Hepatitis C is an important global public health problem, disproportionally affecting HIV positive populations. Worldwide 5 to 15% of HIV patients are infected with hepatitis C virus (HCV), about half live in countries with limited resources for health. Chronic hepatitis C (CHC) can cause severe liver damage, cirrhosis, cancer and premature death. The course of the disease is more severe in people living with HIV, and if left untreated impacting negatively the life-expectancy gains of successful antiretroviral therapy (ART). Hepatitis C can be treated and cured, also in HIV patients, but access to hepatitis C care is still very limited, especially in resource-limited settings (RLS). The complexity, cost and low success rate of the treatment, as well as the long list of laboratory tests and examinations to decide whether a patient needs treatment have been the main disincentives for scale up beyond resource-rich countries. Very recently, more potent (90% cure rate), shorter (12-24 weeks) and tolerable HCV-directed treatment (DAAs = direct-acting antivirals) regimens have become available. Because of the favourable side effects profile and the high efficacy, most patients will qualify for treatment and it is anticipated that patients can be seen by non-specialists. However, cost is still a major issue, and disease staging will remain an important criterion for prioritisation of treatment, especially in RLS. Global advocacy initiatives are increasing pressure to achieve special pricing arrangements for low income countries. Lowering the price of treatment alone will not suffice though. The diagnostic cascade from ‘Screen to Cure’ remains complex. Confirming active infection and determination of staging of liver disease require high-tech tools (molecular testing, transient elastography) currently not widely available. As for staging of liver disease, alternatives (scores and indices based on readily available tests, as APRI, Fib-4) have been developed in the past, but uncertainties remain in terms of their applicability in co-infected populations and their potential for monitoring progression of liver disease remained unexplored. Many parallels can be drawn with the feasibility issues surrounding HIV treatment in RLS in the early years 2000. HIV testing strategies had to be developed including rapid HIV tests. Immunological or clinical staging of HIV disease was used to prioritize treatment to the ones most in need. Well-documented pilot treatment projects, showing that ART could be safely and effectively administered in low-resource contexts, have been instrumental to curb the initial hesitation and have informed the current ART “public health approach”. We propose to set up a pilot HCV/HIV screen, diagnosis & treatment project in Cambodia, and to derive from this project innovative feasible strategies to roll-out this experience. Besides documenting the burden of HCV in HIV patients in Cambodia, patients with severe fibrosis will be treated according to the new WHO guidelines. We will demonstrate the effectiveness and the feasibility of the newly available treatment regimens for HCV in this setting. The above generated data will be used to develop clinical prediction rules to identify the patients with an active HCV infection, and to predict the severity of the liver disease. We hypothesize that we will be able to ‘bypass’ to a large extent the main bottlenecks (molecular testing and transient elastography) in the hepatitis C diagnostic cascade. The research will be completed with cost analyses comparing the different diagnostic strategies. This hepatitis C diagnosis and treatment project will generate awareness of the HIV/HCV co-infection burden in LRS, and provide prime data on the use of DAAs in LRS. The development of simple clinical decision tools to diagnose active hepatitis C and to determine the disease stage will facilitate the public health approach to HCV care in LRS.
|Effective start/end date||1/07/14 → 31/12/19|
- Flemish Government - Department of Economy, Science & Innovation: €592,571.37