of Hepatocellular Carcinoma

The epidemiology of hepatocellular carcinoma (HCC) has shifted significantly in the last 2 decades with non-viral etiologies such as metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease on the rise. Key factors include the global obesity epidemic and the resurgence of alcohol use disorder, both of which were exacerbated by the coronavirus disease 2019 pandemic. While these non-viral etiologies of HCC are becoming the leading cause in developed countries, the potential impact of immigration patterns on Hepatitis B virus epidemiology cannot be ignored. The risk of HCC remains significant in individuals with cirrhosis and viral hepatitis after curative treatments.

Modeling of randomized hepatitis C vaccine trials: Bridging the gap between controlled human infection models and real-word testing

Global elimination of chronic hepatitis C (CHC) remains difficult without an effective vaccine. Since injection drug use is the leading cause of hepatitis C virus (HCV) transmission in Western Europe and North America, people who inject drugs (PWID) are an important population for testing HCV vaccine effectiveness in randomized-clinical trials (RCTs). However, RCTs in PWID are inherently challenging. To accelerate vaccine development, controlled human infection (CHI) models have been suggested as a means to identify effective vaccines. To bridge the gap between CHI models and real-world testing, we developed an agent-based model simulating a two-dose vaccine to prevent CHC in PWID, representing 32,000 PWID in metropolitan Chicago and accounting for networks and HCV infections. We ran 500 trial simulations under 50 and 75% assumed vaccine efficacy (aVE) and sampled HCV infection status of recruited in silico PWID. The mean estimated vaccine efficacy (eVE) for 50 and 75% aVE was 48% (SD ± 12) and 72% (SD ± 11), respectively. For both conditions, the majority of trials (∼71%) resulted in eVEs within 1 SD of the mean, demonstrating a robust trial design. Trials that resulted in eVEs >1 SD from the mean (lowest eVEs of 3 and 35% for 50 and 75% aVE, respectively), were more likely to have imbalances in acute infection rates across trial arms. Modeling indicates robust trial design and high success rates of finding vaccines to be effective in real-life trials in PWID. However, with less effective vaccines (aVEs∼50%) there remains a higher risk of concluding poor vaccine efficacy due to post-randomization imbalances.

405 nm violet-blue light inactivates hepatitis C cell culture virus (HCVcc) in ex vivo human platelet concentrates and plasma

Added safety measures coupled with the development and use of pathogen reduction technologies (PRT) significantly reduces the risk of transfusion-transmitted infections (TTIs) from blood products. Current approved PRTs utilize chemical and/or UV-light based inactivation methods. While the effectiveness of these PRTs in reducing pathogens are well documented, these can cause tolerable yet unintended consequences on the quality and efficacy of the transfusion products. As an alternative to UV-based approaches, we have previously demonstrated that 405 nm violet-blue light exposure successfully inactivates a variety of pathogens, including bacteria, parasites, and viruses, in both platelet concentrates (PCs) and plasma. Herein, we show that 405 nm light treatment effectively inactivates hepatitis C cell culture virus (HCVcc) by up to ~ 3.8 log10 in small volumes of a variety of matrices, such as cell culture media, PBS, plasma, and PCs with 27 J/cm2 of light exposure, and total inactivation of HCVcc after 162 J/cm2 light exposure. Furthermore, we demonstrate that carry-over of media supplemented with fetal bovine serum enhances the production of reactive oxygen species (ROS), providing mechanistic insights to 405 nm light-mediated viral inactivation. Overall, 405 nm light successfully inactivates HCVcc, further strengthening this method as a novel PRT for platelets and plasma.

Diagnostic performance of hepatitis C virus core antigen testing for detecting hepatitis C in people living with hepatitis B: a systematic review and meta-analysis

BACKGROUND

The current diagnostic strategy for hepatitis C virus (HCV) infection involves a two-step approach: antibody HCV screening followed by confirmatory nucleic acid testing. This study aimed to evaluate the diagnostic performance of the Abbott ARCHITECT HCV Ag assay in serum/plasma samples as a potential one-step alternative for diagnosing active HCV infection in people living with hepatitis B virus (PLWHB) through a systematic review and meta-analysis.

METHODS

A systematic review and meta-analysis were conducted following PRISMA-DTA guidelines. This protocol was registered on PROSPERO (CRD42023402093). A comprehensive search of electronic databases identified studies published up to 1 November 2024, comparing the ARCHITECT HCV Ag assay to an HCV-RNA reference standard. Sensitivity, specificity, and likelihood ratios were pooled using a random-effects model within the MIDAS module of Stata software. Study quality was assessed using QUADAS-2. Heterogeneity was evaluated using the Q statistic, quantified using the I², and further explored through meta-regression.

RESULTS

Ten studies (n = 494 participants) met inclusion criteria. The Abbott ARCHITECT HCV Ag assay demonstrated high sensitivity [91%, 95% confidence interval (CI): 76-97%] and specificity (99%, 95% CI: 99-100%). The positive likelihood ratio (PLR) was 81.20 (95% CI: 12.34-534.36), and the negative likelihood ratio (NLR) was 0.09 (95% CI: 0.03-0.27). The area under the summary receiver operating characteristic curve (AUC-SROC) was 99% (95% CI 98-100%). In regions with high HCV prevalence (≥ 10%), the test accurately confirmed active HCV infection in over 90% of cases. However, confirmatory testing remains necessary in low-prevalence settings (≤ 5%). The assay demonstrated an excellent ability to identify individuals without HCV infection, with a low false-negative rate (≤ 2%) regardless of HCV prevalence. Heterogeneity analysis revealed moderate to substantial variation in test performance (I² = 72.09% for sensitivity, 35.47% for PLR, and 78.33% for NLR). QUADAS-2 applicability concerns predicted heterogeneity, but differences were likely insignificant due to minimal variations and limited studies.

CONCLUSIONS

The Abbott ARCHITECT HCV Ag assay exhibited promising accuracy in detecting active HCV infection among PLWHB. This test might help diagnose active HCV infection in high-prevalence scenarios (≥ 10%) but needs further confirmation in low-prevalence settings (≤ 5%).

Elimination of HCV Infection: Recent Epidemiological Findings, Barriers, and Strategies for the Coming Years

Hepatitis C is a disease for which in approximately 30 years we have gone from the discovery of the causative agent in 1989, to the introduction of direct-acting antiviral (DAAs) therapies starting from 2011, and to a proposal for its elimination in 2016, with some countries being on track for this goal. Elimination efforts, in the absence of a vaccine, rely on prevention measures and antiviral therapies. However, treatment rates have declined in recent years and are not considered adequate to achieve this goal at a global level. This poses a great epidemiological challenge, as HCV in many countries still causes a significant burden and most infected people are not yet diagnosed. Consequently, efforts are needed at different levels with common purposes: to facilitate access to screening and diagnosis and to improve linkage to care pathways. In this review, we discuss the latest epidemiological findings on HCV infection, the obstacles to its elimination, and strategies that are believed to be useful to overcome these obstacles but are applied unevenly across the world.

Comparison of anti-HCV combined with HCVcAg (Elecsys HCV Duo immunoassay) and anti-HCV rapid test followed by HCV RNA analysis using qRT-PCR to identify active infection for treatment

Hepatitis C virus (HCV) infection can cause acute and chronic hepatitis, leading to liver cirrhosis and hepatocellular carcinoma. The World Health Organization aims to eliminate viral hepatitis by 2030 through extensive screening and treatment. To achieve this goal, comprehensive and widespread screening is essential for diagnosis and treatment. This study aims to evaluate the diagnostic sensitivity and specificity of the Elecsys® HCV Duo immunoassay (Duo-assay), which simultaneously detects anti-HCV antibodies (Duo/anti-HCV) and HCV core antigen (Duo/HCVcAg) in a single sample, compared with initially antibody testing followed by quantitative real-time polymerase chain reaction (qRT-PCR). Additionally, this study aimed to evaluate a relationship between Duo/HCVcAg and qRT-PCR assay in different genotypes. A total of 769 plasma samples were tested using the Duo-assay to further evaluate the test's performance and conduct Duo/HCVcAg correlation analysis using qRT-PCR for each genotype. Among the active infection group (anti-HCV+/RNA+; n = 473), the Duo-assay showed 100% sensitivity for detecting Duo/anti-HCV and 70.6% for Duo/HCVcAg. In the resolved infection group (anti-HCV+/RNA-; n = 176), the assay showed 100% sensitivity for Duo/anti-HCV and 100% specificity for Duo/HCVcAg. In the non-infected group (anti-HCV-/RNA-; n = 120), the assay showed 100% specificity for both Duo/anti-HCV and Duo/HCVcAg. Moreover, no correlation was observed between the Duo/HCVcAg and HCV RNA tests, irrespective of genotype. These findings indicate that the Duo-assay is highly sensitive for detecting anti-HCV and specifically identifies patients with active infection. Nevertheless, cases with anti-HCV+/HCVcAg-results should undergo additional confirmation with western blot/immunoblot and qRT-PCR to ensure diagnostic accuracy, especially in Blood donation facilities.

The Prevalence and Genotype Distribution of Hepatitis C Virus in Kenya: A Systematic Review and Meta-Analysis

BACKGROUND

Hepatitis C (HCV) is a virus that causes chronic liver disease, end-stage cirrhosis, and liver cancer, yet most infected individuals remain undiagnosed or untreated. Kenya is a country located in Sub-Saharan Africa (SSA) where the prevalence of HCV remains high but with uncertain disease burden due to little population-based evidence of the epidemic. We aimed to highlight the HCV disease burden in Kenya with a summary of the available data.

METHODS

The study was performed as per the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched publications reporting HCV prevalence and genotypes in Kenya between January 2000 to December 2022. The effect size, i.e., the HCV prevalence, was defined as the proportion of samples testing positive for HCV antibody. Study quality was assessed by the Joanna Briggs Institute (JBI) critical appraisal checklist. Due to high study heterogeneity, the studies were categorized into low-, intermediate-, and high-risk for HCV infection. The pooled estimate prevalence per category was determined by the random effects model. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023401892).

RESULTS

A total of 29 studies with a sample size of 90,668 met our inclusion criteria, a third of which were from the capital city Nairobi (34.5%). Half of the studies included HIV-infected individuals (31%) or injection drug users (20.7%). HCV genotype 1 was the most common, with genotype 4 only slightly less common, and together they accounted for 94% of cases. The pooled prevalence for the low-, intermediate- and high-risk groups were 2.0%, 3.4%, and 15.5%, respectively. Over 80% of the studies had a score of > 6 on the JBI scale, indicating a low risk of bias in terms of study design, conduct and analysis.

CONCLUSION

Our findings demonstrate that there is a higher prevalence of HCV in key populations such as HIV-infected individuals and drug users than in the general population in Kenya. We found that HCV genotypes 1 and 4 were the most common genotypes. More data from the general population is required in order to establish baseline data on the prevalence and genotypes of HCV in Kenya.

Efficacy of assisted partner services for people who inject drugs in Kenya to identify partners living with HIV and hepatitis C virus infection: a prospective cohort study

BACKGROUND

People who inject drugs are at increased risk of both HIV and hepatitis C virus (HCV) infections but face barriers to testing and engagement in care. Assisted partner services are effective in locating people with HIV but are understudied among people who inject drugs. We assessed whether assisted partner services could be used to find, test for HIV and HCV infections, and link to care the partners of people who inject drugs in Kenya.

METHODS

In this prospective study at eight sites offering harm-reduction services in Kenya, we enrolled people aged 18 years or older who inject drugs and were living with HIV (index participants) between Feb 27, 2018, and Nov 1, 2021. Index participants provided information about their sexual and injecting partners (ie, anyone with whom they had had sexual intercourse or injected drugs in the previous 3 years), and then community-embedded peer educators located partners and referred them for enrolment in the study (partner participants). All participants underwent testing for HCV infection, and partner participants also underwent HIV testing. Index and partner participants with HIV but who were not on antiretroviral therapy (ART) were linked with treatment services, and those positive for HCV were linked to treatment with direct-acting antivirals. We calculated the number of index participants whom we needed to interview to identify partner participants with HIV and HCV infection.

FINDINGS

We enrolled 989 people living with HIV who inject drugs, who mentioned 4705 sexual or injecting partners. Of these 4705 partners, we enrolled 4597 participants, corresponding to 3323 unique individuals. 597 (18%) partner participants had HIV, of whom 506 (85%) already knew their status. 358 (71%) of those who knew they were HIV positive were virally suppressed. 393 (12%) partner participants were HCV antibody positive, 213 (54%) of whom had viraemia and 104 (26%) of whom knew their antibody status. 1·66 (95% CI 1·53-1·80) index participants had to be interviewed to identify a partner with HIV, and 4·24 (3·75-4·85) had to be interviewed to find a partner living with HIV who was unaware of their HIV status, not on ART, or not virally suppressed. To find a partner seropositive for HCV who did not know their antibody status, 3·47 (3·11-3·91) index participants needed to be interviewed. Among the 331 index and partner participants living with HIV who were not on ART at enrolment, 238 (72%) were taking ART at 6-month follow-up. No adverse events were attributed to study procedures.

INTERPRETATION

Use of assisted partner services among people with HIV who inject drugs was safe and identified partners with HIV and HCV infections. Assisted partner services was associated with increased uptake of ART for both index participants and partners.

FUNDING

US National Institutes of Health.