HIPPOCRATES®project:A proof of concept of a collaborative program for hepatitis C virus micro-elimination in a prison setting

BACKGROUND In the last few years we have witnessed a revolution in the treatment of hepatitis C virus(HCV)infection.With the introduction of direct-acting antiviral agents(DAAs),sustained virological response(SVR)is achieved in more than 95%of the patients.The focus is now being turned to the global targets set by the World Health Organization,with the aim of achieving HCV elimination by 2030.Prison inmates constitute one of the high-risk groups,and receive treatment less frequently due to several barriers in access to health care.AIM To describe the management and follow-up of a cohort of HCV monoinfected patients treated with DAA in the prison setting,where tertial referral liver center specialists locally provide,on-site assessment and treatment for the prisoners.METHODS A prospective observational study was conducted from April 2017 to March 2020,which included all HCV monoinfected prison inmates in the largest Northern Portugal prison.Demographic,clinical,and laboratory data,as well as transient elastography measurements,were collected onsite by the medical team and prospectively recorded.Patients were treated with DAA according to international guidelines.The primary endpoint was SVR at post-treatment week 12.RESULTS There were 98 monoinfected HCV male inmates(mean age,42.7±8.6 years)included in the analysis.Injecting drugs or tattooing were reported in 74.5%,with 38.8%of the latter being done in prison.Alcohol consumption of more than 30 g/d was referred in 69.4%.The most prevalent genotype was 1a(54.1%),followed by 3(27.6%),4(9.2%)and 1b(6.1%).Pretreatment fibrosis degree was mild-tomoderate(F0-F2)in 77.6%and severe in 22.4%(F3-F4).Treatment regimens chosen were:45.9%elbasvir/grazoprevir,29.6%sofosbuvir/velpatasvir,and 12.2%sofosbuvir/ledispavir and glecaprevir/pibrentasvir.No major adverse events were observed.SVR at post-treatment week 12 was 99%.CONCLUSION In a population considered to be both hard-to-access and a cornerstone for HCV elimination,the onsite evaluation and treatment of HCV-infected prisoners,achieved an exceptional highly effective success rate.This type of collaborative program should be considered to be expanded,to support hepatitis C elimination efforts.

Systematic overview of hepatitis C infection in the Middle East and North Africa

AIM To assess the quality of and to critically synthesize the available data on hepatitis C infections in the Middle East and North Africa(MENA) region to map evidence gaps.METHODS We conducted an overview of systematic reviews(SRs) following an a priori developed protocol(CRD42017076736). Our overview followed the preferred reporting items for systematic reviews and metaanalyses guidelines for reporting SRs and abstracts and did not receive any funding. Two independent reviewers systematically searched MEDLINE and conducted a multistage screening of the identified articles. Out of 5758 identified articles, 37 SRs of hepatitis C virus(HCV) infection in populations living in 20 countries in the MENA region published between 2008 and 2016 were included in our overview. The nine primary outcomes of interest were HCV antibody(anti-) prevalences and incidences in different at-risk populations; the HCV viremic(RNA positive) rate in HCV-positive individuals; HCV viremic prevalence in the general population(GP); the prevalence of HCV co-infection with the hepatitis B virus, human immunodeficiency virus, or schistosomiasis; the HCV genotype/subtype distribution; and the risk factors for HCV transmission. The conflicts of interest declared by the authors of the SRs were also extracted. Good quality outcomes reported by the SRs were defined as having the population, outcome, study time and setting defined as recommended by the PICOTS framework and a sample size > 100.RESULTS We included SRs reporting HCV outcomes with different levels of quality and precision. A substantial proportion of them synthesized data from mixed populations at differing levels of risk for acquiring HCV or at different HCV infection stages(recent and prior HCV transmissions). They also synthesized the data over long periods of time(e.g., two decades). Anti-HCV prevalence in the GP varied widely in the MENA region from 0.1%(study dates not reported) in the United Arab Emirates to 2.1%-13.5%(2003-2006) in Pakistan and 14.7%(2008) in Egypt. Data were not identified for Bahrain, Jordan, or Palestine. Good quality estimates of anti-HCV prevalence in the GP were reported for Algeria, Djibouti, Egypt, Iraq, Morocco, Pakistan, Syria, Sudan, Tunisia, and Yemen. Anti-HCV incidence estimates in the GP were reported only for Egypt(0.8-6.8 per 1000 person-year, 1997-2003). In Egypt, Morocco, and the United Arab Emirates, viremic rates in anti-HCV-positive individuals from the GP were approximately 70%. In the GP, the viremic prevalence varied from 0.7%(2011) in Saudi Arabia to 5.8%(2007-2008) in Pakistan and 10.0%(2008) in Egypt. Anti-HCV prevalence was lower in blood donors than in the GP, ranging from 0.2%(1992-1993) in Algeria to 1.7%(2005) in Yemen. The reporting quality of the outcomes in blood donors was good in the MENA countries, except in Qatar where no time framework was reported for the outcome. Some countries had anti-HCV prevalence estimates for children, transfused patients, contacts of HCV-infected patients, prisoners, sex workers, and men who have sex with men.CONCLUSION A substantial proportion of the reported outcomes may not help policymakers to develop micro-elimination strategies with precise HCV infection prevention and treatment programs in the region, as nowcasting HCV epidemiology using these data is potentially difficult. In addition to providing accurate information on HCV epidemiology, outcomes should also demonstrate practical and clinical significance and relevance. Based on the available data, most countries in the region have low to moderate anti-HCV prevalence. To achieve HCV elimination by 2030, up-to-date, good quality data on HCV epidemiology are required for the GP and key populations such as people who inject drugs and men who have sex with men.

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 microelimination 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.