Intravenous Drug Users Can Achieve a High Sustained Virological Response Rate: experience From Croatian Reference Center for Viral Hepatitis

Trends of Late Presentation to Care in Patients with Chronic Hepatitis C during a 10-Year Period in Croatia

Late presentation to care is the major obstacle to receiving treatment for chronic hepatitis C (CHC). Our aim was to analyze the prevalence and trends of late presenters (LP) at first consultations in Croatia during a 10-year period. This retrospective cross-sectional study included all adult CHC patients (n = 854) entering specialist medical care at the University Hospital for Infectious Diseases Zagreb between 2009 and 2018. LP was defined as liver stiffness measurement ≥ 9.5 kPa or biopsy METAVIR F ≥ 3. During the study period, mean patients' age increased from 37 to 52 years while HCV genotype distribution changed leading to the replacement of genotype 1b with 1a (g1b 32% to 21%; g1a 19% to 38%). A total of 320 (37.4%) were LP; they were older (47.5, IQR 40.5-57.6), and more commonly infected with g1b (34.1%) and g3 (42.5%). The prevalence of LP significantly increased from 31.9% in 2009 to 46.5% in 2018. Late presentation for care of CHC is increasing in Croatia suggesting a gap of diagnosing strategies in patients over 50 years.

Integrated Care for the Use of Direct-acting Antivirals in Patients With Chronic Hepatitis C and Substance Use Disorder

OBJECTIVES

Since little is currently known about predictors of response to direct-acting antiviral agents (DAAs) in people who inject drugs, we undertook an analysis of patients attending a hepatitis clinic with addiction services (outpatient clinics and inpatient services) to examine the outcomes associated with the treatment of difficult-to-manage patients with substance use. Our experience was based on integrated care.

METHOD

A retrospective analysis was undertaken of 50 patients with hepatitis C virus (HCV) and a history of addiction who received treatment with DAAs, according to European guidelines. These regimens were sofosbuvir/ledipasvir for 8 weeks (n = 3), sofosbuvir/ledipasvir ± ribavirin for 12 weeks (n = 19), sofosbuvir/daclatasvir for 12 weeks (n = 20), sofosbuvir/simeprevir (n = 1), or sofosbuvir/daclatasvir for 24 weeks (n = 7). Characteristics of patients who did versus did not achieve a sustained virologic response (SVR) 12 weeks after treatment were compared by univariate analysis.

RESULTS

Forty-two patients (84%) were male; mean age was 46.2 ± 7.3 years. Genotypes were 1 (n = 21), 2 (n = 4), 3 (n = 18), 4 (n = 6), or 6 (n = 1). Most patients were treatment-naïve (n = 38). Five patients had coinfection with human immunodeficiency virus (n = 4) or hepatitis B (n = 1), 28 (56%) had evidence of cirrhosis on FibroScan (>12.5 kPa), and 34 (68%) were receiving opioid substitution therapy. Psychiatric disease, illicit drug use, unemployment, and homelessness/precarious housing were common. Forty-five patients (90%) achieved SVR, 2 were lost to follow-up, and 3 had treatment relapse.

CONCLUSIONS

SVR was not significantly associated with sociodemographic or virological characteristics, treatment, social environment, alcohol/drug use, and adherence. Although adherence was slightly worse than in "usual" patients, it did not affect the SVR rate. In these difficult-to-manage patients with HCV and substance use disorder, the real-world SVR rate (90%) was similar to that in nonaddicted populations.

Factors That Influence the Virological Response in Patients with Chronic Hepatitis C Treated with Pegylated Interferon and Ribavirin

INTRODUCTION

The success of the antiviral treatment in patients with chronic hepatitis C depends on the factors related to the virus and the host. The aim of the study is the analysis of the antiviral therapy which is a combination of pegylated interferon and ribavirin, considering various factors that will identify the predictors of the sustained virological response.

MATERIAL AND METHODS

This retrospective study included 226 patients, divided in two groups. Patients with sustained virological response and patients without sustained virological response were compared in terms of the following factors: genotype, viral load, gender, age, inflammatory and fibrotic changes in the liver, metabolic abnormalities, obesity and fatty liver.

RESULTS

The rate of the sustained virological response is 83.6%, more frequently in patients with genotype 3, with evidenced statistical significance (90.54%). The factors that significantly contribute to sustained virological response are related to the age (p = 0.0001), genotype (p = 0.002), mode of transmission (p = 0.005), inflammatory changes in the liver (p = 0.028), body mass index (p = 0.022) and insulin resistance (p = 0.039). The high rate of sustained virological response is related to the younger age of the patients which indirectly means short Hepatitis C Virus infection duration, absence of advanced liver disease and lack of significant co-morbid conditions. Single confirmed independent predictors of sustained virological response are the age (OR 0.928, p = 0.0001) and genotype (OR 3.134, p = 0.005).

CONCLUSIONS

Factors that are related to the virological response are the age, genotype, mode of transmission, inflammatory changes in the liver, body mass index and insulin resistance, but still, independent predictors of sustained virologic response are the age and the genotype.

Treatment of Elderly Patients with Chronic Hepatitis C: A Retrospective Cohort Study

SUMMARY – The prevalence of chronic hepatitis C increases in elderly patients. The aims of this study were to identify the factors associated with hepatocellular carcinoma (HCC) and end-stage liver disease development and to evaluate the efficacy and safety of pegylated interferon (PEG-IFNα) plus ribavirin (RBV) therapy in elderly patients. A retrospective cohort study included all consecutive patients with hepatitis C virus (HCV) infection treated with PEG-IFNα+RBV between 2003 and 2013. Elderly patients had a higher frequency of poor prognostic factors including genotype 1 infection, high fibrosis, and high fibrosis index based on four factors (FIB-4) score. The sustained virologic response (SVR) rate for genotype 1 was significantly lower (35.8% vs. 57.1%), while the frequency of PEG-IFNα (27.2% vs. 7.8%), RBV dose reduction (19.6% vs. 9.7%) and treatment discontinuation (13.0% vs. 4.1%) was significantly higher in elderly patients. However, age was not associated with SVR in multivariate analysis, and comparable SVR rates were achieved when adjusted for fibrosis score (Ishak ≤3: 66.7% vs. 69.8%). During the follow-up, HCC was diagnosed in 18 elderly patients (3 SVR+, 4 SVR- and 9 untreated patients). In conclusion, selected elderly patients can achieve comparable SVR rates as younger patients, but with a higher rate of side effects. Since complications of HCV infection occur more frequently in elderly patients, they should be given priority for antiviral therapy.

Clinical Characteristics and Treatment Efficasy of Chronic HCV Infection Among Intravenous Drug Users in Tuzla Canton

Introduction:

Chronic HCV infection is chronic inflamatory liver disease caused by hepatitis C virus. Anti HCV prevalence among intravenous drug users (IVDU) is very high and it accounts 40% -90% (60%-90%) with the risk of 80% of developing the chronic infection.

Aim:

The aims of this study were: a) to compare clinical characteristics of chronic HCV infection among IVDU and non-users population and to detect their impact to treatment outcome; b) to investigate the treatment efficacy comparing sustained viral response (SVR) in these two populations in Tuzla Canton.

Patients and methods:

The study was retrospective-prospective and included 45 IVDU of both sexes from Tuzla Canton which were treated from chronic HCV infection with Pegilated interferon 2a/2b + ribavirin in the Clinic for Infectious Diseases and Clinic for Internal Disease of University Clinical Centre in Tuzla. The control group were presented by non-users who completed therapy in both Clinics. For statistical analyses it was used statistical package SPSS 20,0 (SPSS Inc, Chicago, IL, USA) with tests of descriptive statistics with measures of central tendency and dispersion. Quantitative variables were tested by t-test or by Mann-Whitney test. Qualitative variables were tested by hi-square test or by Fisher’s test. The standard analyse of level’s risk was used too. The analyse of predictive value of EVR for achieving the ETR and SVR was done by cross-tabulation. The impact of known factors for achieving the SVR was evaluated by logistic regression analyses. All tests were done with statistical level of significance of 95% (p=0,05).

Results:

Men were more dominant in the test group (93,3% / 61,7%), also younger age (p<0,001) and lower BMI (p=0,019). The test group had significant higher basal values of Le, Hb, Plt and ALT and tendency to lower stages of fibrosis (p=0,08). The difference in genotype frequencies was statistically significant (p=0,001) with clearly dominance of G3 and G4 among IVDU. Treatment was not complited by two patients in both groups (4,4% /3,3%). EVR was significantly higher in test group (p=0,001) so did the ETR (p=0,002) and SVR (p<0,001). Predictive factors for SVR were: age (negative predictive factor), male sex, absence of reduction of pegilated interferon and ribavirin, Metavir stage of fibrosis and presence of EVR.

Conclusion:

Population of IVDU were adherent to treatment protocol and with excellent treatment response they justified the hope of health care workers for success treatment of this population.

HCV prevalence and risk behaviours among injectors of new psychoactive substances in a risk environment in Hungary-An expanding public health burden

BACKGROUND

In Hungary a large increase in injecting new psychoactive substances (NPS) coincided with decreasing harm reduction efforts and rising HCV infection. We describe these, and assess changes in HCV prevalence and risk behaviours, 2011-2014, among NPS injectors, using 2011-2015 syringe exchange programme (SEP) data as a key contextual ('risk environment') variable.

METHODS

We conducted repeated national sero-behavioural surveys in people who inject drugs (PWID) injecting in the last month and attending SEPs or drug treatment centres (n=399, 2011; 384, 2014), using face-to-face interviews and dried blood-spot samples. Prevalence of injected drugs and SEP coverage (2011-2015) were assessed through our national SEP monitoring system and using population size estimates.

RESULTS

NPS injecting tripled among PWID attending SEPs in Hungary (2011: 26%; 2015: 80%). Among NPS injectors, HCV prevalence, sharing syringes and sharing any injecting equipment (last month), doubled (2011-2014: 37%-74%, 20%-48%, 42%-71%, respectively), significantly exceeding prevalence in other PWID groups. Among young NPS injectors (aged<25), HCV prevalence increased 7-fold (12%-76%), among new injectors (injecting<2years) 4-fold (13%-42%), coupled with high levels of equipment sharing (79% and 72% respectively). Not using a condom at last intercourse (79%), ever-imprisonment (65%) and last-year homelessness (57%) were highly prevalent among NPS injectors (2014). The number of syringes distributed per estimated PWID nationally fell from 114 to 81 (2011-2014) and dropped to 28 in 2015.

CONCLUSION

NPS injectors in Hungary are at severe risk of blood-borne infections due to high levels of injecting and sexual risk behaviours within a high-risk environment, including continuously low SEP provision, imprisonment and homelessness. An HIV outbreak cannot be excluded. Stronger investment in evidence-based prevention measures, with special focus on young and new injectors, and expansion of hepatitis C treatment are urgently needed.

Global genotype distribution of hepatitis C viral infection among people who inject drugs

BACKGROUND & AIMS

Hepatitis C viral infection (HCV) after injection drug use is very prevalent. The kind of genotype determines the response to treatment. However, no systematic review update on the global genotype distribution of HCV in people who inject drugs (PWID) is currently available.

METHODS

A systematic review was performed by using the keywords: Genotype, Hepatitis C, Injection drug user/Intravenous drug user/Substance user/ PWID, Name of countries in Pubmed, Embase and PsycINFO. The results were compared with the review of Gower et al. in 2014, concerning the distribution of HCV genotypes in the general HCV population.

RESULTS

Using these keywords, 132 studies in 48 countries (from 1995 to 2015) were collected. After grading these results, the data of 48 studies were used to determine the distribution of genotypes in PWID. Genotype 1 is the most prevalent genotype all over the world in PWID. In Europe, genotypes 1, 3 and 4 are highly prevalent. In North and South America and in Australia genotype 1 and 3 are most prevalent. In Asia genotype 2 and 6, and Africa genotype 1a and 4 are mostly observed. Overall, the most important differences comparing with the general population are a lower prevalence of genotype 1b in the PWID population and higher prevalence of genotype 1a and 3.

CONCLUSIONS

There is a different prevalence of genotype distribution in PWID than in the general population. Genotype 3 is especially highly prevalent in the Western countries.

LAY SUMMARY

Hepatitis C viral infection after injection drug use is very prevalent. The most important genotype causing HCV infection in PWID globally is genotype 1, as is the case in the general population, but also genotype 3 is highly prevalent in PWID. Genotype 4 is most prevalent in Africa, spreading into Europe, whereas genotype 2 and 6 are more located in Asia. The most important difference comparing to the general population are generally lower prevalence of genotype 1b, and higher prevalence of genotype 1a and 3 in PWID. As the genotype nowadays still determines the treatment, and as there is a different genotype distribution than in the general population, it is important to identify the genotype also in PWID.

Hepatitis C genotype distribution and homology among geographically disparate injecting drug users in Afghanistan

Hepatitis C virus (HCV) prevalence is high among injecting drug users in Afghanistan, but transmission dynamics are poorly understood. Samples from HCV-infected injecting drug users were sequenced to determine circulating genotypes and potential transmission linkages. Serum samples were obtained from injecting drug user participants in Hirat, Jalalabad, and Mazar-i-Sharif between 2006 and 2008 with reactive anti-HCV rapid tests. Specimens with detected HCV viremia were amplified and underwent sequence analysis. Of 113 samples evaluated, 25 samples (35.2%) were only typeable in NS5B, nine samples (12.7%) were only typeable in CE1, and 37 samples (52.1%) were genotyped in both regions. Of those with typeable HCV, all were Afghan males with a mean age of 31.1 (standard deviation [SD] ± 8.0) years and mean duration of injecting of 3.9 (SD ± 4.3) years. Most reported residence outside Afghanistan in the last decade (90.1%) and prior incarceration (76.8%). HCV genotypes detected were: 1a, (35.2%, n = 25), 3a (62.0%, n = 44), and 1b (2.8%, n = 2). Cluster formation was detected in NS5B and CE1 and were generally from within the same city. All participants within clusters reported being a refugee in Iran compared to 93.5% of those outside clusters. Only 22.2% (4/11) of those within clusters had been refugees in Pakistan and these four individuals had also been refugees in Iran. Predominance of genotype 3a and the association between HCV viremia and having been a refugee in Iran potentially reflects migration between Afghanistan and Iran among IDUs from Mazar-i-Sharif and Hirat and carry implications for harm reduction programs for this migratory population.

The comparison of chronic hepatitis C treatment outcome between intravenous drug users and non-intravenous drug users

Despite the fact that the majority of prevalent and incident cases of HCV are associated with intravenous drug use (IVDU), these patients have largely been excluded from HCV care. The aim of this study was to examine the treatment outcome of chronic hepatitis C in IVDUs compared to non-IVDUs.

PATIENTS AND METHODS

Patients with chronic hepatitis C (CHC) who initiated and completed combination antiviral therapy with pegilated interferon and ribavirin, at the Hepatology Department of the University Hospital for Infectious and Tropical Diseases in Belgrade, were retrospectively analyzed. The study included a series of 254 patients of which 100 (39.4%) were former IVDU.

RESULTS

Sustained virological response (SVR) was recorded in a total of 172 patients (67.7%). The analyses of the favorable treatment outcome, regarding particular viral genotypes, revealed that among those with genotype 1 and/or 4, including patients with genotype 1 recombinants with genotype 3, SVR was achieved in 114 (63.3%), while it was almost equally distributed between subgroups of former IVDU and all others (P=0.079). Among patients infected with HCV genotypes 2 and/or 3 the SVR rate was as high as 86.6%.

CONCLUSION

IVDU with CHC infection should be treated with standard combination antiviral therapy for CHC, since the success rate is equal or even better than in non-IVDU patients.

Influence of healthcare-associated factors on the efficacy of hepatitis C therapy

Hepatitis C infection is a complex entity associated with sizable morbidity and mortality, with great social and economic consequences that put a heavy potential burden on healthcare systems allover the world. Despite the great improvement of hepatitis C virus (HCV) therapy and its high clinical efficacy, major influencing factors are still hindering and diminishing the effectiveness of hepatitis C treatment. This minimizes the quality of life of the infected patients and reduces the outcome of such therapy, particularly in certain groups of patients such as intravenous drug users and patients coinfected with human immune deficiency virus (HIV). A variety of factors were evolved either at patient individual level, healthcare providers, community surrounding levels, or healthcare setting systems. Analyzing and understanding these factors could help to improve HCV interventions and, thus, reduce the burden of such infection. The objectives of this paper were to highlight such factors and outline the holistic approaches that could be used to overcome such factors.