Working towards HCV elimination in Hong Kong through simplification of treatment
Early initiation of DAA therapy a major step in HCV elimination
“Treating patients early in the course of chronic HCV infection can prevent progression to hepatocellular carcinoma [HCC] and significantly reduce healthcare costs,” Li pointed out. [Elgart JF, et al, EASL 2020, abstract THU708] “On the other hand, established HCC negatively impacts the clinical efficacy of DAAs, which has prompted recommendations to treat HCC before commencing DAA therapy.” [J Hepatol 2017;67:32-39; J Hepatol 2017;66:1173-1181; J Hepatol 2020;S0168-8278(20)30548-1]
“In Hong Kong, subsidized DAA therapy was previously restricted to patients with advanced liver fibrosis [F2–3] or cirrhosis [F4]. As a result, about 40 percent of HCV-infected patients with insignificant liver fibrosis [F0–1] were ineligible for subsidized treatment,” noted Li. [Liver Int 2018;38:1911-1919]
“In line with the WHO’s HCV elimination strategy, the Hospital Authority [HA] recently introduced a new policy to provide subsidized DAA treatment to all HCV-infected persons regardless of fibrosis stage,” he added.
The expanded access to subsidized DAA therapy should pave the way for Hong Kong to achieve the WHO’s goal of treating ≥80 percent of HCV-infected individuals by the year 2030. [WHO, 2016, Global health sector strategy on viral hepatitis 2016–2021: https://www.who.int/hepatitis/publications/2016/en/]
Prioritizing HCV treatment in high-risk groups
“The risk of HCV transmission is high among certain groups of patients, such as those in correctional service, people who inject drugs [PWID] and HIV co-infected patients, due to high-risk behaviours, while their treatment uptake rates are among the lowest. These patients should be prioritized for DAA treatment,” advised Li. [Curr Opin HIV AIDS 2015;10:374-380; CMAJ Open 2019;7:E674-E679; Liver Int 2018;38:1911-1919]
Overcoming barriers to HCV treatment in marginalized populations
A real-world study in Germany showed that patients’ hesitation to initiate treatment, fear of treatment/side effects, and lack of insight about HCV infection were common barriers to HCV treatment. [Buggisch P, et al, EASL 2020, abstract SAT286] “The fear of side effects, which relates to the era of interferon therapy, can be overcome with increased reassurance on the safety of DAA drugs,” Li pointed out. “In my experience, adherence to DAA therapy is high among HCV-infected patients in our locality.”
“The main challenge in treating marginalized individuals is HCV carrier detection. Patients with a history of drug or alcohol abuse are not easily reachable unless they seek medical attention. HCV screening is not routinely performed in methadone clinics or psychiatric hospitals/clinics in Hong Kong, though psychiatric hospitals/clinics can refer patients to HCV screening services if needed,” he explained.
Several HCV elimination initiatives are currently underway in Hong Kong. These include nurse-led hepatitis clinics in major public hospitals that offer patient counselling and service coordination, government HIV clinics that provide HCV screening and free DAA treatment, and specialist outreach teams who offer HCV screening and immediate treatment to individuals in prisons.
“This ‘test-and-treat’ strategy for high-risk groups plays an important role in micro-elimination of HCV infection,” noted Li. “Similar programmes using rapid ‘point-of-care’ [POC] tests in selected populations have proven to be successful in other countries.” [Open Forum Infectious Diseases 2020;7:ofaa196; Int J Drug Policy 2019;72:91-98; J Community Health 2014;39:922-934]
High efficacy of 8-week oral G/P treatment in various subgroups
According to Li, the high efficacy, tolerability and simplicity of G/P treatment play an important role in HCV elimination, including in high-risk or marginalized patient populations.
A pooled analysis of eight phase II and III clinical trials involving 1,248 HCV treatment–naïve patients treated with G/P for 8 weeks revealed high rates of SVR at post-treatment week 12 – 97.6 percent and 99.3 percent in the intention-to-treat (ITT) and modified ITT (mITT) populations, respectively. High SVR12 rates were observed regardless of baseline patient demographics and clinical/viral characteristics, including HCV genotype, HCV viral load, cirrhosis status, and across various marginalized patient subgroups. (Figure 1) [Zuckerman E, et al, EASL 2020, abstract THU406]
Another pooled analysis of real-world data from post-marketing observational studies of HCV-infected patients with psychiatric and substance use disorders treated with G/P for 8 or 12 weeks showed an overall SVR12 rate of 98 percent (n=1,684). The efficacy was maintained in all vulnerable subgroups, including patients with single or dual pathologies. (Figure 2) [Lampertico P, et al, EASL 2020, abstract THU440]
“Overall, G/P treatment was well tolerated. Treatment-related side effects led to G/P discontinuation in only ≤0.3 percent of patients,” commented Li. [Zuckerman E, et al, EASL 2020, abstract THU406; Lampertico P, et al, EASL 2020, abstract THU440]
“These findings support the use of G/P as a simplified HCV treatment, without the need for genotyping, resistance testing or intensive on-treatment monitoring,” he added. [Hepatology 2020;71:686-721] “These may contribute to higher treatment uptake and adherence rates in marginalized patients.”
The safety and efficacy of the 8-week G/P regimen has allowed simplification of HCV treatment. However, diagnosis and linkage to care remain major barriers to HCV elimination, especially in vulnerable groups.
“With universal access to subsidized DAA therapy, Hong Kong should soon be on track for achieving WHO’s HCV elimination target,” Li suggested.