Integrating hepatitis C care for at-risk groups (HepLink): baseline data from a multicentre feasibility study in primary and community care

Benchmarking of an Intervention Aiming at the Micro-Elimination of Hepatitis C in Vulnerable Populations in Perpignan, France, to Inform Scale-Up and Elimination on the French Territory

Hepatitis C virus (HCV) is an important cause of chronic liver disease. Among at-risk populations, access to care is challenging. The French Ministry of Health has supported a seek-and-treat pilot intervention aiming at micro-elimination in Perpignan, France, to inform scale-up of elimination efforts across the whole territory. University College Dublin (UCD) led a successful EU funded project, called HepCare, focusing on the micro-elimination of HCV. UCD was contracted to evaluate and benchmark the Perpignan results against results from HepCare. Using mixed-method approaches including qualitative interviews with patients, a focus group with healthcare professionals, and quantitative analyses of the cascade of care against results obtained at other European sites, we analyse the acceptability, reproducibility, replicability, and effectiveness of the Perpignan intervention. A total of 960 participants were recruited in the Perpignan area. HCV antibody test results were obtained for 928 (96.6%), of which 150 (15.6%) were antibody-positive. Of the antibody-positive participants, 68 (45.3%) tested positive for HCV-RNA, 141 (94%) were linked to care, and of the HCV-RNA-positive participants, 60 (88%) started treatment. Of those who underwent treatment, 34 (56.7%) completed treatment and achieved a sustained viral response (SVR) at dataset closure, 18 (30%) were still in treatment, 5 (8.3%) defaulted from treatment, and 3 (5%) had a virologic failure or died. The intervention in Perpignan was acceptable to patients, but had limitations in effectiveness, as shown in comparisons with HepCare results. To engage harder-to-reach cohorts in France, future models of care in the territory should incorporate peer support.

Predictors of engagement in screening for a hepatitis C virus (HCV) treatment trial in a rural Appalachian community

An HCV treatment trial was initiated in September 2019 to address the opioid/hepatitis C virus (HCV) syndemic in rural Kentucky. The focus of the current analysis is on participation in diagnostic screening for the trial. Initial eligibility (≥18 years of age, county resident) was established by phone followed by in-person HCV viremia testing. 900 rural residents met the inclusion criteria and comprised the analytic sample. Generalized linear models were specified to estimate the relative risk of non-attendance at the in-person visit determining HCV eligibility. Approximately one-quarter (22.1%) of scheduled participants were no-shows. People who inject drugs were no more likely than people not injecting drugs to be a no-show; however, participants ≤35 years of age were significantly less likely to attend. While the median time between phone screening and scheduled in-person screening was only 2 days, each additional day increased the odds of no-show by 3% (95% confidence interval: 2%-3%). Finally, unknown HCV status predicted no-show even after adjustment for age, gender, days between screenings and injection status. We found that drug injection did not predict no-show, further justifying expanded access to HCV treatment among people who inject drugs. Those 35 years and younger were more likely to no-show, suggesting that younger individuals may require targeted strategies for increasing testing and treatment uptake. Finally, streamlining the treatment cascade may also improve outcomes, as participants in the current study were more likely to attend if there were fewer days between phone screening and scheduled in-person screening.

The Efficiency of Increased HCV Testing and Treatment Strategies in Spain to Achieve Elimination Goals

BACKGROUND

In 2015, Spain launched a national eradication strategy for hepatitis C virus (HCV), resulting in the highest treatment rate in Europe and substantial reductions in HCV prevalence. However, to achieve the goal of HCV elimination, it is necessary to scale-up the diagnosis, treatment, and management of HCV infection.

OBJECTIVE

Our aim was to assess the prevalence, incidence, and cost effectiveness of scaling-up compared with status quo scenarios.

METHODS

A compartmental dynamic transmission model was developed comprising of a cascade of care and a liver progression module. Cost and quality-of-life inputs were sourced from the literature. Key outcomes were the prevalence and incidence of HCV and the incremental cost per quality-adjusted life-year (QALY) and per life-year (LY). Outcomes for a hypothetical elimination strategy were compared with the status quo.

RESULTS

The base-case analysis found that scaling-up testing and treatment reduced both the prevalence and incidence of HCV over time, resulting in incremental costs per QALY and LY of €13,291 and €12,285 respectively, compared with the status quo. The main drivers of the cost-effectiveness results included cost of diagnosis, cost of treatment, proportion of people who are unaware, percentage of population who inject drugs, and calibration parameters related to HCV infection prevalence.

CONCLUSIONS

This analysis demonstrated that scaling-up testing and treatment with direct-acting antivirals may be an efficient strategy for reducing the incidence and prevalence of HCV and may help achieve HCV elimination goals in Spain.

The signal-to-cutoff ratios to predict HCV infection among people who inject drugs

People who inject drugs (PWIDs) are primarily the high-risk population for HCV infection. This study aims to determine the optimal cut-off values for predicting HCV infection status based on the Signal-to-Cutoff (S/CO) ratio. In this study, a total of 719 PWIDs’ samples were collected, and performed for screening test by ELISA assay, and followed by RIBA assay and NAT assay to detect HCV antibody and HCV RNA levels, respectively. The findings revealed that the prevalence of HCV infection among PWIDs was 54.66% (393/719), and the false-positive rate of HCV antibody detection by ELISA assay among PWIDs was only 3.85% (16/416). In addition, when the optimal cut-off value for S/CO ratio was 2.0, the sensitivity and specificity of HCV antibody were 100.00% and 93.55%, respectively. And when the optimal cut-off value for S/CO ratio was 21.36, the sensitivity and specificity of HCV RNA positive were 89.90% and 72.73%, respectively. In conclusion, the status of HCV infection can be predicted based on the S/CO ratios of the ELISA assay, which can improve diagnosis and facilitate timely treatment to effectively prevent the spread of HCV infection.

Hepatitis C: Problems to extinction and residual hepatic and extrahepatic lesions after sustained virological response

Loss of follow-up or reinfections hinder the expectations of hepatitis C eradication despite the existence of highly effective treatments. Moreover, the elimination of the infection does not imply the reversion of those chronic alterations derived from the previous infection by hepatitis C virus (HCV). This review analyzes the risk factors associated with loss to follow-up in diagnosis or treatment, and the possibility of reinfection. Likewise, it assesses the residual alterations induced by chronic HCV infection considering the liver alterations (inflammation, fibrosis, risk of decompensation, hepatocellular carcinoma, liver transplantation) and, on the other hand, the comorbidities and extrahepatic manifestations (cryoglobulinemia, non-Hodgkin lymphoma, peripheral insulin resistance, and lipid, bone and cognitive alterations). Peculiarities present in subjects coinfected with human immunodeficiency virus are analyzed in each section.

Cost-effectiveness of mass screening for Hepatitis C virus among all inmates in an Irish prison

BACKGROUND

In Irish prisons, there is a high proportion of people who inject drugs (PWID; 26%) and a high prevalence of HCV (16%), making prison a high priority setting for HCV testing and treatment. We evaluate the cost-effectiveness of a mass HCV screening intervention in Mountjoy Prison, Dublin, compared to the standard-of-care of intermittent screening on committal.

METHODS

Primary cost data was collected from the intervention using an overall provider perspective. Standard-of-care (SOC) costs were estimated through interview. All costs were inflated to 2020 Euros. An HCV transmission and disease progression model among incarcerated and community PWID and ex-injectors was calibrated to the Dublin HCV epidemic, allowing inclusion of population-level health benefits. The model used intervention data, suggesting 419 individuals were screened, 50 HCV infections diagnosed and 32 individuals initiated treatment, to project the resulting costs and health benefits (quality adjusted life years or QALYs) over 50 years with 5% discounting. The incremental cost effectiveness ratio (ICER), cost per QALY gained, was estimated for the screening intervention compared to the standard-of-care. Probabilistic sensitivity analyses (PSA) determined the probability that the intervention was cost-effective compared to a willingness-to-pay threshold of €30,000/QALY as used in Ireland. The ICER for 1- or 3-yearly mass screening in all Dublin prisons was also calculated.

RESULTS

The total direct costs of the intervention (not including treatment drug costs) was €82,392, with most costs being due to staff (43%) and overhead or management costs (38%). Despite having little epidemiological impact due to the small numbers treated, over 50 years the incremental cost of the intervention was €36,592 and 3.8 QALYs were gained, giving a mean ICER of €9,552/QALY. The majority (84%) of PSA runs were below the willingness-to-pay threshold. Yearly mass screening had an ICER of €2,729/QALY compared to SOC and gave a higher net monetary benefit (€7,393,382) than screening every 3 years (€6,252,816).

CONCLUSION

Prison mass screening could be a cost-effective initiative for increasing testing and treatment of HCV in Ireland.

What is the clinical course of patients hospitalised for COVID-19 treatment Ireland: a retrospective cohort study in Dublin’s North Inner City (the ‘Mater 100’)

Background: Ireland has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While several cohorts from China have been described, there is little data describing the epidemiological and clinical characteristics of Irish patients with COVID-19. To improve our understanding of this infection we performed a retrospective review of patient data to examine the clinical characteristics of patients admitted for COVID-19 hospital treatment. Methods: Demographic, clinical and laboratory data on the first 100 patients admitted to Mater Misericordiae University Hospital for in-patient COVID-19 treatment after onset of the outbreak in March 2020 was extracted from patient records. Results: The median age was 45 years (interquartile range [IQR] =34-64 years), 58% were male, and 63% were Irish nationals. Patients had symptoms for a median of five days before diagnosis (IQR=2.5-7 days), most commonly cough (72%), fever (65%), dyspnoea (37%), fatigue (28%), myalgia (27%) and headache (24%). Of all cases, 54 had at least one pre-existing chronic illness (most commonly hypertension, diabetes mellitus or asthma). At initial assessment, the most common abnormal findings were: C-reactive protein >7.0mg/L (74%), ferritin >247μg/L (women) or >275μg/L (men) (62%), D-dimer >0.5μg/dL (62%), chest imaging (59%), NEWS Score (modified) of ≥3 (55%) and heart rate >90/min (51%). Supplemental oxygen was required by 27 patients, of which 17 were admitted to the intensive care unit - 14 requiring ventilation. Antiviral therapy was administered to 40 patients (most commonly hydroxychloroquine or lopinavir/ritonavir). Four died, 17 were admitted to intensive care, and 74 were discharged home, with nine days the median hospital stay (IQR=6-11). Conclusion: Our findings reinforce the consensus of COVID-19 as an acute life-threatening disease and highlights the importance of laboratory (ferritin, C-reactive protein, D-dimer) and radiological parameters, in addition to clinical parameters. Further cohort studies followed longitudinally are a priority.

HepCare Ireland-a service innovation project

Hepatitis C virus (HCV) remains a major cause of morbidity and death worldwide, with prevalence highest among people who inject drugs (PWID), homeless populations and prisoners. The World Health Organization has published targets to be achieved by 2030 as part of its global health sector strategy to eliminate viral hepatitis. Recent innovations in testing and treatment of HCV mean such goals are achievable with effective infrastructure, political will and funding. 'HepCare Europe' was a 3-year, EU-funded project involving four member states. It sought to develop, implement and evaluate interventions to improve HCV outcomes through multiple-level interventions, running between 2016 and 2019. This paper aims to summarize the methods and present the aggregate cascade of care figures for the Irish components of HepCare. 'HepCare Ireland' contained five integrated work packages: HepCheck, HepLink, HepFriend, HepEd and HepCost. Interventions included intensified screening, community-based assessment, linkage to specialist care, peer training and support, multidisciplinary educational resources and cost-effectiveness analysis. A total of 812 participants were recruited across the three clinical work packages in Ireland. Two hundred and fifty-seven (31.7%) of the tested participants had an HCV antibody-positive result, with 162 (63.0%) testing positive for HCV RNA. At the time of writing (6th of November 2019), 57 (54.8%) of participants put on treatment had achieved SVR12, with 44 (42.3%) still undergoing treatment. In HepCheck, HepLink. HepEd and HepFriend, we demonstrate a series of interventions to improve Irish HCV outcomes. Our findings highlight the benefits of multilevel interventions in HCV care.