Multicenter study on the discontinuation and efficacy of chronic hepatitis C treatment in the Spanish penitentiary population (EPIBAND study)

Elimination of hepatitis C virus in a prison: An 18-year experience

INTRODUCTION

Despite the decrease of hepatitis C in Spanish prisons in the last years, it still remains a reservoir for infection. The aim of this work is to analyze the characteristics of these patients and the response to antiviral treatment over the last 18 years.

METHODS

Retrospective observational study in inmates of Araba penitentiary center diagnosed with HCV infection between 2002 and 2020. A descriptive analysis of patient characteristics and the response to the three antiviral treatment modalities was performed: peg-interferon and ribavirin, peg-interferon, ribavirin and a first-generation protease inhibitor and different combinations of direct-acting antivirals.

RESULTS

A total of 248 antiviral treatments were prescribed. Treatment response rate up to 2015 was 65% and 93,7% after that year. Interferon non-responders were the main cause of non-response to treatment in periods 1 and 2 (40%-50%). Conversely, in period 3 viral breakthrough (67%) was the main culprit.

CONCLUSION

After 18 years, active hepatitis C infection in prison inmates has resolved with treatment according to clinical criteria. Therefore, the stay in prison may represent an opportunity to reduce the reservoir of the disease in the community, together with continued health care for those released from prison.

The impact of unrestricted access to direct-acting antiviral among incarcerated hepatitis C virus-infected patients

BACKGROUND/AIMS

Despite the disproportionally high prevalence rates of hepatitis C virus (HCV) amongst the incarcerated population, eradication remains challenging due to logistic and financial barriers. Although treatment prioritization based on disease severity is commonly practiced, the efficacy of such approach remained uncertain. We aimed to compare the impact of unrestricted access to direct-acting antiviral (DAA) among incarcerated HCV-infected patients in Singapore.

METHODS

In this retrospective study, we reviewed all incarcerated HCV-infected patients treated in our hospital during the restricted DAA era (2013-2018) and unrestricted DAA access era (2019). Study outcomes included the rate of sustained virological response (SVR), treatment completion and treatment default. Subgroup analysis was performed based on the presence of liver cirrhosis, HCV genotype and HCV treatment types.

RESULTS

A total of 1,001 HCV patients was followed-up for 1,489 person-year. They were predominantly male (93%) with genotype-3 HCV infection (71%), and 38% were cirrhotic. The overall SVR during the restricted DAA access era and unrestricted DAA access era were 92.1% and 99.1%, respectively. Unrestricted access to DAA exponentially improved the treatment access among HCV-infected patients by 460%, resulting in a higher SVR rate (99% vs. 92%, P=0.003), higher treatment completion rate (99% vs. 93%, P<0.001) and lower treatment default rate (1% vs. 9%, P<0.001).

CONCLUSION

In this large cohort of incarcerated HCV-infected patients, we demonstrated that unrestricted access to DAA is an impactful strategy to allow rapid treatment up-scale in HCV micro-elimination.

A systematic review on models of care effectiveness and barriers to Hepatitis C treatment in prison settings in the EU/EEA

Hepatitis C prevalence in prison populations is much higher than in the community. Effective hepatitis C treatment within this population does not only have a direct individual health benefit, but may lead to substantial community dividend. We reviewed available evidence on hepatitis C treatment in prison settings, with a focus on the European Union/European Economic Area. A systematic review of the literature (PubMed, EMBASE, Cochrane library) was performed and complemented with searches for conference abstracts and grey literature. Thirty-four publications were included reporting on the effectiveness, acceptability and economic aspects of hepatitis C virus treatment models of care to achieve treatment completion and sustained viral response in prison settings. Available evidence shows that hepatitis C treatment in prison settings is feasible and the introduction of direct-acting antivirals will most likely result in increased treatment completion and better clinical outcomes for the prison population, given the caveats of affordability and the need for increased funding for prison health, with the resulting benefits accruing mostly in the community.

Comparison of effectiveness and discontinuation of interferon-free therapy for hepatitis C in prison inmates and noninmates

Chronic hepatitis C treatment with direct acting antiviral (DAA) therapy during incarceration is an attractive option, due to its short duration and to the possibility of directly observed treatment or supervision. The aim of this study is to compare the effectiveness and rates of discontinuation of DAA treatment in prisoners and nonprisoners. We studied all patients treated in the 10 prisons of Catalonia and at 3 public hospitals in the Barcelona area between 1 January 2015 and 30 April 2016. We analysed sustained viral response (SVR) and rates of discontinuation through intention-to-treat and modified-intention-to-treat analyses, the latter excluding discontinuations due to release from prison. One hundred and eighty-eight inmates and 862 noninmates were included. Prisoners were significantly younger than nonprisoners, with higher proportions of men, drug users, HIV infection, genotypes 1a and 3 and more treatment with psychiatric drugs. Overall, 98.4% of patients completed treatment. The discontinuation rate was low, but higher in inmates (3.7% vs 1.2% noninmates; P = .003) and in community patients >65 years old (2.8% vs 1.2% in under 65 seconds; P = .008). Among the inmates, 7 (42.8%) discontinuations were due to release. SVR was 93.1% in inmates vs 96.5% in noninmates (P = .08) by intention-to-treat and 95.1% vs 96.5% (P = .37) by modified intention-to-treat. Virologic failure rates were similar (3.8% vs 3% in noninmates; P = .60). SVR, virologic failure and discontinuation rates were similar in inmates and noninmates. Currently, prisons are considered a priority for the implementation of DAA. Improved coordination between penitentiary and community health systems would help to ensure therapeutic continuity in released prisoners.

Harm reduction and viral hepatitis C in European prisons: a cross-sectional survey of 25 countries

Background

Current estimates suggest that 15% of all prisoners worldwide are chronically infected with the hepatitis C virus (HCV), and this number is even higher in regions with high rates of injecting drug use. Although harm reduction services such as opioid substitution therapy (OST) and needle and syringe programs (NSPs) are effective in preventing the further spread of HCV and HIV, the extent to which these are available in prisons varies significantly across countries.

Methods

The Hep-CORE study surveyed liver patient groups from 25 European countries in 2016 and mid-2017 on national policies related to harm reduction, testing/screening, and treatment for HCV in prison settings. Results from the cross-sectional survey were compared to the data from available reports and the peer-reviewed literature to determine the overall degree to which European countries implement evidence-based HCV recommendations in prison settings.

Results

Patient groups in nine countries (36%) identified prisoners as a high-risk population target for HCV testing/screening. Twenty-one countries (84%) provide HCV treatment in prisons. However, the extent of coverage of these treatment programs varies widely. Two countries (8%) have NSPs officially available in prisons in all parts of the country. Eleven countries (44%) provide OST in prisons in all parts of the country without additional requirements.

Conclusion

Despite the existence of evidence-based recommendations, infectious disease prevention measures such as harm reduction programs are inadequate in European prison settings. Harm reduction, HCV testing/screening, and treatment should be scaled up in prison settings in order to progress towards eliminating HCV as a public health threat.

Extrahepatic manifestations associated with Chronic Hepatitis C Virus Infection

Chronic hepatitis C virus (HCV) infection has been associated with both organ-specific and systemic autoimmune diseases, with cryoglobulinemia being the most frequent associated disease. Experimental, virologic, and clinical evidence have demon-strated a close association between HCV infection and some systemic autoimmune diseases, especially Sjögren's syndrome, but also rheumatoid arthritis and lupus. A higher prevalence of hematological processes has also been described in patients with HCV infection, including cytopenias and lymphoproliferative disorders (B-cell lymphoma). In addition, patients with chronic HCV infection have a higher frequency of other extrahepatic manifestations including endocrine, metabolic and cardiovascular disorders that may worse the prognosis of patients, along with neuropsychiatric manifestations and general symptoms that have a significant influence on the quality of life of the patient. Direct-acting antiviral therapies (DAAs) that have recently begun to be used are providing the opportunity to effectively cure chronic HCV infection and reduce the burden of both hepatic and extrahepatic complications.

Personality disorders do not affect treatment outcomes for chronic HCV infection in Spanish prisoners: the Perseo study

Background

The link between infection with hepatitis C virus (HCV) and personality disorders (PD) has not been investigated in detail. The aim of this study was to compare the effectiveness of HCV treatment in prisoners with and without PD.

Methods

We performed a prospective multicentre study in inmates from 25 Spanish prisons who had been treated with pegylated interferon alfa-2a plus ribavirin in 2011. PD diagnosis was based on the Personality Diagnostic Questionnaire-4+. We calculated adjusted Odds Ratios (AOR) and 95 % confidence intervals (95 % CI) using logistic regression.

Results

The sample included 236 patients (mean age: 40.3 years, 92.8 % male, 79.2 % intravenous drug users, and 26.3 % HIV-coinfected). The prevalence of PD was 72.5 %. 32.2 % of patients discontinued treatment; this percentage was higher in patients with HCV genotypes 1/4 (AOR = 3.55; CI:1.76–7.18) and those without PD (AOR = 2.51; 1.23–5.11). Treatment discontinuation was mainly for penitentiary reasons (40.3 %): release or transfer between prisons.

The rate of sustained viral response (SVR) was 52.1 % by ITT and 76.9 % by observed treatment (OT). SVR was higher among patients with genotype 2 or 3, and those with low baseline HCV-RNA. We did not observe any differences between individuals with and without PD in term of SVR, HCV genotype or HIV infection.

Conclusions

Our results support the safety and clinical effectiveness of the treatment of chronic HCV infection in correctional facilities, both in prisoners with PD and those without. Our data support non-discrimination between patients with and without PD when offering treatment for HCV infection to prison inmates.

Trial registration

Trial registration number (TRN) NCT01900886. Date of registration: July 8, 2013