Experiences of an HCV Patient engagement group: a seven-year journey

Historically, few publications exist where patient engagement in clinical studies is a driving force in study design and implementation. The Patient Centered Outcomes Research Institute (PCORI), established in 2010, employed a new model of integrating stakeholder perspectives into healthcare research. This manuscript aims to share the experience of a Patient Engagement Group (PEG) that has engaged in hepatitis C (HCV) clinical research alongside investigators conducting two studies funded by PCORI and to inspire others to get more involved in research that can impact our healthcare and health policies.There are many gaps in treating infectious diseases. Traditionally, treatment and research have been strictly clinical/medical approaches with little focus on the biopsychosocial aspects of individual patients. Our PEG reflected on its own personal experiences regarding how research design can affect study implementation by including patients who are normally excluded. We considered barriers to treatment, out of pocket costs, access to insurance, and patient race/ethnicity. Common themes were discovered, and four major topics were discussed. In addition, measures used in the two studies to collect patient data were considered, tested, and implemented by the group.We describe in detail how we were formed and how we have worked together with researchers on two PCORI funded projects over the past 7 years. We formulated and implemented guidelines and responsibilities for operating as a PEG as well as appointing a chair, co-chair, and primary author of this manuscript.Written from the perspective of a PEG whose members experienced HCV treatment and cure, we provide lessons learned, and implications for further research to include patients. PEGs like ours who are included as active partners in research can provide useful input to many areas including how patients are treated during clinical trials, how they interact with research teams, and how the clinical benefits of drugs or devices are defined and evaluated. PCORI believes engagement impacts research to be more patient-centered, useful, and trustworthy, and will ultimately lead to greater use and interest of research results by the patient and the broader healthcare community.

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.

Seroprevalence and trends in transfusion transmissible infections among voluntary non-remunerated blood donors at the Malawi Blood Transfusion Service-a time trend study

Introduction

Collecting blood from voluntary non-remunerated blood donors from low risk populations is a key strategy for blood safety. Identifying such populations involves analysis of population and blood donor data to identify risk factors for transfusion transmissible infections (TTIs). There are no recent seroprevalence statistics for blood donors in Malawi. This study fills this gap by describing characteristics of blood donors, trend of annual prevalence of HIV, HBV, HCV and syphilis and factors associated with each TTI.

Methods

Retrospective analysis of blood donors' records in the MBTS database from 2011 to 2015 was undertaken. Summary statistics were performed to describe characteristics of the blood donors. Univariable and multivariable logistic regression analyses were performed to determine association between prevalence of infections and socio-demographic factors. Time trend analysis was done to assess changes in prevalence. P-value <0.05 was considered statistically significant.

Results

The number of blood donors screened over the 5 year period was 125,893. The mean number of donors donating blood per year was 39, 289; median age was 19 years; 82% were male, 87% single and 72% students and56% were repeat blood donors. Overall prevalence of each TTI decreased. The 2015 prevalence was: 3.6% for HBV; 1.9% for HIV; 2.6% for Syphilis and 1.0% for HCV while the 2011 prevalence was 4.7% for HBV; 3.5% for HIV 3.2% for syphilis and 2.4% for HCV.

Repeat blood donors had significantly lower prevalence of TTIs than first time donors. Females were associated with lower risk for HBV, HCV and syphilis. Age ≥25 years and being out of school were associated with HIV. Age ≥25 years was associated with reduced risk for HCV and being self-employed and married were each associated with syphilis.

Conclusion

The typical blood donor is a young single male student. Repeat blood donation improves safety of the blood supply.

Safety and efficacy of immune checkpoint inhibitors (ICIs) in cancer patients with HIV, hepatitis B, or hepatitis C viral infection

Background

Patients with chronic viral infections including human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) are at increased risk of developing malignancies. The safety and efficacy of ICI therapy in patients with both cancer and chronic viral infections is not well established as most clinical trials of ICIs excluded these patient populations.

Methods

We performed a retrospective analysis of patients with advanced-stage cancers and HIV, HBV, or HCV infection treated with ICI therapy at 5 MedStar Health hospitals from January 2011 to April 2018.

Results

We identified 50 patients including 16 HIV, 29 HBV/HCV, and 5 with concurrent HIV and either HBV or HCV. In the HIV cohort (n = 21), any grade immune-related adverse events (irAEs) were 24% with grade ≥ 3 irAEs 14%. Among 5 patients with matched pre/post-treatment results, no significant changes in HIV viral load and CD4+ T-cell counts were observed. RECIST confirmed (n = 18) overall response rate (ORR) was 28% with 2 complete responses (CR) and 3 partial responses (PR). Responders included 2 patients with low baseline CD4+ T-cell counts (40 and 77 cells/ul, respectively). In the HBV/HCV cohort (n = 34), any grade irAEs were 44% with grade ≥ 3 irAEs 29%. RECIST confirmed ORR was 21% (6 PR). Among the 6 patients with known pre/post-treatment viral titers (2 HCV and 4 HBV), there was no evidence of viral reactivation.

Conclusions

Our retrospective series is one of the largest case series to report clinical outcomes among HIV, HBV and HCV patients treated with ICI therapy. Toxicity and efficacy rates were similar to those observed in patients without chronic viral infections. Viral reactivation was not observed. Tumor responses occurred in HIV patients with low CD4 T-cell counts. While prospective studies are needed to validate above findings, these data support not excluding such patients from ICI–based clinical trials or treatment.

Considerations When Treating Hepatitis C in a Cirrhotic Transplant Candidate

PURPOSE OF REVIEW

This review examines the issues in determining the decision to treat a HCV-positive patient who is a liver transplant (LT) candidate with highly effective and well-tolerated direct-acting antiviral (DAA) therapies.

RECENT FINDINGS

Cure of HCV with DAA can improve liver function and allow delisting in some patients. Beyond a threshold of hepatic impairment (likely MELD score > 16 to 20), patients may experience a decline in MELD score with HCV cure without improvement in liver-related complications resulting in decreased opportunity to receive a LT. Eradicating HCV from patients who need LT regardless also deprives them of the option of receiving HCV-positive donor organs. Patients with MELD > 16 or Child-Pugh B/C may also have reduced cure rates of HCV, increased risk of hepatic decompensation, and adverse events with DAA pre-LT compared to post-LT DAA therapy. Preliminary data demonstrates increase risk of hepatocellular carcinoma (HCC) recurrence after treatment with DAA with subsequent studies raising doubts about this association. Patients with HCV cirrhosis on the LT waiting list with MELD score > 16, CTP-B/C, and HCC are best treated after LT with better response, tolerability, and the ability to receive organs from a larger donor pool that includes HCV-positive donors. Larger, prospective studies are needed to assess whether increased HCC recurrence after DAA is a true effect.

Rheumatologic Manifestations of Hepatitis C Virus Infection

Hepatitis C virus (HCV) infection is associated with a morbidity and mortality due to liver complications. HCV infection is also frequently associated with rheumatic disorders, such as arthralgia, myalgia, cryoglobulinemia vasculitis, and sicca syndrome, as well as the production of autoantibodies. The treatment of HCV infection with interferon alpha (IFN) has been contraindicated for a long time in many rheumatologic autoimmune/inflammatory disorders. New oral IFN-free combinations offer an opportunity for HCV-infected patients with extrahepatic manifestations, including rheumatologic autoimmune/inflammatory disorders, to be cured with a short treatment duration and a low risk of side effects.

Hepatitis C testing in substance use disorder treatment: the role of program managers in adoption of testing services

BACKGROUND

Health care organizations do not adopt best practices as often or quickly as they merit. This gap in the integration of best practices into routine practice remains a significant public health concern. The role of program managers in the adoption of best practices has seldom been investigated.

METHODS

We investigated the association between characteristics of program managers and the adoption of hepatitis C virus (HCV) testing services in opioid treatment programs (OTPs). Data came from the 2005 (n = 187) and 2011 (n = 196) National Drug Abuse Treatment System Survey (NDATSS). We used multivariate regression models to examine correlates of the adoption of HCV testing. We included covariates describing program manager characteristics, such as their race/ethnicity, education, and their sources of information about developments in the field of substance use disorder treatment. We also controlled for characteristics of OTPs and the client populations they serve.

RESULTS

Program managers were predominantly white and female. A large proportion of program managers had post-graduate education. Program managers expressed strong support for preventive services, but they reported making limited use of available sources of information about developments in the field of substance use disorder (SUD) treatment. The provision of any HCV testing (either on-site or off-site) in OTPs was positively associated with the extent to which a program manager was supportive of preventive services. Among OTPs offering any HCV testing to their clients, on-site HCV testing was more common among programs with an African American manager. It was also more common when program managers relied on a variety of information sources about developments in SUD treatment.

CONCLUSIONS

Various characteristics of program managers are associated with the adoption of HCV testing in OTPs. Promoting diversity among program managers, and increasing managers' access to information about developments in SUD treatment, may help foster the adoption of best practices.