Aiming towards hepatitis C virus elimination in Greece

HCV-HIV co-infection in people who inject drugs: Barriers to treatment and cure of HCV infection in the era of DAAs, a prospective study in Athens, Greece

OBJECTIVES

HIV/hepatitis C virus (HCV) co-infection among people who inject drugs (PWID) remains a global health problem. The goal of our study was to evaluate, in a real-world setting, success rates of sustained virological response (SVR) using direct-acting antivirals (DAAs) to treat a population of PWID living with HCV/HIV.

METHODS

This was a prospective single-center observational study. We collected demographic, socioeconomic, and clinical data pertaining to HIV and HCV infection in PWID with several barriers to care. We identified risk factors for SVR failure.

RESULTS

Among 130 individuals retained to HIV care, we planned HCV treatment in 119/130 (91.5%); 106/119 (89.1%) started treatment with DAAs and 100/106 (94.3%) completed treatment. People not starting treatment were more often in active opioid drug use (odds ratio [OR] 0.25; 95% confidence interval [CI] 0.07-0.97, p = 0.045) and benzodiazepine abuse (OR 0.25; 95% CI 0.07-0.95, p = 0.042). Only 86/100 (86%) were tested for SVR at 12 weeks (SVR12) and 72/86 (83.7%) achieved SVR. PWID in opioid substitution programmes tended to return for SVR12 testing more often (54.7% vs. 30%, p = 0.081). Individuals in active opioid drug use (OR 0.226; 95% CI 0.064-0.793, p = 0.02) or with poor adherence (OR 0.187; 95% CI 0.043-0.814, p = 0.025) were less likely to achieve SVR. At the end of our study period, 113/119 (95%) treatment-eligible patients remained alive. HCV infection was cured in 68/113 (61.1%) people.

CONCLUSIONS

Our findings underscore the importance of prioritizing combatting substance use to achieve HCV elimination goals. A systematic approach with effort to overcome barriers to receiving and completing treatment and encourage to enrol in opioid substitution programmes if not possible to completely abstain from use, can help increase chances of HCV cure.

Impact of the 2008 economic crisis on the burden of hepatitis B and C diseases in Southern European countries

BACKGROUND

The economic crisis that began in 2008 has severely affected Southern (Greece, Italy, Portugal, Spain) Western European (SWE) countries of Western Europe (WE) and may have affected ongoing efforts to eliminate viral hepatitis. This study was conducted to investigate the impact of the economic crisis on the burden of HBV and HCV disease.

METHODS

Global Burden of Diseases 2019 data were used to analyse the rates of epidemiological metrics of HBV and HCV acute and chronic infections in SWE and WE. Time series modelling was performed to quantify the impact of healthcare expenditure on the time trend of HBV and HCV disease burden in 2000-2019.

RESULTS

Declining trends in incidence and prevalence rates of acute HBV (aHBV) and chronic HBV were observed in SWE and WE, with the pace of decline being slower in the post-austerity period (2010-2019) and mortality due to HBV stabilised in SWE. Acute HCV (aHCV) metrics and chronic HCV incidence and mortality showed a stable trend in SWE and WE, whereas the prevalence of chronic HCV showed an oscillating trend, decreasing in WE in 2010-2019 (p < 0.001). Liver cancer due to both hepatitis infections showed a stagnant burden over time. An inverse association was observed between health expenditure and metrics of both acute and chronic HBV and HCV.

CONCLUSIONS

Epidemiological metrics for HBV and HCV showed a slower pace of decline in the post-austerity period with better improvement for HBV, a stabilisation of mortality and a stagnant burden for liver cancer due to both hepatitis infections. The economic crisis of 2008 had a negative impact on the burden of hepatitis B and C. Elimination of HBV and HCV by 2030 will be a major challenge in the SWE countries.

Implementing a Managed Entry Agreement Framework in Cyprus

INTRODUCTION

The aim of this study is to explore the current practice in Cyprus regarding the introduction and reimbursement of innovative pharmaceuticals through Managed Entry Agreements (MEA), assess its operational context, and suggest approaches toward spanning the knowledge gap consequential to these efforts, especially the barriers of a small country context.

AREAS COVERED

The recent introduction of a National Health System (NHS), brought about fundamental reforms in Cyprus' Healthcare sector. Among such reforms, of particular interest, has been the introduction of a Managed Entry Agreements (MEA) mechanism. The first preliminary results indicate that despite being a small and unattractive market, Cyprus can apply a substantial MEA program. Concomitantly, it annotates the need to design an operational framework which should include, the definition of important technical parameters, clear demarcation of the scope, cooperation principles ensuring the effective operation of scientific committees, and clear delineation of what 'value' is. Moreover, in the context of the unified healthcare market, budget transfers should be considered, which could alleviate the inordinate budget impact of new products, which nevertheless will cut down on hospital expenditures. Narrative synthesis and health policy analysis-related resources were used.

EXPERT OPINION

The implementation of MEA in Cyprus provides an ideal testing ground for innovative reimbursement approaches. This will streamline the country's efforts toward reimbursement of innovation, while concomitantly add to the collective MEA experience.

The role of vitamin D receptor polymorphisms in the course of chronic hepatitis C infection

BACKGROUND

Vitamin D and its receptor (VDR) exert important immunoregulatory functions that contribute to liver homeostasis. The aim of this study was to investigate the influence of FokI, ApaI, BsmI and TaqI VDR polymorphisms on cirrhosis development and laboratory variables in patients with chronic hepatitis C (CHC).

METHODS

A total of 48 patients were enrolled in this retrospective, observational study and underwent genotype analysis; their medical records were examined to obtain relevant data.

RESULTS

The cumulative rate of progression to cirrhosis during the course of CHC was 31.3% after a median period of 11 years from diagnosis. Importantly, in multivariate analysis, FokI ff (adjusted hazard ratio [aHR] 13.6, 95% confidence interval [CI] 2.51-73.73; P=0.002) and ApaI aa (aHR 4.69, 95%CI 1.13-19.43; P=0.033) genotypes were independently associated with progression to cirrhosis. The presence of the aa genotype was also associated with higher liver stiffness measurements measured by transient elastography compared to the AA/Aa genotype (12.3kPa interquartile range [IQR] 9.6-17.3 vs. 7.1kPa IQR 5.6-11.1; P=0.012). In addition, higher HCV RNA and lower serum albumin levels were observed in patients with the tt genotype of the TaqI polymorphism compared to TT/Tt carriers, and in patients with the aa genotype compared to AA/Aa carriers. In haplotype analysis, no association was found between any haplotype and disease progression.

CONCLUSIONS

In patients with CHC, laboratory parameters are influenced by VDR polymorphisms and the development of cirrhosis is related to homozygosity for the dominant trait of ApaI and FokI variants.

The changing epidemiology of hepatocellular carcinoma in Greece

BACKGROUND

Hepatocellular carcinoma (HCC) is the sixth most common cancer globally, and is attributable mainly to viral hepatitis, alcohol and nonalcoholic fatty liver disease.

METHODS

Three hundred Greek patients diagnosed with HCC between 2000 and 2019 were retrospectively evaluated for patient and HCC characteristics. Patients were classified as before 2011 (A) or after 2011 (B) and HCC risk factors were compared with historic Greek cohorts.

RESULTS

The median age was 64 years and 86% were male; 45% had chronic hepatitis B virus (HBV) infection, 26% chronic hepatitis C virus (HCV) infection, and 30% non-viral liver diseases (nvLD). No change was observed among liver diseases between periods A and B. However, there was a trend towards a decrease in virally and an increase in non-virally induced HCC (P=0.075). Patients in period B (vs. A) were more likely to be diagnosed with fewer (<3, P=0.006) and smaller (<3 cm, P=0.005) nodules. Compared with 1558 Greek HCC patients from 1974-2000, there was a decrease in HBV and an increase in HCV and nvLD-related HCCs (P<0.001).

CONCLUSIONS

In Greece, after 2000, there was a decrease in the proportion of HBV and an increase in the proportion of HCV and nvLD-related HCC, while over the last 2 decades there has been a trend towards a decrease in virally and an increase in non-virally induced HCC. Since 2011, HCC is being diagnosed at an earlier stage, possibly reflecting improved surveillance strategies.

Evaluation of a Novel Enzyme-Linked Immuno Assay Model to Detect E2 Antigen and Antibodies Against Core, NS3, NS4, and NS5 Antigens of Hepatitis C Virus

Background: The serological measurement of the anti‐hepatitis C virus antibody is a widely used tool in the first-line diagnosis of HCV infection. Therefore, increasing the testing criteria of these tests is of crucial importance for screening HCV infection. Objectives: The current study aimed to optimize a novel enzyme-linked immuno assay model to detect E2 antigen with or without sample pretreatment in combination with antibodies against core, NS3, NS4, and NS5 antigens of the hepatitis C virus and to compare the performances of these assays with indirect antigen (Ag), biotin/HRP labeled Antigen Sandwich and methods of enzyme-linked immunosorbent assay (ELISA) for their ability to detect HCV. Methods: A total of 107 positive and 415 negative controls from volunteer whole blood donors in Blood Transfusion Organization and 204 blood samples from patients under hemodialysis treatment in Tehran and Bandar Abbas hemodialysis centers are investigated. Six different methods of ELISA test were used to detect anti-HCV antibodies and/or HCV antigens in serum samples. Results: Regarding sensitivity, specificity, and accuracy, E2 Antigen detection alone or combined with antibody detection have the highest accuracy value (99% and 98%, respectively) compared to other methods for antibodies detection. The results of the combined Ag/Ab ELISA test were closer to the results of real-time PCR. Conclusions: This new approach to the detection of antigen and antigen/antibody has better performance criteria concerning the serologic detection of HCV, especially in HD patients who might experience a longer window period.

Accelerating the elimination of hepatitis C in Kuwait: An expert opinion

The hepatitis C virus (HCV) is estimated to affect 71 million people worldwide. In 2016, the World Health Organization adopted the first global health sector strategy to eliminate viral hepatitis as a public health threat by 2030. In December 2018, the European Association for the Study of the Liver, International Liver Foundation convened an expert panel to address the elimination of HCV in Kuwait. Several steps have already been taken to eliminate HCV in Kuwait, including free HCV treatment for Kuwait's citizens, high blood safety standards, and the implementation of screening and awareness programs. The expert panel made several recommendations aimed at accelerating the elimination of HCV in Kuwait: The development of a national strategy and action plan to guide all HCV elimination activities; the formation of a coordination mechanism to support collaboration between hepatitis working committees; the prioritization of micro-elimination at primary, secondary or tertiary facilities, in prisons and rehabilitation centers; and ensuring the involvement of multiple stakeholders - including relevant civil society groups - in all activities. Enhanced screening and linkage to care should be prioritized in Kuwait, with the expansion of the prescriber base to primary healthcare providers and nurse practitioners to be considered. Raising awareness and educating people about HCV infection also remain essential to achieve the goal of HCV elimination. Lastly, a national HCV registry should be developed to help monitor the implementation of viral hepatitis plans and progress towards achieving national and international targets.