Hepatitis C (HCV) therapy for HCV mono-infected and HIV-HCV co-infected individuals living in Nepal

Background

Despite direct-acting antivirals (DAA), aims to “eradicate” viral hepatitis by 2030 remain unlikely. In Nepal, an expert consortium was established to treat HCV through Nepal earthquakes aftermath offering a model for HCV treatment expansion in a resource-poor setting.

Methodology/Principal findings

In 2015, we established a network of hepatologists, laboratory experts, and community-based leaders at 6 Opioid Substitution Treatment (OST) sites from 4 cities in Nepal screening 838 patients for a treatment cohort of 600 individuals with HCV infection and past or current drug use. During phase 1, patients were treated with interferon-based regimens (n = 46). During phase 2, 135 patients with optimal predictors (HIV controlled, without cirrhosis, low baseline HCV viral load) were treated with DAA-based regimens. During phase 3, IFN-free DAA treatment was expanded, regardless of HCV disease severity, HIV viremia or drug use. Sustained virologic response (SVR) was assessed at 12 weeks.

Median age was 37 years and 95.5% were males. HCV genotype was 3 (53.2%) or 1a (40.7%) and 32% had cirrhosis; 42.5% were HIV-HCV coinfected. The intention-to-treat (ITT) SVR rates in phase 2 and 3 were 97% and 81%, respectively. The overall per-protocol and ITT SVR rates were 97% and 85%, respectively. By multivariable analysis, treatment at the Kathmandu site was protective and substance use, treatment during phase 3 were associated with failure to achieve SVR.

Conclusions/Significance

Very high SVR rates may be achieved in a difficult-to-treat, low-income population whatever the patient’s profile and disease severity. The excellent treatment outcomes observed in this real-life community study should prompt further HCV treatment initiatives in Nepal.

Despite very effective antiviral therapies, Hepatitis C virus (HCV) eradication remains a major challenge, especially in resource-limited countries. In Nepal, which ranks among the poorest countries in the world an expert consortium was established to treat HCV patients in six centers throughout the country.

A cohort of 600 individuals with HCV infection and past or current drug use were treated using different treatment strategies over time. Very high treatment response rates were achieved in a difficult-to-treat, low-income population whatever the patient’s profile and disease severity and despite the severe 2015 earthquakes in Nepal. The excellent treatment outcomes observed in this real-life community study should prompt further HCV treatment initiatives in Nepal.

Outcomes of Patients in Long-Term Opioid Maintenance Treatment

BACKGROUND

Despite the importance of duration of opioid maintenance treatment (OMT), only few studies have reported outcomes of long-term OMT.

OBJECTIVES

To describe outcomes of long-term (> 5 years) OMT patients with respect to substance use, physical and mental health, and socioeconomic characteristics.

METHODS

Patients (n = 160) were recruited from 15 OMT offices in different regions of Germany. Data were collected using a structured interview at baseline, and clinical recordings, including urine drug screenings, during 12 monhts follow-up.

RESULTS

Patients had a mean age of 44 years. During follow-up, 23% of patients showed indications of an alcohol problem. Cannabis was used by 56%, often frequently. Heroin was used by 28%, mostly infrequently. Three quarters of patients either had a non-substance related mental disorder (48.1%, most frequently affective and anxiety disorders) or somatic diagnosis (61.3%, frequently hepatitis C, HIV, or cardiovascular diseases), or both. Unemployment rate was 43.1% at baseline (27% for patients without comorbidity) and remained generally stable during follow-up. No arrests or incarcerations were recorded. During follow-up, 2.5% of patients prematurely terminated OMT, 2.5% regularly completed OMT.

CONCLUSIONS

The sample as a whole was characterized by stable living conditions, high unemployment, low illicit opiate use, and a high retention rate. Continuation of OMT could enable further treatment of comorbidity and prevent resumption of a drug-dominated lifestyle. But it may well be asked how within the context of OMT further improvements can be achieved, especially with regard to further decrease of alcohol use and the treatment of depression.

Psychoeducation improves hepatitis C virus treatment during opioid substitution therapy: a controlled, prospective multicenter trial

BACKGROUND

People who inject drugs (PWID) have a high prevalence of hepatitis C virus (HCV) infection. However, PWID are considered "difficult to treat," requiring a specifically adapted treatment setting, including psychosocial support.

METHODS

In this prospective, German trial, the impact of psychoeducation (PE) on retention and sustained virologic response (SVR) during HCV therapy among PWID was evaluated. We included 198 patients in opiate substitution therapy, who fulfilled indications for antiviral treatment. All patients received pegylated interferon alfa-2a and ribavirin therapy. Patients in the intervention group (n = 82) received manualized PE sessions.

RESULTS

In patients with HCV genotype 1 or 4 (GT 1/4), PE was associated with increased treatment completion (76% vs 55%, P = .038), whereas PE had no such effect among GT 2/3 patients, who showed fewer dropouts and higher SVR rates. Among GT 1/4 patients, a minimum of 5 PE sessions was associated with increased SVR (71% vs 48%, P = .037). Multivariate regression analyses confirmed the impact of PE in GT 1/4 and revealed further predictors for retention and SVR, such as preexisting mental distress and adverse events.

CONCLUSIONS

In patients with a higher risk of dropout due to GT 1/4 or mental distress, PE was shown to improve retention and SVR. PE is an effective supportive intervention for HCV therapy among PWID.

Safety, effectiveness and tolerance of buprenorphine-naloxone in the treatment of opioid dependence: results from a nationwide non-interventional study in routine care

INTRODUCTION

Buprenorphine is well known in the treatment of opioid dependence. Despite a high safety profile and good tolerance buprenorphine has been subject to misuse and diversion. To reduce misuse the antagonist naloxone was added and the 4:1 combination of buprenorphine-naloxone was launched in Germany in March 2007. On the basis of the results from international clinical trials a non-interventional study was conducted to gather data on safety, effectiveness, retention and acceptability of buprenorphine-naloxone in the treatment of opioid dependent patients in routine care.

METHODS

A nationwide multicentre 12-month prospective, non-interventional, post-marketing, surveillance study was carried out with 12 assessment points in N=384 opioid dependent patients currently in maintenance treatment from N=69 general practitioners, clinics and outpatient clinics in Germany.

RESULTS

N=337 data sets were eligible for analysis. The rates of patients with serious and non-serious adverse events were low with 1.2% and 17.5%, respectively. No deaths occurred during the observational period and only one hospitalization was documented. Concomitant drug use decreased for all illicit substances. Mental health and quality of life measured with standardized self-assessment questionnaires improved significantly. The 12-month retention rate was 57.1%. Of the n=181 patients still in treatment at the end of the observation period, 96.7% continued treatment with buprenorphine-naloxone.

CONCLUSION

The findings of the non-interventional study indicate high effectiveness and safety of buprenorphine-naloxone in the treatment of opioid dependence. The medication was well accepted by opioid dependent patients in long-term substitution treatment with substantial reductions of concomitant drug use and measurable improvement in quality of life.

Efficacy, adherence and tolerability of once daily tenofovir DF-containing antiretroviral therapy in former injecting drug users with HIV-1 receiving opiate treatment: results of a 48-week open-label study

OBJECTIVE

To assess efficacy, adherence and tolerability of once daily antiretroviral therapy containing tenofovir disoproxil fumarate (DF) 300 mg in HIV-1-infected former injecting drug users receiving opiate treatment (IVDU).

METHODS

European, 48-week, open-label, single-arm, multicenter study. Patients were either antiretroviral therapy-naive, restarting therapy after treatment discontinuation without prior virological failure or switching from existing stable treatment.

RESULTS

Sixty-seven patients were enrolled in the study and 41 patients completed treatment. In the primary analysis (intent-to-treat missing=failure) at week 48, 34% of patients (23/67; 95% CI: 23%-47%) had plasma HIV-1 RNA <50 copies/mL. Using an intent-to-treat missing=excluded approach, the week 48 proportion of patients with plasma HIV-1 RNA <50 copies/mL increased to 56% (23/41; 95% CI: 40%-72%). Mean (standard deviation) increase from baseline in CD4+ cell count at week 48 was 176 (242) cells/mm(3). Although self-reported adherence appeared high, there were high levels of missing data and adherence results should be treated with caution. No new safety issues were identified.

CONCLUSIONS

Levels of missing data were high in this difficult-to-treat population, but potent antiretroviral suppression was achieved in a substantial proportion of HIV-infected IVDU-patients.

The influence of HAART on the efficacy and safety of pegylated interferon and ribavirin therapy for the treatment of chronic HCV infection in HIV-positive Individuals

Objective

This study was performed to investigate the impact of HAART versus no HAART and nucleoside free versus nucleoside containing HAART on the efficacy and safety of pegylated interferon and ribavirin therapy for the treatment of chronic HCV infection in HIV/HCV co-infected patients. In addition a control group of HCV mono-infected patients undergoing anti-HCV therapy was evaluated.

Methods

Multicenter, partially randomized, controlled clinical trial. HIV-negative and -positive patients with chronic HCV infection were treated with pegylated interferon alfa-2a and ribavirin (800 - 1200 mg/day) for 24 - 48 weeks in one of four treatment arms: HIV-negative (A), HIV-positive without HAART (B) and HIV-positive on HAART (C). Patients within arm C were randomized to receive open label either a nucleoside containing (C1) or a nucleoside free HAART (C2).

Results

168 patients were available for analysis. By intent-to-treat analysis similar sustained virological response rates (SVR, negative HCV-RNA 24 weeks after the end of therapy) were observed comparing HIV-negative and -positive patients (54% vs. 54%, p = 1.000). Among HIV-positive patients SVR rates were similar between patients off and on HAART (57% vs. 52%, p = 0.708). Higher SVR rates were observed in patients on a nucleoside free HAART compared to patients on a nucleoside containing HAART, though confounding could not be ruled out and in the intent-to-treat analysis the difference was not statistically significant (64% vs. 46%, p = 0.209).

Conclusions

Similar response rates for HCV therapy can be achieved in HIV-positive and -negative patients. Patients on nucleoside free HAART reached at least equal rates of sustained virological response compared to patients on standard HAART.

[Pain therapy in addicted patients]

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

Treatment during primary HIV infection does not lower viral set point but improves CD4 lymphocytes in an observational cohort

Objective

To investigate if early treatment of primary HIV-1 infection (PHI) reduces viral set point and/or increases CD4 lymphocytes.

Methods

Analysis of two prospective multi-centre PHI cohorts. HIV-1 RNA and CD4 lymphocytes in patients with transient treatment were compared to those in untreated patients. Time to CD4 lymphocyte decrease below 350/μl after treatment stop or seroconversion was calculated using Kaplan-Meier and Cox-PH-regression analyses.

Results

156 cases of PHI were included, of which 100 had received transient HAART (median treatment time 9.5 months) and 56 remained untreated. Median viral load (563000 cop/ml vs 240000 cop/ml; p < 0.001) and median CD4 lymphocyte (449/μl vs. 613/μl; p < 0.01) differed significantly between treated and untreated patients. Median viral load was 38056 copies/ml in treated patients (12 months after treatment stop) and 52880 copies/ml in untreated patients (12 months after seroconversion; ns). Median CD4 lymphocyte change was +60/μl vs. -86/μl (p = 0.01). Median time until CD4 lymphocytes decreased to < 350/μl (including all patients with CD4 lymphocytes < 500/μl during seroconversion) was 20.7 months in treated patients after treatment stop and 8.3 months in untreated patents after seroconversion (p < 0.01). Cox-PH analyses adjusting for baseline VL, CD4 lymphocytes, stage of early infection and symptoms confirmed these differences.

Conclusions

Treatment during PHI did not lower viral set point. However, patients treated during seroconversion had an increase in CD4 lymphocytes, whereas untreated patients experienced a decrease in CD4 lymphocytes. Time until reaching CD4 lymphocytes < 350/μl was significantly shorter in untreated than in treated patients including patients with CD4 lymphocytes < 500/μl during seroconversion.

Psychopathological changes and quality of life in hepatitis C virus-infected, opioid-dependent patients during maintenance therapy

AIMS

To examine among maintenance patients (methadone or buprenorphine) with and without hepatitis C virus (HCV) infection (i) the frequency of psychopathological symptoms at baseline and 1-year follow-up; (ii) the association between antiviral interferon (IFN) treatment and psychopathological symptoms; and (iii) to explore whether IFN therapy has an effect on 1-year outcome of maintenance treatment.

DESIGN

Naturalistic prospective longitudinal cohort design.

SETTING

A total of 223 substitution centres in Germany.

PARTICIPANTS

A nationally representative sample of 2414 maintenance patients, namely 800 without and 1614 with HCV infection, of whom 122 received IFN therapy.

MEASURES

HCV infection (HCV+/HCV-), IFN (IFN+/IFN-) treatment status and clinical measures. Diagnostic status and severity (rated by clinician), psychopathology (BSI--Brief Symptom Inventory) and quality of life (EQ-5D--EuroQol Group questionnaire).

FINDINGS

HCV+ patients revealed indications for a moderately increased psychopathological burden and poorer quality of life at baseline and follow-up compared to HCV- patients. HCV+ patients showed a marked deterioration over time only in the BSI subscale somatization (P = 0.002), and the frequency of sleep disorders almost doubled over time (12.8% at baseline; 24.1% at follow-up; P < 0.01). IFN treatment, received by 10% of HCV+ patients, did not impair efficacy or tolerability of maintenance therapy and was associated overall with neither increased psychopathological burden nor reduced quality of life.

CONCLUSIONS

Findings suggest no increased risk among HCV+ patients on maintenance therapy for depressive or other psychopathological syndromes. In our patient sample, IFN treatment was not associated with increased psychopathological burden, reduced quality of life or poorer tolerability and efficacy of maintenance treatment.

Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: a naturalistic study in 2694 patients

BACKGROUND

In many countries, buprenorphine and methadone are licensed for the maintenance treatment (MT) of opioid dependence. Despite many short-term studies, little is known about the long-term (12-month) effects of these treatments in different settings, i.e. primary care-based (PMC) and specialized substitution centers (SSCs).

OBJECTIVES

To describe over a period of 12 months: (1) mortality, retention and abstinence rates; (2) changes in concomitant drug use, somatic and mental health; and (3) to explore differences between different types of provider settings.

METHODS

12-Month prospective-longitudinal naturalistic study with four waves of assessment in a prevalence sample of N=2694 maintenance patients, recruited from a nationally representative sample of N=223 substitution physicians.

RESULTS

The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became "abstinent" during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. When controlling for initial severity, small PMC settings revealed better retention, abstinence and concomitant drug use rates.

CONCLUSION

The study underlines the overall 12-month effectiveness of various forms of agonist MT. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life. PMC settings appear to be a good additional option to improve access to MTs.

[Prevention of HIV in injecting drug addicts. What has been done - what could be better?]

Efficient prevention of HIV in drug users has had to overcome major political opposition in the last decade. Even today many evidence-based measures for the prevention of infections in drug users are still not being applied. Only a few preventive approaches are broadly carried out in the GFR: methadone maintenance performed by general practitioners, antiretroviral therapy and information about safer use given by AIDS- and drug-consultants and syringeexchange by pharmacies and at special institutions. In contrast, injection room facilities, street workers council, vaccination programs and low threshold medical treatment are only implemented in isolated cases. Nevertheless, HIV prevalence among drug users has been reduced successfully and the rate of new infections has decreased from 13.2% in 1994 to 9% in 2006. These strategies, however, do not seem to have any effect on the spread of hepatitis C among drug users. Here we still face a prevalence of 45-70%. Therefore, future research should focus on preventive measures against HCV infection of drug users.

A new approach to preventing relapse in opiate addicts: A psychometric evaluation

The present study investigated psychological aspects after different methods of withdrawal treatments in opiate addicts had been conducted. Two pharmacological strategies based on delivering an opioid agonist or antagonist were used for withdrawal in opiate addicts. After detoxification, the antagonist was delivered by a pellet implanted subcutaneously. Four days after the beginning of the treatment several psychological variables such as craving, anxiety, depression, and mood were assessed and compared with data from actively consuming opiate addicts and healthy controls. In addition, 6 and 12 weeks later the relapse rates were assessed. Compared with addicts detoxified and treated with Levomethadone as well as actively heroin consuming addicts, subjects treated with Naltrexone demonstrated significantly higher positive psychological outcome concerning all assessed variables and significantly lower relapse rates. Naltrexone implants prove prevention of relapse during the most vulnerable period after detoxification. Compared with Levomethadone withdrawal, they lead to a significantly better psychological condition in patients.

Buprenorphine and methadone in the treatment of opioid dependence: methods and design of the COBRA study

Buprenorphine and methadone are the two established substitution drugs licensed in many countries for the treatment of opioid dependence. Little is known, however, about how these two drugs are applied and how they work in clinical practice. In this paper we present the aims, methods, design and sampling issues of a collaborative multi-stage epidemiological study (COBRA) to address these issues. Based on a nationally representative sample of substitution physicians, the study is designed as an observational, naturalistic study, consisting of three major parts. The first part was a national survey of substitution doctors (prestudy, n = 379 doctors). The second part was a cross-sectional study (n = 223 doctors), which consisted of a target-week assessment of 2,694 consecutive patients to determine (a) the severity and problem profiles and treatment targets; (b) the choice and dosage scheme of the substitution drug; (c) past and current interventions, including treatment of comorbid hepatitis C; and (d) cross-sectional differences between the two drugs with regard to comorbidity, clinical course, acceptance/compliance and social integration. The third part consists of a prospective-longitudinal cohort study of 48 methadone-treated and 48 buprenorphine-treated patients. The cohort is followed up over a period of 12 months to investigate whether course and outcome of the patients differ by type or treatment received in terms of clinical, psychosocial, pharmaco-economic and other related measures. The response rate among substitution doctors was 57.1%; that among eligible patients was 71.7%. Comparisons with the federal registers reveal that the final samples of doctors and patients may be considered nationally representative with regard to regional distribution, training, type of setting as well as the frequency of patients treated with buprenorphine or methadone. The COBRA study provides a unique comprehensive database, informing about the natural allocation and intervention processes in routine care and about the course and outcome of patients treated with buprenorphine or methadone.

German-Austrian recommendations for the antiretroviral therapy of HIV-infection (status May 2004)

The availability and application of effective antiretroviral combination therapies have now almost become routine. More than 20 antiretroviral substances in four classes have been approved. Although an almost incalculable number of combinations can be conceived, it must be stressed, that only a small number of the theoretically possible combinations are actually applicable. As a result of the broad therapeutic armamentarium, HIV infection can be better treated. However, the decisions to start, monitor and change therapy have become even more difficult because the indication for treatment, the selection of the most suitable therapy for an individual, the information and counselling of the patient, and the monitoring of the success of treatment all demand a high level of knowledge and experience. This guideline evaluates the indication and selection of the initial antiretroviral therapy for HIV infection.

Pilot study of interferon alpha high-dose induction therapy in combination with ribavirin for chronic hepatitis C in HIV-co-infected patients

Twenty-three HIV/hepatitis C virus (HCV)-co-infected patients received dose-escalated IFN-alpha (5 MIU/day) induction therapy for 10 weeks, followed by 36 weeks of thrice-weekly IFN-alpha treatment (5 MIU), both in combinations with ribavirin. Sustained HCV clearance was observed in three patients. Nine patients discontinued the study aas a result of adverse reactions such as anaemia, pancreatitis and depression. In HIV/HCV-co-infected patients, the therapeutic benefit of high-dose IFN-alpha therefore seems to be limited by its poor tolerability.

Diagnostics and treatment of HIV-discordant couples who wish to have children

Over the last years the reality surrounding HIV-infection has undergone a considerable change with regard to the life expectancy of patients, and the plans they can make for their lives. Because the majority of the HIV positive population is of reproductive age, one of these plans might be to have children, often as an expression of a fulfilled partnership. The need for medical support to realize this wish, however, is often confronted with ethical, medical or forensic restraints. For this reason, interdisciplinary recommendations have now been developed--for the first time on a global basis--which aim to provide guidelines for practitioners in this complicated area.

[Ambulatory medical treatment of drug dependent patients]

The treatment and counseling of drug addicts increasingly comes under the responsibility of family physicians. Since the onset of the AIDS epidemic this applies in particular to the methadone treatment of chronically ill heroin addicts. Medical education concerning the treatment of addiction is insufficient. Unprofessional dealing with drug addicts may easily result in serious obstruction of the relation between physician and patient. Thus it endangers the success of treatment. Basic guidelines of interaction, possibilities of abstinence therapy as well as harm reducing strategies are presented.

Differences between the course of the drug addict's HIV infection and that of other HIV-infected patients

Drug addicts have, in general, a less complicated course of HIV infection than homosexual HIV patients. They show fewer opportunistic infections and tumors. But this advantage is lost by unnecessary complications due to their psychic disorders. Their non-compliance and concealment of signs of disease lead to worse outcomes of infections, which could be well-treated or prevented.