Cirrhotic patients coinfected with HIV, HCV less responsive to peg-IFN/RBV

Mira JA. Clin Infect Dis. 2012;doi:10.1093/cid/cis779.

October 10, 2012

Treatment with pegylated interferon and ribavirin was less effective in patients with cirrhosis and coinfected with HIV and HCV than noncirrhotic patients in a recent study.

In a multicenter prospective cohort study, researchers evaluated 629 patients coinfected with HCV and HIV, including 175 with cirrhosis. All participants received treatment with pegylated interferon (peg-IFN) and ribavirin (RBV), and had undergone either a biopsy or liver stiffness measurement within 1 year of starting therapy. Follow-up included plasma HCV RNA measurement and assessment of adverse events, and occurred at least once every 4 weeks during the initial 24 weeks of treatment, then every 2 months until conclusion.

In intention-to-treat analysis, sustained virological response (SVR) occurred in 38.9% of noncirrhotic patients compared with 25.1% of those with cirrhosis (P=.001 for difference). Per-protocol analysis of 521 patients indicated significantly more incidence of SVR among those without cirrhosis (46% of patients compared with 33%, P=.007), and lack of cirrhosis was associated with SVR via multivariate analysis (adjusted OR=2.02; 95% CI, 1.1-3.4). Patients with cirrhosis also were significantly more likely to discontinue treatment due to adverse events than noncirrhotic patients (17% of patients vs. 8%, P=.001).

SVR was more common in cirrhotic patients with HCV genotype 2-3 (47% of patients) than those with genotype 1 (14%) or 4 (30%), and researchers observed a significant association between SVR and HCV genotype 1 or 4 (aOR=8.9, 2.7-29). Other factors predictive of SVR included baseline liver stiffness measurements of less than 30 kPa (aOR=4.1, 1.02-16.7) and a baseline HCV viral load of 600,000 IU/mL or less (aOR=6.0, 1.8-2.0) (95% CI for all).

“Although HIV-infected patients with compensated HCV-related cirrhosis are a hard-to-cure population, HCV therapy is a priority in these patients,” the researchers wrote. “Because of this, HCV therapy with peg-IFN plus RBV should be recommended to patients with genotype non-1 until more effective drugs are available. New drugs are needed to improve the efficacy of HCV therapy in HIV/HCV coinfected patients with compensated liver cirrhosis.”

Disclosure: See the study for a full list of relevant disclosures.

Source

The 63rd Annual Meeting of the American Association for the Study of Liver Diseases in Boston, MA - Hynes Convention Center: November 10 - 13, 2012

ALEXANDRIA, Va. and BOSTON, Oct. 10, 2012 /PRNewswire/ -- The Liver Meeting® is the premier Annual Meeting in the science and practice of hepatology, including the latest findings on new drugs, novel treatments, and the results from pilot and multicenter studies.

Approximately 10 percent of Americans have some form of liver disease, but fortunately, the research community has made great strides in recent years in developing new treatments for patients.

At this year's meeting, 2107 abstracts addressing these issues that will be presented, including 258 abstracts that will be presented in oral sessions. Those abstracts are available to members of the press at our website (www.aasld.org).

Boston, MA: November 10 – 13, 2012

• Poster Presentations: November 10 – 13
• Oral Presentations: November 11 – 13

An AASLD President's press conference highlighting key abstracts and issues presented at The Liver Meeting® is scheduled for Saturday, November 10 at 4:00 pm.

Founded in 1950, AASLD is the leading organization of scientists and healthcare professionals committed to preventing and curing liver disease. AASLD has grown into an international society responsible for all aspects of hepatology, and our annual meeting attracts more than 8,000 physicians, surgeons, researchers, and allied health professionals from around the world.

Please contact AASLD at 703-299-9766 begin_of_the_skype_highlighting 703-299-9766 end_of_the_skype_highlighting for information about the above presentations, or to receive any additional information about The Liver Meeting® – or visit our website at www.aasld.org.

Please visit our website to register as press for the meeting, or contact Ann Haran at aharan@aasld.org with any questions.

This release was issued through The Xpress Press News Service, merging e-mail and satellite distribution technologies to reach business analysts and media outlets worldwide. For more information, visit http://www.xpresspress.com.

SOURCE American Association for the Study of Liver Diseases (AASLD)

RELATED LINKS
http://www.aasld.org/

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Update on the Diagnosis and Treatment of Hepatitis C

Infectious Disease Special Edition

ISSUE: OCTOBER 2012 | VOLUME: 15

by Arun B. Jesudian, MD and Ira M. Jacobson, MD

HCV infection is a national and global public health concern, affecting up to 4 million individuals in the United States and 200 million individuals worldwide. Despite a declining incidence of new HCV infections in the United States, the prevalence of advanced liver disease secondary to chronic HCV infection, including cirrhosis and hepatocellular carcinoma, is expected to rise in the coming years.

Download to read this article in PDF document:
-- Update on the Diagnosis and Treatment of Hepatitis C

This article is in PDF format and it requires Abobe Reader. If you do not have Adobe Reader installed on your computer then please download and install from the link below.

-- Download Adobe Reader

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New hepatitis C initiative launched in the Bay (New Zealand)

the Hepatitis Foundation Wednesday 10 October 2012, 11:09AM

Media release from the Hepatitis Foundation

The Hepatitis Foundation (NZ), in partnership with the Ministry of Health and the Bay of Plenty DHB, have launched an innovative pilot targeting chronic hepatitis C in the Bay of Plenty. The pilot intends to significantly improve health outcomes and access to care for people living with this disease.

Chronic hepatitis C is the main cause of liver transplantation in New Zealand. Despite the serious nature of the disease, most people know very little about hepatitis C. "Hepatitis C has been ignored for too long," John Hornell, CEO of The Hepatitis Foundation (NZ) said. "Now is the time to confront this disease, to tackle it head on and to win the fight."

Hepatitis C is a global health issue, as recognised by the World Health Organisation. In New Zealand there are approximately 50,000 people living with chronic hepatitis C. Over 75% of these people are unaware they have the disease as many don't experience signs or symptoms for many decades after infection.

"Our integrated hepatitis C pilot aims to increase the number of people diagnosed, assessed and treated for hepatitis C", Kelly Barclay, Hepatitis C Project Manager said. "It will involve a hepatitis nurse delivering specialist care in the community. The goal is to provide those with hepatitis C with better access to testing, care and support where they live. This will help them make lifestyle changes to slow the progression of the disease before they consider treatment."

Over the coming months, The Hepatitis Foundation (NZ) will be working closely with General Practitioners, Specialists and other health providers to enrol those with hepatitis C onto a Community Assessment and Support Programme. The Community Hepatitis C Nurse will provide enrolled patients with an initial FibroScan®assessment (a non-invasive new ultrasound technique to assess the level of liver disease), blood tests, on-going support and education, and will liaise with health providers to centrally manage patients' needs. In the majority of cases, Fibroscan® takes away the need for liver biopsy altogether.

The Bay of Plenty DHB will be backing this pilot across the region. Phil Cammish, CEO for the BOPDHB said, "The innovative approach being introduced with this improved service should make a big difference to the lives of people with hepatitis C. This service will bring together all parts of the health service to address this health need."

Early 2013, a public campaign will be launched to identify people who are at risk or have been at risk of contracting hepatitis C and are currently undiagnosed. "We'll be actively encouraging people to get tested if they are or have been at risk of hepatitis C," Barclay said. "It's important people are diagnosed as early as possible."

Hepatitis C is spread through blood-to-blood contact. The virus causes inflammation of the liver, which can lead to cirrhosis or liver cancer if left undiagnosed. Current treatment provides 45-80% chance of cure (depending on the disease strain).

The Hepatitis Foundation (NZ) is a charitable trust promoting positive health outcomes for people living with chronic hepatitis.

Source

Pilot to offer better support for Hep C patients in the sub‐region (New Zealand)

the Hepatitis Foundation Wednesday 10 October 2012, 11:43AM

Media release from the Hepatitis Foundation

People in the Wairarapa and greater Wellington regions will have better access to testing, assessment and treatment for hepatitis C thanks to a two‐year pilot programme being rolled out in the sub‐region.

Capital and Coast, Hutt Valley and Wairarapa DHBs are working with The Hepatitis Foundation (NZ) and community‐based health providers to improve access to support services for patients living with chronic hepatitis C and encourage people that may be at risk to get tested. Preparations are underway to launch the pilot at Capital and Coast, Hutt Valley and Wairarapa DHBs in early 2013.

According to the Foundation there are an estimated 5,800 people living with hepatitis C across the sub‐region. Chronic hepatitis C is the main cause of liver transplants in New Zealand and if left untreated can have serious health effects.

"This programme will be a terrific help to identify people that need treatment and offer them ongoing support," said Dr Richard Stein, supervising clinician for the Wairarapa pilot. "We have around 50 patients we hope to enrol in the Wairarapa and combined with the Hutt Valley and Wellington pilots will mean better service coverage and better outcomes for our populations," he said.

During the first stage of the pilot, people already diagnosed with hepatitis C will be enrolled into a Community Assessment and Support Programme. Patients' care is centrally managed by a community hepatitis nurse who is supported by a range of specialists including hospital staff, GPs and other community‐based health providers.

Patients will have improved access to services, including FibroScan. This ultrasound technique measures the amount of scar tissue (fibrosis) in the liver, which helps measure the progression of the disease. Patients will also receive ongoing follow‐up care which is important for managing their condition. During the second stage of the pilot, people will be encouraged to get tested if they are, or have been at risk of hepatitis C.

Those at risk of hepatitis C are people who have ever: injected drugs; received a blood transfusion before 1992; lived or received medical attention in high‐risk countries; been in prison; or used unsterile equipment for tattooing or body piercing. Children born to mothers with hepatitis C are also at risk.

Dr Nigel Stace, Wellington Hospital Gastroenterologist says, "the key to this pilot is to encourage and support people to come forward early to be tested and treated. It's easier to treat the disease in its early stages and there is a much better chance of a cure when patients complete their treatment."

"Before Fibroscan was available, patients had a biopsy and spent up to a day in hospital after the procedure to make sure they were fit to go home," says Dr Stace. "Results also took several days to come back from the lab. Now testing takes around 20 minutes and doesn't involve needles which can discourage people from being tested."

"The gastroenterology services at the three DHBs are looking for opportunities to work more closely together. We see the pilot as a great opportunity to get this started," says Dr Stace.
Gastroenterology involves providing care for people with diseases of the 'gut', liver and pancreas.

Dr Jeff Wong, Hutt Hospital gastroenterology specialist says, "we are delighted to participate in the Foundation's Hepatitis C Pilot Programme. We hope it will increase the number of people completing treatment and with the treatment currently available, two thirds of patients can be cured," he said.

Source

FDA takes action against thousands of illegal Internet pharmacies

FDA NEWS RELEASE

For Immediate Release: Oct. 4, 2012
Media Inquiries: Sarah Clark-Lynn, 301-796-9110, sarah.clark-lynn@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA

En Español¹

Agency participates in international Operation Pangea V to protect consumers from potentially dangerous, unapproved drugs

The U.S. Food and Drug Administration, in partnership with international regulatory and law enforcement agencies, took action this week against more than 4,100 Internet pharmacies that illegally sell potentially dangerous, unapproved drugs to consumers. Actions taken include civil and criminal charges, seizure of illegal products, and removal of offending websites.

The announcement takes place during the 5th annual International Internet Week of Action (IIWA), a global cooperative effort to combat the online sale and distribution of potentially counterfeit and illegal medical products. This year’s effort – Operation Pangea V – operated between Sept. 25 and Oct. 2 and resulted in the shutdown of more than 18,000 illegal pharmacy websites and the seizure of about $10.5 million worth of pharmaceuticals worldwide.

The goal of this annual effort, which involved law enforcement, customs and regulatory authorities from 100 countries, is to identify producers and distributors of illegal pharmaceutical products and medical devices and remove these products from the supply chain.

“Consumers in the United States and around the world face a real threat from Internet pharmacies that illegally sell potentially substandard, counterfeit, adulterated or otherwise unsafe medicines,” said FDA Commissioner Margaret A. Hamburg, M.D. “This week’s efforts show that strong international enforcement efforts are required to combat this global public health problem. The FDA is committed to joining forces to protect consumers from the risks these websites present.”

Last week, the FDA reinforced its online efforts with the launch of a national campaign to educate Americans about the risks of buying prescription medications over the Internet. BeSafeRx – Know Your Online Pharmacy² seeks to raise public awareness about the health risks of using fraudulent Internet pharmacies and what consumers can do to protect themselves.

During Operation Pangea V, the FDA targeted websites selling unapproved and potentially dangerous medicines. In many cases, the medicines can be detrimental to public health because they contain active ingredients that are approved by FDA for use only under the supervision of a licensed health care practitioner or active ingredients that were previously withdrawn from U.S. market due to safety issues.

Among the illegal medicines identified through the operation were:

• Domperidone: This medicine was removed from the United States market in 1998 because it may cause serious adverse effects, including irregular heartbeat, stopping of the heart, or sudden death. These dangers could convey to the nursing baby of breastfeeding women, who may be using domperidone to try increase milk production (which is not an approved use).
• Isotretinoin (previously marketed as Accutane in the United States): This medicine is used to treat severe nodular acne and carries significant potential risks, including severe birth defects if pregnancy occurs while using this medicine. To minimize potential risks to consumers, FDA-approved isotretinoin capsules are only available through restricted distribution in the United States.
• Tamiflu (oseltamivir phosphate): This medicine, which is used to treat the flu, is often sold online as “generic Tamiflu.” However, there is no FDA-approved generic version of Tamiflu. Previous FDA tests found that fraudulent versions of “generic Tamiflu” contained the wrong active ingredient, which would not be effective in treating flu. In these cases, the wrong active ingredient was similar to penicillin and may cause a severe allergic reaction, including a sudden, potentially life-threatening reaction called anaphylaxis, in consumers allergic to penicillin products.
• Viagra (sildenafil citrate): This medicine is used to treat erectile dysfunction. Due to its vasodilation effects, sildenafil citrate should not be used by consumers with certain heart conditions. Consumers taking this medicine without the supervision of a health care professional may not learn about potential drug interactions, such as increased blood pressure lowering effects of organic nitrates when taken with sildenafil citrate.

The FDA sent Warning Letters to the operators of more than 4,100 identified websites. As a follow up, the agency sent notices to Registries, Internet Service Providers (ISPs), and domain Name Registrars (DNRs) informing them that these websites were selling products in violation of U.S. law. The FDA is working with its foreign counterparts to address the remaining websites that continue to offer unapproved or misbranded prescription medicines to U.S. consumers.

“Internet pharmacies that illegally sell unapproved, counterfeit, or potentially adulterated or substandard drugs are an inherently international crime problem,” said John Roth, director of the FDA’s Office of Criminal Investigation. “The FDA is pleased to work with INTERPOL, the international police agency, to fight this problem. Because these criminals do not respect international borders, the international coordinated law enforcement response represented by Operation Pangea demonstrates that international cooperation is the best way to protect the American public from the risk of unsafe drugs.”

The FDA coordinated the efforts of this year’s Operation Pangea V, including screening all drug products received through the international mail facilities during the IIWA. Preliminary findings showed that certain products from abroad, such as antibiotics, antidepressants, and other drugs to treat high cholesterol, diabetes, and high blood pressure, were on the way to U.S. consumers. Many of those products can pose health risks if taken without the supervision of a health care practitioner or if the products have been removed from the market for safety reasons.

The FDA encourages consumers to report suspected criminal activity at www.fda.gov/oci³.

The IIWA is a collaboration between FDA, INTERPOL^{4 5}, the World Customs Organization, Permanent Forum of International Pharmaceutical Crime, Heads of Medicines Agencies Working Group of Enforcement Officers, the Medicines and Healthcare products Regulatory Agency of the United Kingdom, the Irish Medicines Board, the London Metropolitan Police, the U.S. Department of Homeland Security, the Center for Safe Internet Pharmacies, and national health and law enforcement agencies from 100 participating countries.

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, and products that give off electronic radiation, and for regulating tobacco products.

Source

Etanercept Recommended for RA Complicated by Hepatitis C

By: M. ALEXANDER OTTO, Family Practice News Digital Network

NEWPORT BEACH, CALIF. – Etanercept and a few other tumor necrosis factor inhibitors should be considered first-line therapy for treating rheumatoid arthritis in patients with active hepatitis C virus infection, according to Dr. Leonard Calabrese, chair of clinical immunology and professor of medicine at the Cleveland Clinic.

A systematic literature review (Rheumatology (Oxford) 2011;50:1700-11) that included 153 patients – 91 with rheumatoid arthritis (RA) – "demonstrated quite clearly that there are no safety signals from this. TNF inhibitors work in the same general manner with the same predicted responses in hepatitis C patients as they do in patients who are uninfected," he said.

"Most of the data are on etanercept," and recent guidelines from the American College of Rheumatology recommend it in RA patients with hepatitis C based on observations and other level-C evidence, he noted.

For those and other reasons, "I consider TNF inhibitors first-lines of therapy. These drugs can [also] be used concomitantly" with hepatitis C treatments, including protease inhibitors, which seem to greatly improve cure rates when included with other antiviral therapies, he said at Perspectives in Rheumatic Diseases 2012, sponsored by Skin Disease Education Foundation (SDEF).

"When we find somebody with hepatitis C in our practice, we are doing them a huge favor because we can bring them into the circle of care and treat the thing that is more serious than their" RA, Dr. Calabrese said.

Meanwhile, the guidelines do not recommend methotrexate or leflunomide in the setting of hepatitis C virus infection because the drugs might cause additional liver damage.

Among others, Dr. Calabrese screens baby boomers – the largest reservoir of hepatitis C in the United States – and people going on to high-risk drugs, "which is basically anyone going onto a" disease-modifying antirheumatic drug, he said.

"Having antibody to hepatitis C does not prove you have chronic hepatitis C infection, only that you have immunologic memory to the virus. The confirmatory test [for active infection] is the presence of [hepatitis C virus] RNA in the serum, detected by" polymerase chain reaction. "When you find this, the most important part is to refer [the patient] to a hepatologist," he said.

Screening for hepatitis C based on liver enzymes "is a fallacy," he said. Patients with chronic infection can have normal levels, and persistently normal levels do not rule out significant disease.

Perhaps 5 million people in the United States have active, chronic infection. There’s been a slight uptick in cases among men who have sex with men and drug users in rural areas who inject prescription drugs, he noted.

Dr. Calabrese is a consultant for Aventis, Bristol-Myers Squibb, Genentech, Janssen, and Pfizer. He is a speaker for Amgen. SDEF and this news organization are owned by Frontline Medical Communications.

Source

HIV Mortality Falls but Some Gaps Persist

By Charles Bankhead, Staff Writer, MedPage Today

Published: October 09, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

HIV mortality has decreased significantly across racial and ethnic groups and in men and women but remains much higher in nonwhite than in white individuals, an analysis of vital statistics showed.

In absolute terms, the largest decreases occurred among black men with the most education (117.89 per 100,000 population during 1993 to 1995, and 15.35/100,000 in 2005 to 2007) and Hispanic men with the least education (61.60 versus 9.01/100,000), according to Edgar P. Simard, PhD, of the American Cancer Society in Atlanta, and co-authors.

Although mortality declined in both sexes and across all education levels, rates remained substantially higher in minority groups, owing to higher baseline rates, they reported online in Archives of Internal Medicine.

"There were strong declines for all groups except for non-Hispanic black women of low SES (socioeconomic status)," the authors wrote in conclusion. "Relative declines were generally greater for those with higher educational attainment and for non-Hispanic whites, and these trends resulted in widening gaps between these groups."

"The black-to-white mortality disparities were generally similar across educational levels in both periods ... , highlighting racial disparities in HIV prevalence, treatment, and prevention within each level of education, which may be due to a combination of societal and environmental factors," they added.

Total HIV mortality has declined substantially since the mid-1990s. Overall declines can obscure subgroups that have benefited more or less from earlier diagnosis and highly active antiretroviral therapy (HAART). Simard and colleagues sought to identify such subgroups by examining trends over time in HIV mortality by sex, race/ethnicity, and education level.

The authors searched the National Vital Statistics System for HIV-related deaths among men and women ages 25 to 64 in 26 states, covering the years 1993 to 2007, inclusive.

Investigators compared mortality during two periods: 1993 to 1995 (pre-HAART) and 2005 to 2007 (HAART era). The primary outcomes were age-standardized HIV mortality, mortality differences, and rate ratios by education and between the least- and most-educated individuals (≤12 versus ≥16 years).

The search of the database identified 91,307 HIV deaths during 1993 to 2007 (74,445 men and 16,862 women). White men accounted for 35,149 deaths, black men for 34,783, and Hispanic men for 4,513. Corresponding numbers for women were 4,147, 11,663, and 1,052, respectively.

Comparison of the pre-HAART and HAART eras showed little variation in death rates by education among white men (25.77 to 26.42/100,000 for least to most education) in the pre-HAART period. By 2005 to 2007, rates had declined to 5.04, 2.82, and 1.79/per 100,000 for white men with ≤12 years, 13 to 15 years, and ≥16 years of education, respectively.

Black men with the least education had the highest mortality in both periods: 122.02/100,000 during 1993 to 1995 and 52.71/100,000 in 2005 to 2007.

Among Hispanic men, those with the least education had an HIV mortality of 58.67/100,000 during 1993 to 1995, declining to 9.01/100,000 during 2005 to 2007. Hispanic men with the most education had HIV death rates of 49.84 and 3.13/100,000 for the early and later periods of years included in the study.

For both the pre-HAART and HAART eras, women of all races and education levels had lower HIV mortality compared with men. Nonetheless, HIV mortality declined across the board: 1.97 to 0.80/100,000 in white women; 22.50 to 16.97/100,000 in black women; and 12.24 to 2.32/100,000 in Hispanic women.

Despite declines in HIV mortality across all ethnic groups, disparities increased by level of education in two groups: most- and least-educated white men and black men.

During 1993 to 1995, the mortality disparity by education in white men was <1/100,000 but increased to >3/100,000 by 2005 to 2007. Among black men, the education-related disparity increased from ~4/100,000 during 1993 to 1995 to >37/100,000 during 2005 to 2007.

"HIV death rates remained markedly high among non-Hispanic black men of all SES levels and were unchanged for non-Hispanic black women in the lowest SES strata," the authors wrote in conclusion.

"These findings suggest the need for focused interventions and resources to facilitate the identification of high-risk individuals, as well as entry and retention into care for these most vulnerable groups affected by the HIV epidemic in the U.S."

The study was supported by the American Cancer Society.

The authors had no disclosures.

Primary source: Archives of Internal Medicine
Source reference:
Simard EP, et al "The influence of sex, race/ethnicity, and educational attainment on human immunodeficiency virus death rates among adults, 1993-2007" Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4508.

Source

‘Like this page’ to prevent sexually transmitted infections

Posted October 8, 2012 on ScienceBlog.com

Sexually transmitted infection (STI) prevention messages delivered by Facebook can be effective in promoting condom use among young adults in the short term, a new study has found. Few students and young adults receive comprehensive sexuality education or guidance on HIV and other STI risks. Social media may provide a viable alternative to promote safe sex using online networks of friends, the study published in the November issue of the American Journal of Preventive Medicine reports.

“The use of social media to influence sexual risk behavior in the short term is novel. It is a first step in considering how to reach the overwhelming numbers of youth online, and how to maximize approaches to technology-based interventions,” says lead investigator Sheana S. Bull, PhD, MPH, of the Department of Community and Behavioral Health at the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus, Aurora, CO.

Researchers initially recruited study participants in community settings and through postings on popular blogs and websites, as well as advertisements in college and local papers in US cities with higher than average rates for STI and HIV. Recruitment focused on African-American and Latino youth given the disparity of infections between these groups and other young adults. Each recruit was given an incentive to recruit three friends to participate, and each new recruit was also incentivized to recruit three friends, for five recruitment waves.

Participants and those they recruited were randomly assigned as a network to either an intervention group or a control group. The intervention group signed up to “Like” and receive news from Just/Us, a Facebook community developed to promote sexual health. Each week a new topic such as communicating about sexual history, skills building for condom negotiation and use, and how to access STI testing was discussed on the site, with updates each day from youth facilitators in the form of video links, quizzes, blogs, and threaded discussions. The control page was called “18-24 News,” and shared news that happened during the hours of 6 pm to midnight on the 24 hour clock that was of interest to 18-24 year olds.

Demographic information and baseline information on condom use at last sexual encounter and the proportion of sex acts protected by condom use in the last 60 days were collected at the start of the study. 636 people were enrolled in the 18-24 News intervention and 942 in the Just/Us intervention. Surveyed two months after the intervention, 68% of the Just/Us group reported using a condom during the last sex act, versus 56% of the controls, and the proportion of sex acts protected by condom use in the last 60 days was 63% for the Just/Us group versus 57% for controls. The effects decreased over time and a survey six months after the intervention found no difference between the two groups. There was no evidence that any demographic characteristics influenced response to the intervention.

“The effect size from the short-term outcomes match or exceed those observed in other Internet interventions, suggesting Facebook for sexual health interventions is at least equally effective as other technology-based mechanisms, and these effects match those observed for more traditional HIV prevention programs delivered in real-world settings,” Dr. Bull observes.

Results also show success in recruitment of youth of color and youth living in geographic regions with high STI and HIV prevalence, and success in reaching large numbers of people with STI- and HIV-related content through Facebook. There is little evidence that youth actively seek out and engage with organizations on Facebook. Thus approaches like that of Just/Us to push messages out offer one way to get messages in front of a large number of youth.

Dr. Bull notes that the study relied on self-reporting, and condom use may have been over-reported. Another concern is that the number of active participants declined over time, as did the treatment effect. “Although this type of attrition has been documented in other online STI-related research, it underscores the need to redouble efforts to attract and engage higher-risk youth in prevention efforts using social media. Future work should explore approaches to keep audiences engaged in social media content related to sexual health,” she concludes.

In a commentary accompanying the article, Nathan K. Cobb, MD, from the Schroeder Institute for Tobacco Research and Policy Studies at the American Legacy Foundation, Washington, DC, says, “For health behavior change intervention designers, Facebook offers something unprecedented – direct access to an individual’s social network, in real time, and without the need for tedious network enumeration by participants. However, such approaches require multidisciplinary teams that include social media specialists, marketers, and software developers as equal partners in design and intervention development. Building such teams will undoubtedly require changes to traditional funding and development models, but the potential is too large to be ignored or minimized.”

Source

Insulin Resistance Is Associated With Progression to Hepatic Fibrosis in a Cohort of HIV/Hepatitis C Virus-Coinfected Patients

From AIDS

Mark W. Hull; Kathleen Rollet; Erica E.M. Moodie; Sharon Walmsley; Joseph Cox; Martin Potter; Curtis Cooper; Neora Pick; Sahar Saeed; Marina B. Klein

Posted: 10/08/2012; AIDS. 2012;26(14):1789-1794. © 2012 Lippincott Williams & Wilkins

Abstract and Introduction

Abstract

Objective: Hepatitis C virus (HCV) infection is associated with higher insulin levels and insulin resistance. We evaluated factors associated with insulin resistance in a cohort of HIV/HCV-coinfected patients and determined the effect of insulin resistance on the development of hepatic fibrosis.
Methods: Data were analysed from 158 nondiabetic participants in a prospective Canadian cohort of HIV/HCV-coinfected patients. Patients were defined as having insulin resistance using the homeostasis model for assessment of insulin resistance (HOMA-IR) index. Factors associated with a high index (HOMA-IR ≥2) were identified using multivariate logistic regression. Incidence rates of liver fibrosis [aspartate aminotransferase-to-platelet ratio index (APRI) ≥1.5] were calculated, and multivariate time-dependent Cox regression models used to assess the effect of baseline insulin resistance on the risk of developing an APRI score of at least 1.5 during follow-up.
Results: Overall, 56% had baseline HOMA-IR of at least 2. In the adjusted multivariate logistic analysis, only baseline BMI of more than 25 kg/m² remained associated with insulin resistance [adjusted odds ratio 3.66, 95% confidence interval (CI) 1.70–7.92]. Rates of progression to significant hepatic fibrosis (APRI ≥1.5) were higher in those with HOMA-IR of at least 2 (16.32 per 100 person-years, 95% CI 6.68–25.97) compared with those with HOMA-IR less than 2 (7.95 per 100 person-years, 95% CI 0.16–15.75). Baseline HOMA-IR of at least 2 was associated with the development of significant fibrosis (adjusted hazard ratio 7.71, 95% CI 2.55–23.36).
Conclusion: In this first longitudinal analysis, insulin resistance was very common among coinfected patients and was associated with modifiable risk factors such as elevated BMI. Insulin resistance was found to be strongly associated with progression to hepatic fibrosis over time.

Introduction

Hepatitis C virus (HCV) infection has been associated with an increased risk for insulin resistance and diabetes^[1] with 30–70% exhibiting some degree of insulin resistance.^[2] Insulin resistance has been associated with a wide variety of adverse health outcomes such as cardiovascular disease and cancer and with decreased response to HCV therapy among HCV-monoinfected patients.^[3–6] The homeostasis model for assessment of insulin resistance (HOMA-IR) index is a well validated noninvasive method to measure insulin sensitivity.^[7] HCV-infected individuals have been shown to have higher HOMA-IR scores (compared with uninfected matched controls)^[1] which have been associated with fibrosis and steatosis in cross-sectional analyses.^[8] In HIV-infected patients, HCV has also been shown to be associated with the presence of insulin resistance,^[9–11] but its association with progressive fibrosis is less clear.^[12] We evaluated factors associated with insulin resistance in a cohort of HIV/HCV-coinfected patients and determined the impact of insulin resistance on the development of liver fibrosis prospectively.

Materials and Methods

Study Design, Setting and Population

The Canadian Co-infection Cohort Study [CCC, CIHR Canadian HIV Trials Network (CTN222)] is a prospective multicentre study recruiting HIV/HCV-coinfected patients at 16 centres across Canada since 2003 with approval by participating research ethics boards and has been described in detail elsewhere.^[13] As of October 2010, 955 patients were enrolled. To evaluate factors associated with insulin resistance, we included nondiabetic participants (based on recorded medical history and current prescription for insulin or oral hypoglycaemic medication) with at least one study visit between April 2003 and October 2010 and available baseline values of fasting insulin and glucose (n = 185). This sample was further restricted to assess the effect of insulin resistance on fibrosis progression. Only participants (n = 85) with virologic evidence of active HCV infection (HCV-RNA-positive, COBAS AMPLICOR HCV Test, version 2.0, Roche Diagnostics, Hoffmann-La Roche Ltd, Laval, Canada), an aspartate aminotransferase (AST)-to-platelet ratio index (APRI) less than 1.5 and absence of end-stage liver disease (ESLD) at study entry were studied. Patients were censored on their last clinic visit prior to October 2010, when an outcome occurred, at death or at initiation of HCV treatment.

Measurements

Insulin resistance was determined at baseline for all eligible patients using the HOMA-IR [fasting insulin (mIU/l) × fasting glucose (mmol/l)/22.5].^[7] APRI was used as a noninvasive surrogate marker for liver fibrosis defined as follows: 100 × (AST (U/l)/upper limit of normal)/platelet count (10⁹ cells/l).^[14] An APRI of at least 1.5 was considered significant fibrosis (corresponding to a biopsy score ≥F2).^[14–16]

Statistical Analyses

Multiple logistic regression was used to identify factors independently associated with insulin resistance (HOMA-IR ≥2, a cut-point indicative of insulin resistance in other analyses.^[5,17,18] The natural logarithm of the APRI [ln(APRI)], which nearly normalizes the distribution, was used in these analyses.^[19]

We estimated incidence rates of liver fibrosis (APRI≥1.5) among those without fibrosis at baseline. Poisson count models were used to calculate confidence intervals (CIs) for incidence rates. Multivariate time-dependent Cox regression models were constructed to assess the effect of insulin resistance at baseline on the risk of developing an APRI of at least 1.5 during follow-up and included covariates that had statistically significant hazard ratios in univariate analyses along with those determined a priori to be clinically important. Insulin resistance was modelled either as a categorical variable (HOMA-IR<2 or ≥2) or as a continuous variable, using 2 log-base HOMA-IR to account for the skewed distribution of HOMA-IR values while allowing for straightforward clinical interpretation (e.g. risk for each doubling in HOMA-IR was estimated). Robust variance estimation was used in all Cox regression analyses to account for the correlation of data contributed by the same participant at multiple visits. Statistical analyses were performed using R program for Windows Release 2.11.1 (R cran, Auckland, New Zealand).

Results

Overall, 158 individuals were included in the primary analysis. The major reason participants were excluded from the study was lack of fasting measures of insulin or glucose (n = 755). Included patients were similar in all regards to those excluded except there were fewer men (63 vs. 76%) and IDUs (74 vs. 82%) and more combination antiretroviral therapy (cART) users (88 vs. 80%). Notably, there was no difference in BMI, alcohol use, median CD4 cell count or types of ART (protease inhibitor vs. nonnucleoside reverse transcriptase inhibitor) used between those included and excluded. Overall, the median age was 45 years [interquartile range (IQR) 40–50], 63% were male, 23% had history of recent IDU and 89% received cART. At baseline, 70 (44%) had HOMA-IR less than 2; 45 (28%) had an index of 2.0–3.9; 22 (14%), had an index of 4.0–5.9, and 21 (13%) had HOMA-IR at least 6. There was no statistically significant association between baseline insulin resistance and baseline hepatic fibrosis (n = 32), although the median HOMA-IR was higher at 2.7 (IQR 1.8–4.5) compared with 0.8 (IQR 0.5–1.4, P = 0.35) for those with baseline APRI less than 1.5.

Factors Associated With Baseline Insulin Resistance

In adjusted multivariate analysis, only BMI of at least 25 was strongly associated with baseline insulin resistance (seeTable 1, HOMA-IR ≥2). Although receipt of protease inhibitor-based therapy was associated with insulin resistance in univariate analysis, this association was attenuated in multivariate analysis.

Factors Associated With the Development of Fibrosis

Fifteen individuals (18%) developed significant hepatic fibrosis (APRI ≥1.5) with median follow-up of 1.4 (IQR 1.0, 1.7) years. Rates of progression to significant fibrosis were higher in those with HOMA-IR of at least 2 (16.32 per 100 person-years, 95% CI 6.68–25.97, n = 11) compared with those with HOMA-IR less than 2 (7.95 per 100 person-years, 95% CI 0.16–15.75, n = 4).

In multivariate analyses, baseline HOMA-IR of at least 2 and HOMA-IR modelled as a continuous variable were both strongly associated with progression of hepatic fibrosis (Table 2). Among other covariates, only baseline APRI was also associated with fibrosis progression. Given the small number of events, we did not include more covariates in the final model. In sensitivity analyses, we examined cART use, triglycerides and ethnicity which were not associated with fibrosis nor did their inclusion in the multivariate model alter the main results (data not shown).

Discussion

Insulin resistance was present in a majority of HIV/HCV-coinfected cohort participants with 56% having a baseline HOMA-IR of at least 2 and a significant proportion having very high levels of insulin resistance (27% having HOMA-IR score ≥4). As we excluded those receiving oral hypoglycaemics or insulin, this finding suggests that a substantial number of coinfected persons are not recognized as having impaired glucose tolerance and are, thus, at risk for common complications of insulin resistance.^[3,4,20] Presence of insulin resistance was associated primarily with classic and potentially modifiable risk factors: elevated BMI and waist circumference. Although fasting glucose was higher among those having HOMA-IR of at least 2, all had values within the normal range; thus, fasting insulin levels are required to identify individuals with insulin resistance.

To understand whether insulin resistance contributes to the development of hepatic fibrosis, longitudinal studies in persons not having fibrosis or advanced liver disease are required. Ours is the first such longitudinal study to examine this question in coinfected patients. We found insulin resistance was strongly associated with development of hepatic fibrosis. In adjusted analyses, the risk of developing fibrosis was nearly eight times greater in the presence of insulin resistance and was independent of BMI. Furthermore, for each doubling in HOMA-IR score there was a 48% increase in risk for progression to fibrosis. This finding suggests that efforts to improve insulin sensitivity may potentially reduce rates of fibrosis progression among coinfected persons. Given the rise of ESLD morbidity and mortality among HIV/HCV-coinfected persons, the identification of this potentially modifiable risk factor for liver disease progression is of enormous relevance.

The prevalence of insulin resistance in our Canadian cohort is somewhat greater than that reported in other populations. Among 170 coinfected patients from France, the prevalence of insulin resistance was 37%.^[17] In 1041 HIV-infected Spanish patients, the prevalence was 48% among 373 HIV/HCV-coinfected patients compared with 33% in those without HCV infection.^[11]

We could not demonstrate an association of specific antiretroviral agents with the presence of insulin resistance at baseline. Particularly, certain protease inhibitors and cumulative exposure to nucleoside reverse transcriptase inhibitors, especially stavudine, have been implicated in previous studies.^[21–24] In contrast, there has been no clear association of specific drug class or duration of ART exposure and insulin resistance in coinfected populations.^[9,10] The lack of association between ART exposure and insulin resistance in our study and others may be due to a lack of power, given the relatively small numbers of individuals analysed to date, or may reflect more complex effects of ART on HCV-related disease.^[25,26]

Prior cross-sectional studies in coinfected persons have not identified a clear relationship between insulin resistance and presence of hepatic fibrosis.^[12,17] In contrast, in a cross-sectional study of 330 coinfected patients undergoing transient elastography, 64% of those with HOMA-IR of at least 4 had measures of at least 9 kPa compared with 39% of those with HOMA-IR less than 4 (P < 0.0001), and HOMA-IR of at least 4 was an independent predictor of elevated liver stiffness (adjusted odds ratio 5.33, 95% CI 2.70–10.49).^[27] Insulin resistance has been associated with higher estimated fibrosis progression rates in monoinfected populations^[1] but not in a small study of coinfected patients.^[12] Finally, in HCV monoinfection, HOMA-IR more than 2 has been associated with decreased sustained virologic responses (SVRs) to HCV therapy. In coinfected patients, however, studies on the impact of insulin resistance on SVR have been contradictory.^[18,28,29]

Mechanisms by which insulin resistance occur in HCV-infected patients have not been fully elucidated, but include effects of inflammatory cytokines such as tumour necrosis factor alpha,^[30] other cytokine signalling pathways (e.g. upregulation of suppressor of cytokine signaling-3 protein)^[31] and effects on insulin–receptor substrate which interferes with insulin signalling.^[32] Whether HIV directly plays a role remains unclear.

Our study has some potential limitations. Overall, a significant proportion lacked fasting glucose and insulin values and, therefore, was excluded from analysis. This limited our power to determine associations between insulin resistance and such factors as specific antiretroviral drug classes or HCV genotype. The large number of excluded patients also potentially could have introduced a selection bias. Use of HOMA-IR in the evaluation of insulin resistance in HCV-infected patients is well established,^[33] and we used a HOMA-IR score of at least 2 to define significant insulin resistance, as used in other North American and European coinfected populations,^[5,17,18,34] although other cut-offs have been used.^[12] We used the APRI score as a surrogate marker for hepatic fibrosis rather than liver biopsy. APRI has been validated against liver biopsy in our cohort as well as others and is widely accepted as a surrogate marker and is highly specific for fibrosis stages equal to or greater than F2 Metavir score (significant fibrosis, few septa).^[14] A limitation of not using serial biopsies is the potential interplay between insulin resistance and hepatic steatosis, itself a consequence of insulin resistance, which may contribute to fibrosis progression.^[17]

Conclusion

Given the very high prevalence of insulin resistance, its known association with important health outcomes and its associated high risk for liver disease progression observed in this study, routine screening for insulin resistance among coinfected persons may be warranted. Interventional studies to manage modifiable risk factors for insulin resistance and evaluate the role of pharmacotherapy in modifying the course of liver disease progression and improving HCV treatment outcomes among HIV/HCV-coinfected persons are needed.

Acknowledgements

The authors thank Alex Schnubb, Manon Desmarais, Curtis Sikora, Christine O'Reilly, Brenda Beckthold, Heather Haldane, Laura Puri, Nancy McFarland, Claude Gagne, Elizabeth Knight, Lesley Gallagher, Warmond Chan, Sandra Gordan, Judy Latendre-Paquette, Natalie Jahnke, Viviane Josewski, Evelyn Mann and Anja McNeil for their assistance with study coordination, participant recruitment and care.

The Canadian Co-infection cohort investigators (CTN222) are Jeff Cohen, Windsor Regional Hospital Metroplitan Campus, Windsor, Ontario, Canada; Brian Conway, Downtown IDC, Vancouver, British Columbia; C.C., Ottawa General Hospital, Ottawa, Ontario, Canada; Pierre Côté, Clinique du Quartier Latin, Montreal, Quebec, Canada; J.C., Montreal General Hospital, Montreal, Quebec, Canada; John Gill, Southern Alberta HIV Clinic, Calgary, Alberta, Canada; Mark Tyndall, Native Health Centre, Vancouver, British Columbia, Canada; Shariq Haider, McMaster University, Hamilton, Ontario, Canada; Marianne Harris, St Paul's Hospital, Vancouver, British Columbia, Canada; David Hasse, Capital District Health Authority, Halifax, Nova Scotia, Canada; Julio Montaner, St Paul's Hospital, Vancouver, British Columbia, Canada; E.E.M.M., McGill University, Montreal, Quebec, Canada; N.P., Oak Tree Clinic, Vancouver, British Columbia, Canada; Annita Rachlis, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada; Roger Sandre, HAVEN Program, Sudbury, Ontario, Canada; Danielle Rouleau, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; David Wong, University Health Network, Toronto, Ontario, Canada; M.W.H., British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; and S.W., Toronto General Hospital, Toronto, Ontario, Canada.

This study was funded by the Fonds de recherche en santé du Québec, Réseau SIDA/maladies infectieuses (FRSQ), the Canadian Institutes of Health Research (CIHR MOP-79529) and the CIHR Canadian HIV Trials Network (CTN222). M.B.K. is supported by a 'Chercheur-boursiers cliniciens senior' career award from the FRSQ.

AIDS. 2012;26(14):1789-1794. © 2012 Lippincott Williams & Wilkins
Lippincott Williams & Wilkins

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Source

HIV/AIDS: Free ARVs for all in England

Photo: Georgina Cranston/IRIN

Free treatment regardless of immigration status

LONDON, 8 October 2012 (PlusNews) - On the first day of October, a law change enabled everyone in England, regardless of their immigration status, to obtain free treatment for HIV and AIDS. This marks a victory for advocacy groups that have long argued that the health system restricted access to HIV treatment for some of the country's most vulnerable people.

Every resident in Britain contributes to the National Health Service (NHS) through their taxes, and gets free treatment. People without residency have to pay for treatment, with two exceptions: Cases of accidents or emergencies, where everyone receives free treatment from hospitals, and cases where serious infectious disease could be passed on to members of the public. But while treatment for STIs like syphilis and gonorrhoea fell under this latter category, treatment for HIV and AIDs did not.

This has changed, and HIV is now eligible for free treatment. "We have been campaigning on this for something like seven years," Eleanor Briggs, of the National AIDS Trust (NAT) policy and campaigns team, told IRIN/PlusNews. "So we are very pleased, and see it as a very positive development. It really was an anomaly that treatment for HIV was chargeable when other infectious conditions and STIs were not. Tests were always free but we know some people were put off taking the test because they were afraid of the cost of treatment, and so could have been infected and spreading the virus."

Those benefitting most from the change will not be short-term visitors to the UK, experts say, but people living there without proper documentation, including illegal migrants, those who have overstayed their visas, and asylum seekers whose claims have been turned down but who haven't left the country. Many are members of the African diaspora, a community with a relatively high rate of HIV infection and a lot of issues over visas.

Jackie Stevenson of the African Health Policy Network says the previous policy was inhibiting treatment even among people who could have received free treatment, either because they met NHS criteria but didn't realize it, or because, in practice, health workers often don't demand fees from people they know will have difficulty paying.

Fear unfounded

The change was slow in coming, partly because of fears about 'HIV health tourism' - people coming to the UK illegally to benefit from free treatment - and partly because of the perception that HIV-positive people, even on treatment, can still spread the virus to others. However, recent research shows that HIV treatment can vastly diminish the risk of transmission.

Meanwhile, another study showed that, among heterosexual adults born abroad but diagnosed with HIV in Britain, a third likely acquired the infection since their arrival in the UK - three times higher than previous estimates. The lead author of the study, Brian Rice, principal HIV scientist at the Health Protection Agency, says the new figures will have an impact on the understanding of prevention. "If you focus on heterosexuals, as we did, the majority are in African communities, and there are implications for prevention policy because it means that transmission in these communities is much higher than we thought."

He, too, welcomes the new policy. "It's important for prevention that everyone who needs treatment gets that treatment and gets it promptly; thankfully this change in the law helps that."

NAT investigated fears of 'health tourism', and its study concluded that the concerns were unfounded. It point out that, on average, migrants in Britain diagnosed as HIV-positive had already been in the country for five years.

When the change in the law allowing free treatment was introduced, British authorities promised what they called 'tough guidance' to prevent the abuse of the system. But Eleanor Briggs, of NAT, sees that as primarily a political gesture. "I think they just wanted to make clear their concerns around health tourism [being a problem], but there is lots of evidence to show that this is simply not the case."

Source

Interferon-Induced Depression in Chronic Hepatitis C: A Systematic Review and Meta-Analysis

Marc Udina, MD; Pere Castellví, PhD; José Moreno-España, MD; Ricard Navinés, MD, PhD; Manuel Valdés, MD, PhD; Xavier Forns, MD, PhD; Klaus Langohr, PhD; Ricard Solà, MD, PhD; Eduard Vieta, MD, PhD; and Rocío Martín-Santos, MD, PhD

J Clin Psychiatry 2012;73(8):1128–1138

10.4088/JCP.12r07694

Copyright 2012 Physicians Postgraduate Press, Inc

Objective: To carry out a systematic review of the risk factors for, and incidence of, major depressive episode (MDE) related to antiviral therapy for chronic hepatitis C.

Data Sources: The MEDLINE, PsycINFO, and Cochrane databases were searched to locate articles published from the earliest available online year until June 2011 using the keywords hepatitis C, interferon-alpha,peginterferon, pegylated interferon, depression, and mood and Boolean operators. Articles written in English, Spanish, and French were included.

Study Selection: Prospective studies reporting incidence of interferon-alpha–induced MDE were included. At baseline, patients did not present a DSM-IV/ICD depressive episode, and evaluation was performed by a trained clinician. Twenty-six observational studies met the inclusion criteria.

Data Extraction: Extracted data included authors, year of publication, design, characteristics of the population, viral coinfection, adjunctive psychopharmacology, instruments to assess depression, dose and type of interferon-alpha, adjunctive ribavirin treatment, and follow-up time. Outcome of incidence of MDE (primary outcome measure) was abstracted, as were potential predictive variables.

Data Synthesis: A full review was performed. Meta-analysis of the cumulative incidence of induced MDE as a function of time was carried out. Odds ratios (ORs) and mean differences were used to estimate the strength of association of variables.

Results: Overall cumulative incidence of depression was 0.25 (95% CI, 0.16 to 0.35) and 0.28 (95% CI, 0.17 to 0.42) at 24 and 48 weeks of treatment, respectively. According to our analysis, high baseline levels of interleukin 6 (mean difference=1.81; 95% CI, 1.09 to 2.52), female gender (OR=1.40; 95% CI, 1.02 to 1.91), history of MDE (OR=3.96; 95% CI, 2.52 to 6.21), history of psychiatric disorder (OR=3.18; 95% CI, 1.60 to 6.32), subthreshold depressive symptoms (mean difference=0.96; 95% CI, 0.31 to 1.61), and low educational level (mean difference=−0.99; 95% CI, –1.59 to −0.39) were predictive variables of MDE during antiviral treatment.

Conclusions: One in 4 chronic hepatitis C patients who start interferon and ribavirin treatment will develop an induced major depressive episode. Clinicians should attempt a full evaluation of patients before starting antiviral treatment in order to identify those at risk of developing interferon-induced depression.

J Clin Psychiatry 2012;73(8):1128–1138

© Copyright 2012 Physicians Postgraduate Press, Inc.

Submitted: February 2, 2012; accepted March 28, 2012 (doi:10.4088/JCP.12r07694).

Corresponding author: Rocío Martín-Santos, MD, PhD, Clinical Institute of Neuroscience, Hospital Clínic, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain, Villarroel, 170, 08036-Barcelona (rmsantos@clinic.ub.es).

Source

Treatment with Peg-IFNα2a/ribavirin and low-dose NSAID for patients with chronic hepatitis C and rheumatoid syndrome

Lilea GC,et al. Show all

Lilea GC, Streba CT, Vere CC, Rogoveanu I.

Journal

Eur J Gastroenterol Hepatol. 2012 Sep 24. [Epub ahead of print]

Affiliation

Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania.

Abstract

OBJECTIVE: To examine the safety and efficiency of using Peg-IFNα2a/ribavirin and low-dose NSAID therapy in patients with rheumatoid syndrome (RS) and chronic hepatitis C (CHC).

METHODS: A group of 10 patients (group 1) known to have RS and established CHC undergoing Peg-IFNα2a/ribavirin and low-dose NSAID therapy was compared with a control group of 10 patients (group 2) also with CHC and associated RS, with no antiviral treatment. Their charts were reviewed for serological and clinical signs of rheumatic disease evolution while undergoing this type of treatment.

RESULTS: At the end of a follow-up period of 12 months, patients receiving low-dose NSAID and Peg-IFNα2a/ribavirin therapy showed a sustained virusological response and also decreased levels of inflammation serological markers, with an improvement in the clinical rheumatic symptoms. In contrast, patients in group 2 showed no significant clinical modification in their rheumatic status.

CONCLUSION: Peg-IFNα2a/ribavirin and low-dose NSAID in patients with RS and CHC appear to be well tolerated and can be efficient for rheumatic manifestations. Further controlled studies are required to confirm the results.

PMID

23011037 [PubMed - as supplied by publisher]

Full text: Lippincott Williams & Wilkins

Source

Combinations of simple baseline variables accurately predict sustained virological response in patients with recurrent hepatitis C after liver transplantation

Crespo G,et al. Show all

Crespo G, Carrión JA, Coto-Llerena M, Mariño Z, Lens S, Pérez-Del-Pulgar S, García-Retortillo M, Miquel R, Bosch J, Navasa M, Forns X.

Journal

J Gastroenterol. 2012 Sep 26. [Epub ahead of print]

Affiliation

Liver Unit, Institut de Malalties Digestives, Hospital Clínic, CIBERehd, IDIBAPS, Villarroel 170, 08036, Barcelona, Spain.

Abstract

BACKGROUND: The efficacy of antiviral therapy in patients with hepatitis C recurrence after liver transplantation (LT) is far from optimal and a careful selection of candidates with the best chances to achieve sustained virological response (SVR) is relevant. Moreover, investigating the effects of sustained viral clearance on clinical outcomes is particularly significant. We aimed to identify and combine the best baseline predictors of SVR and to assess the clinical outcomes of antiviral therapy after LT.

METHODS: We studied 144 hepatitis C virus (HCV)-infected LT recipients who underwent antiviral therapy following transplantation. Baseline predictors of SVR including donor and recipient interleukin IL28B (IL28B) rs12979860 genotype were evaluated, and the long-term effects of antiviral therapy on clinical outcomes were assessed.

RESULTS: The presence of an IL28B CC genotype with either low viral load (VL), young donor age, or cyclosporine A (CsA)-based immunosuppression identified individuals with 69-80 % probabilities of SVR. In contrast, only 20 % of recipients with a CT/TT IL28B genotype and either high VL, old donor age, or non-CsA immunosuppression achieved an SVR (p = 0.004). Regarding clinical outcomes, the 5-year cumulative probability of graft loss was 2 % for the SVR patients and 48 % for non-responders (p < 0.001).

CONCLUSIONS: The use of simple combinations of baseline variables including IL28B polymorphisms identifies HCV-infected LT recipients with different probabilities of response to antiviral treatment. SVR is associated with improved clinical outcomes.

PMID

23011083 [PubMed - as supplied by publisher]

Full text: Springer

Source

HCV Treatment in Prison Could Be Key Public Health Measure

Last Updated: October 05, 2012

Incarcerated patients with hepatitis C virus infection are as likely to be treated and to achieve a sustained viral response as non-incarcerated patients, according to research published in the October issue of Hepatology.

FRIDAY, Oct. 5 (HealthDay News) -- Incarcerated patients with hepatitis C virus (HCV) infection are as likely to be treated and to achieve a sustained viral response (SVR) as non-incarcerated patients, according to research published in the October issue of Hepatology.

John P. Rice, M.D., of the University of Wisconsin School of Medicine and Public Health in Madison, and colleagues conducted a study involving 521 non-incarcerated and 388 incarcerated patients evaluated for HCV treatment at a single academic center from 2002 through 2007.

The researchers found that 61.2 percent of non-incarcerated and 60.3 percent of incarcerated patients underwent treatment with pegylated interferon and ribavirin. Patients who were incarcerated were more likely to be male, black, and have a history of alcohol or intravenous drug use; and those who were treated were less likely to have received previous treatment or to have genotype 1 virus. The prevalence of HIV co-infection was similar between the groups. An SVR was achieved in 42.9 and 38.0 percent of incarcerated and non-incarcerated patients, respectively (P = 0.304). Increased SVR was significantly associated with full treatment course, non-genotype 1 virus, younger age at start of treatment, and negative HIV status. Incarceration status was not a significant predictor of SVR.

"Anti-viral treatment of the HCV-infected incarcerated population is not only effective but can be as successful as HCV treatment in the general population," the authors write. "Given the scale of the prevalence of HCV infection in the incarcerated population, we suggest that anti-viral treatment while in prison is the optimal time for treatment to reverse a public health crisis."

One author disclosed financial ties to the pharmaceutical industry.

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Cleanse your liver in seven days

Onions and garlic help the liver detoxify.

Michele Chevalley Hedge

From: body and soul

October 06, 2012 6:00PM

NUTRITIONIST Michele Chevalley Hedge provides a day-by-day guide to liver cleansing

Monday
Spice things up. Turmeric helps protect the liver against toxic damage and can even regenerate damaged liver cells. Turmeric also boosts the production of bile and hepatic dusts, which is beneficial to those with gall bladder issues.

Tuesday
Go green. Green tea has antioxidant properties and is loaded with catechins, a type of antioxidant that helps eliminate fat accumulation and promote proper liver function. It also protects against toxins that can cause serious liver damage.

Wednesday
Befriend onions and garlic. Foods rich in sulphur-containing compounds are one of the primary types of molecules used to help the liver detoxify. Garlic contains allicin and selenium which help protect the liver from toxic overload.

Thursday
Try grapefruit. This fruit is rich in vitamin C and antioxidants which are excellent for cleansing the liver. One of the flavonoids in grapefruit, naringenin, contains a compound that causes the liver to burn fat rather than store it.

Friday
Sidestep alcohol and fructose. Both are very hard on the liver. Fructose is converted into fat that gets stored in your liver and other tissues. When consumed in excess this can lead to non-alcoholic fatty liver disease (NAFLD).

Saturday
Go nuts for walnuts. All nuts contain amino acids and essential fatty acids, but walnuts in particular are high in the amino acid L-arginine and antioxidant glutathione which can assist in detoxifying the liver and oxygenating
the blood.

Sunday
Eat. People sometimes think that cleansing the liver is best supported by strict detoxing or fasting, however the simple act of eating whole foods can clean up your liver. We need nutrients to support our body’s natural detoxification.

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What Is Cirrhosis?

October 6, 2012

I’ve heard a lot about liver cirrhosis. Can you tell me what it means, what causes it and what types of treatment are available?

— Stan, Hollister

Answered by Dr. Brian Berk, St. Luke’s Clinic, Gastroenterology:

Cirrhosis is a term used to describe advanced scarring of the liver. There are four stages of scarring. In stage 1, you are replacing single cells in the liver with scar. With stage 2, you are replacing several cells in a row with scar. In stage 3, you are creating bands of scarring that replace entire sheets of cells. Finally in stage 4, the bands of scarring interconnect and form nodules of scarring, which trap cells. The condition of cirrhosis interferes with the flow of blood through the liver, which leads to a decrease in normal liver functions and an increase in blood detouring around the liver.

Any chronic liver disease that inflames liver cells can progress into cirrhosis. The most common causes of cirrhosis are excessive long-term use of alcohol viral hepatitis (B and C), and NASH (a type of fatty liver disease). There are also a variety of inherited liver diseases, autoimmune liver diseases, medication-induced liver conditions and other causes.

Many times, you are not aware that you have liver disease until the organ is failing. You can maintain liver function with as little as 10 percent of the total number of functioning liver cells. Subtle symptoms that may indicate liver failure including pain in the upper right side of your abdomen, fatigue, muscle wasting, pain in muscles or joints, headaches, and nausea. The more visible symptoms include jaundice, confusion (dementia-like symptoms), ascites/edema (fluid accumulation in the abdomen and legs), and intestinal bleeding from engorged veins that line the esophagus or stomach. Cirrhosis can also lead to liver cancer that arises in the nodules of scar from chronic liver cell inflammation.

To determine if there is liver disease, blood tests and imaging (ultrasound or CAT scan) are done to determine the scope of the problem. If there is further concern, a liver biopsy can be performed to clarify the type of disease and stage of scarring. This procedure is performed with sedation to minimize discomfort. Once the underlying disease is confirmed, treatment options are available for most chronic liver diseases.

In terms of treatment for cirrhosis, management of the underlying disease can help slow down or reverse the damage. This is most notable with Hepatitis C and NASH. Routine blood testing and imaging are performed to monitor liver functions and watch for liver cancer. Routine endoscopic monitoring of the engorged veins that line the stomach and esophagus allows for the prevention of bleeding with medication and variceal ligation. There are also a variety of treatment options for the other complications of cirrhosis including liver cancer. In some cases, a liver transplantat may be a treatment option.

If you think you may have liver disease, the best course of action is to see your primary care physician and get blood tests that can detect liver disease. Your liver health will be determined by these tests. If liver disease is suspected, you will be referred to a specialist who will determine the cause of liver disease, stage of the condition and treatment options.

Disclaimer: The content of this article is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Do not stop or delay seeking treatment because of something you read in this article. Further, the views or opinions expressed in this article are for informational purposes only and do not necessarily represent those of St. Luke’s. Reliance on any information provided by St. Luke’s, St. Luke’s employees or others supplying information for the column at the invitation of St. Luke’s is solely at your own risk.

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Proton pump inhibitors increased infection rate in decompensated cirrhosis patients

Bajaj JS. Aliment Pharmacol Ther. 2012;doi:10.1111/apt.12045.

September 19, 2012

Veterans with decompensated cirrhosis who started proton pump inhibitor therapy after decompensation were more likely than nonusers to develop serious infections in a recent study.

Researchers evaluated data from 1,268 US veterans who began proton pump inhibitor (PPI) use for decompensated cirrhosis between 2001 and 2009, along with 1,268 matched controls who did not use PPI. A parallel analysis was conducted of patients using H2 receptor antagonists (H2RA) (n=199) and matched controls (n=199). Incidence of serious infections requiring hospitalization, including skin, lower respiratory, urinary and kidney infections, along with Clostridium difficile, infectious gastroenteritis, sepsis and bactremia, was recorded.

Serious infections occurred in 25.3% of PPI users, with an incidence rate of 675 per 1,000 person-years. No association was found between PPI use and serious infection incidence rate (crude propensity-matched HR=1.08; 95% CI, 0.90-1.31), but infections related to acid suppression tended to occur more frequently in this group than among nonusers (crude HR=1.22; 95% CI, 0.97-1.52). Potential confounders, including age, race/ethnicity and concomitant medication, were similarly distributed between the two groups, but PPI users were more likely to have five or more comorbidities (41.2% of patients vs. 32.1% of nonusers).

Accounting for time-varying PPI use, serious infections were found to develop more quickly among PPI users than nonusers (adjusted HR=1.66; 95% CI, 1.31-2.12). Serious infections related to acid suppression also developed more quickly among PPI users (adjusted HR=1.75; 95% CI, 1.32-2.34), and comprised a larger number of all infections (75%) than among nonusers (64%).

Among H2RA users, 25.9% experienced serious infections, with 17.7% of patients developing infections related to acid suppression. Adjusted HRs were 1.59 for serious infection (95% CI, 0.80-3.18) and 0.92 for infections related to acid suppression (95% CI, 0.31-2.73) compared with nonusers. Neither result was statistically significant.

“Veterans with decompensated cirrhosis who were started on PPI therapy after decompensation had a significantly higher risk of developing serious infections compared with those who were not initiated on gastric acid suppression,” the researchers concluded. “As patients with decompensated cirrhosis remain at a high risk of serious infections, clinicians should reevaluate the reason for prescribing PPI and, wherever possible, replace their acid suppressive needs with H2RAs.”

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Hepatitis C Is an Emerging Infection Among HIV-Infected MSM

During the past 13 years, the incidence of HCV infection among men who have sex with men increased 18-fold in the Swiss HIV Cohort Study.

Hepatitis C virus (HCV) infection is common among HIV-infected individuals, especially injection-drug users (IDUs) and hemophiliacs. However, during the past few years, HIV-infected men who have sex with men (MSM) have also been identified as a high-risk group for HCV infection (JW AIDS Clin Care Aug 8 2011). To assess changes in the incidence of HCV infection among these various risk groups, investigators looked at 13 years' worth of data (1998–2011) from the Swiss HIV Cohort Study. Study participants were screened for HCV infection at entry into the cohort and every 2 years thereafter.

At study enrollment, 3% of MSM, 92% of IDUs, and 11% of heterosexuals were already HCV positive. Of the 8709 study participants who were HCV negative at baseline, 6534 had follow-up HCV serology results and were included in this analysis; 51% were MSM, 2% IDUs, and 47% heterosexuals. During follow-up, 3% of MSM, 33% of IDUs, and 0.8% of heterosexuals experienced an HCV seroconversion. The incidence rate among MSM increased from 0.2 per 100 person-years in 1998 to 4.1 per 100 person-years in 2011, an 18-fold increase. In contrast, the incidence rate among IDUs decreased, from 13.9 to 2.2 per 100 person-years. Among MSM, inconsistent condom use and a past history of syphilis were significantly associated with HCV seroconversion.

Comment: HIV-infected MSM are at high risk for HCV coinfection and should be screened at entry into care. Those who are HCV negative should undergo liver function testing every 6 months and HCV antibody testing every year, as recommended by the European AIDS Treatment Network (JW AIDS Clin Care Feb 28 2011 and May 25 2012). Prompt recognition of HCV infection may allow patients to be treated during acute HCV infection, when response to therapy may be greater.

— Carlos del Rio, MD

Published in Journal Watch HIV/AIDS Clinical Care September 24, 2012

Citation(s):

Wandeler G et al. Hepatitis C virus infections in the Swiss HIV Cohort Study: A rapidly evolving epidemic. Clin Infect Dis 2012 Sep 12; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cis694)

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Retinopathy Is Common with Interferon Therapy for HCV Infection

Ophthalmologic screening is warranted in patients with hypertension.

Interferon-based therapy is currently the standard treatment for hepatitis C virus (HCV) infection and likely will be for the near future. Retinopathy has been associated with interferon therapy, but few studies have described its frequency or clinical significance.

In this prospective, longitudinal study, the occurrence of retinopathy was evaluated in 97 consecutive patients at a single center who received treatment for HCV infection with interferon and ribavirin for 48 weeks. All patients underwent extensive ophthalmologic examinations at baseline, 3 months, 6 months, and 3 months posttreatment. Retinopathy was defined as the presence of cotton wool spots, retinal hemorrhages, or microaneurysms.

During therapy, retinopathy occurred in 31% of patients, including nine (9.3%) with retinopathy at baseline. In univariate analysis, age, hypertension, preexisting intraocular lesions, metabolic syndrome, and cryoglobulinemia were associated with retinopathy. In multivariate analysis, only hypertension remained a significant risk factor (hazard ratio, 4.99; 95% confidence interval, 2.29–10.89). The frequency of retinopathy increased with successive ophthalmologic examinations and was consistently higher for patients with hypertension than for others, peaking at 68% and 19% respectively at the 6-month exam. Thirty percent of patients complained of visual disturbances. One patient (1.1% of the cohort) had persistent long-term vision loss and was discontinued from therapy at 6 months. This patient had baseline preexisting retinopathy.

Comment: This prospective study is one of the few to specifically address the issue of interferon-induced retinopathy. Approximately one third of patients developed or experienced worsening of baseline retinopathy during therapy. Moreover, patients with hypertension had a fivefold higher incidence of retinopathy than those without hypertension. Permanent visual problems developed in only one patient, who was hypertensive with baseline retinopathy. These findings support ophthalmologic examinations in patients with HCV infection and hypertension who are about to undergo interferon-based therapy.

— Atif Zaman, MD, MPH

Published in Journal Watch Gastroenterology September 14, 2012

Citation(s):

Vujosevic S et al. Pegylated interferon-associated retinopathy is frequent in hepatitis C virus patients with hypertension and justifies ophthalmologic screening. Hepatology 2012 Aug; 56:455.

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OraQuick® In-home HIV Test- How-to Video

Uploaded to YouTube by OraSure on Sep 12, 2012

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Also See: Home Test for H.I.V. As a Screen of Partners