A global view of hepatitis C: Physician knowledge, opinions, and perceived barriers to care

Hepatology. 2013 Apr;57(4):1325-32. doi: 10.1002/hep.26246.

McGowan CE, Monis A, Bacon BR, Mallolas J, Goncales FL, Goulis I, Poordad F, Afdhal N, Zeuzem S, Piratvisuth T, Marcellin P, Fried MW.

UNC Liver Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Abstract

Chronic infection with the hepatitis C virus (HCV) is a leading cause of global morbidity and mortality. Although recent advances in antiviral therapy have led to significant improvements in treatment response rates, only a minority of infected patients are treated. Multiple barriers may impede the delivery of HCV therapy. The aim of this study was to identify perceived barriers to care, knowledge, and opinions among a global sample of HCV treatment providers. An international, multidisciplinary survey of HCV treatment providers was conducted. Each physician responded to a series of 214 questions concerning his or her practice characteristics, opinions regarding the state of HCV care, knowledge regarding HCV treatment, and perception of treatment barriers. A total of 697 physicians from 29 countries completed the survey. Overall, physicians viewed patient-level barriers as most significant, including fear of side effects and concerns regarding treatment duration and cost. There were distinct regional variations, with Central and Eastern European physicians citing government barriers as most important. In Latin America, the Middle East, and Africa, payer-level barriers, including lack of treatment coverage, were prominent. Overall, the perception of barriers was strongly associated with physician knowledge, experience, and region of origin, with the fewest barriers reported by Nordic physicians and the most reported by Middle Eastern and African physicians. Globally, physicians demonstrated deficits in basic treatment principles, including the role of viral kinetics and the management of treatment nonresponders. Two thirds of surveyed physicians believed that patients do not have adequate access to providers in their community. Conclusion: Barriers to HCV treatment vary globally, though patient-level factors are viewed as most significant by treating physicians. Efforts to improve awareness, education, and specialist availability are needed. (HEPATOLOGY 2013;57:1325-1332).

Copyright © 2013 American Association for the Study of Liver Diseases

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Hepatitis C care "at risk" in the UK, say Roche

UK News | May 10, 2013

Ben Adams

A new report by Roche and hep C patient groups says that more needs to be done to better that rate of treatment of hepatitis C in the UK.

The ‘Confronting the silent epidemic: a critical review of hepatitis C management in the UK’ report, found that a quarter of health commissioners in the NHS had yet to estimate the numbers diagnosed with hepatitis C, with two-thirds having no estimate of the numbers cured by treatment.

The report has also been released at a time when research shows a decline in treatment rates, and concerns over the impact the NHS reforms could have on hepatitis treatment services.

Roche, which develops and sells the ageing hep C treatments Pegasys and Copegus, believes encouraging innovative, localised approaches to service design based on improving patient outcomes through effective, early interventions is key to improving treatment rates.

The report was funded by Roche and endorsed by The Hepatitis C Trust and British Liver Trust – both of which Roche gives financial support to – as well as the European Liver Patients Association.

Charles Gore, chief executive of The Hepatitis C Trust, which receives the highest level of funding from Roche for any patient organisation, said: “The alarming rise in hepatitis C related deaths must be addressed and innovative approaches to service design are essential to improving patient outcomes and saving lives. At a time of reform, it is now more important than ever that hepatitis C is a priority for commissioners and service providers throughout the UK.

“Through re-thinking the design and delivery of services, we can help ensure patients receive early, effective treatment and reduce the significant costs to the health service and society more widely.”

Roche said it also wants to help assist doctors and commissioners to meet the “achievable goal” of reducing the burden of disease on health services, as it says associated annual healthcare costs are around £83 million, estimated to rise to £115 million by 2035.

It believes that by using hep C drugs such as its own products and increasing treatment, costs can be brought down as the disease will be more manageable in patients, with less risk of cirrhosis and the need for liver transplants, which are costly to the NHS and a bad outcome for patients.

Impact of NHS reform

In addition, new hepatitis specialist qualitative research in the report suggests current challenges in the management of hepatitis C, including service capacity and commissioning, may be exacerbated by the major reorganisation of the NHS.

One respondent said that: “Capacity to treat patients is always an issue, even more so now with triple therapy. Our nurses cannot cope with more patients at any one time.”

Another added: “I think the pressure from commissioners is only going to increase. Although NICE has approved treatments, I’m not sure commissioners will continue to see it as good value for their money.”

Links

www.roche.co.uk
www.hepctrust.org.uk

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Scientists Develop Experimental Vaccine Against Heroin

Jessica Berman

May 10, 2013

Scientists have developed an experimental vaccine to treat heroin addicts. Such a vaccine would be a major advance for both public health and safety. Addiction to the powerful, illicit narcotic not only destroys human lives, but also fuels a violent global drug trade.

An estimated 20 million people around the world are addicted to heroin and related opiates. Their addiction, and frequent use of contaminated syringes, put heroin users at risk of a variety of diseases - notably HIV/AIDS and Hepatitis C. They are also more likely to die prematurely, either from a drug overdose or the violence related to drug trafficking.

Drug relapse after conventional treatment for heroin addiction is an especially difficult challenge. The experimental vaccine may prevent addiction even if a user is re-exposed to the drug.

The heroin vaccine developed by Kim Janda and colleagues at the Scripps Research Institute in La Jolla, California essentially tricks the body's immune system into thinking heroin is a pathogen, like a bacterium or virus.

The experimental compound stimulates the production of antibodies that keep the drug from reaching the brain, which is where Janda notes the drug produces the euphoric high that heroin addicts crave.

"So, it creates like a wall to block the drug from entering the brain, the pleasure centers," said Janda. "And when it’s in circulation, our own body has enzymes that degrade heroin. And as it degrades it loses its ability to cross the blood-brain barrier, it loses its potency and eventually it’s just removed.”

Janda, a chemist and immunologist, says developing a vaccine against heroin has been especially challenging because the body rapidly metabolizes the drug into several byproducts, the last being morphine, the compound which actually triggers the high.

So, researchers had to develop a pretty versatile vaccine - one able to empower the immune system to recognize and produce antibodies that bind to all of the breakdown products before they reach the brain.

In experiments with heroin-addicted rats exposed to an unlimited supply of the drug, Janda says the results were striking. The drug-sated rodents were detoxified for one month, a period similar to a human going through drug rehabilitation.

Next, researchers divided the rats into two groups, again giving them as much heroin-laced water as they wanted. Only this time, Janda says half the rats had been vaccinated against heroin.

“What happens if you don’t vaccinate them [is] they re-escalate and double the amount of intake," he said. "In the case of the [rats given the] vaccine, they completely don’t recognize the heroin at all and stop taking it.”

None of the vaccinated rats relapsed after being re-exposed to heroin.

The National Institute on Drug Abuse, which has been interested in drug vaccine development, helped fund the research.

David Shurtleff, acting deputy director of the institute, says a heroin vaccine is not a "magic bullet" [complete cure] and would have to be used as part of a comprehensive treatment program that also addresses drug-seeking behavior. Like heroin-addicted humans who continue to crave the drug even after going through treatment, Shurtleff notes that the vaccinated rats persisted for a while in trying to get high.

"Once they are in an environment where they've been using the drug, they start to crave the drug and they will use it even though the vaccine may kick in to prevent the high," said Shurtleff. "They will still try and attempt to take the drug to overcome the craving, to reduce the craving for the drug. So, there's a lot of behavioral [elements] to addiction beyond what the vaccine can do."

Scripps investigators are currently seeking funding to begin human trials of the vaccine, possibly by later this year.

An article describing an experimental heroin vaccine is published in Proceedings of the National Academy of Sciences

Study: HIV Infection Does Not Adversely Affect Outcomes of Liver Transplantation for Hepatocellular Carcinoma

Liver transplantation for hepatocellular carcinoma (HCC) is feasible for HIV-infected patients, with no differences in post-transplant survival or HCC recurrence rates compared with liver transplantation for HCC in HIV-uninfected patients. The study, published in The Oncologist, was led by Dr. Fabrizio Di Benedetto, MD, PhD, Associate Professor of Surgery, University of Modena and Reggio Emilia, Modena, Italy, and represents the largest multicenter study of liver transplant for HCC in HIV-infected patients to date.

Durham, NC (PRWEB) May 10, 2013

Liver transplantation for hepatocellular carcinoma (HCC) is feasible for HIV-infected patients, with no differences in post-transplant survival or HCC recurrence rates compared with liver transplantation for HCC in HIV-uninfected patients. The study, published in The Oncologist, was led by Dr. Fabrizio Di Benedetto, MD, PhD, Associate Professor of Surgery, University of Modena and Reggio Emilia, Modena, Italy, and represents the largest multicenter study of liver transplant for HCC in HIV-infected patients to date.

Patients infected with HIV experience a more aggressive course of HCC, in part due to the tumor-enhancing effects of HIV proteins, including increased growth signaling and diminished antitumor immune response. Moreover, as highly active antiretroviral therapy (HAART) prolongs the life expectancy of HIV-infected patients, the progression of underlying liver disease toward HCC is increasingly a major cause of morbidity and mortality in this patient population. Liver transplantation for HCC in HIV-infected patients is a recent indication, and its viability as a treatment option has been a matter of debate.

In the current study, researchers evaluated post-transplant outcomes in 30 HIV-positive patients and 125 HIV-uninfected patients who underwent liver transplantation for HCC at three transplantation centers in northern Italy between 2004 and 2009. Two patients in the HIV-positive cohort (6.7%) and 18 uninfected patients (14.4%) experienced a recurrence of HCC during the follow-up period of approximately 32 months (p = .15). Overall survival was similar for HIV-infected and -uninfected patients at 1 year (77% vs. 86.4%) and 3 years (65% vs. 70%), respectively, after liver transplantation (p = .32).

“The key message of this study is that liver transplantation is a valid option for HCC treatment in HIV-infected patients,” Dr. Di Benedetto and colleagues wrote. “We suggest that HIV-infected patients must be offered the same liver transplant options for HCC treatment currently provided to HIV-uninfected subjects.”

All HIV-infected patients were given HAART until liver transplantation, and antiviral therapy was discontinued only until liver function stabilized. No patients developed AIDS-defining events during the follow-up period, which the study authors attributed to early HAART resumption following transplantation. In particular, ritonavir-boosted protease inhibitor (PI) therapy appeared to induce more rapid increases in immunosuppressive drug serum levels than unboosted PI therapy, and is the preferred HAART regimen. In the future, new options for antiviral therapy may further improve HIV control and post-transplantation outcomes in HIV-infected patients undergoing liver transplantation for HCC.

The transplantation centers used a multidisciplinary approach to patient care that included input from oncologists, radiologists, gastroenterologists, liver surgeons, and infectious disease specialists. Dr. Di Benedetto and colleagues urged clinicians to adopt a similar collaborative approach to optimize outcomes for HIV-infected patients undergoing liver transplantation for HCC.

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The full article, titled “Multicenter Italian Experience in Liver Transplantation for Hepatocellular Carcinoma in HIV-Infected Patients,” can be accessed at http://www.TheOncologist.com.

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