Margaret E. Hellard

Description:Background: Successful treatment of hepatitis C virus (HCV) can lead to liver fibrosis regression. It is not known who will experience fibrosis regression or how quickly it will occur. Methods: We modeled transient elastography (TE) measurements from 1470 HIV-HCV coinfected participants followed in cohorts contributing data to InCHEHC, an international collaboration. Participants were eligible if they had at least 1 TE measurement in the year before starting a successful direct-acting antiviral treatment for HCV. This measurement was used to classify participants into 1 of 3 fibrosis subgroups. We analyzed measurement sequences in each subgroup using a covariate-adjusted generalized additive mixed model, with an adaptive spline representing changes in the mean measurement before, during, and after treatment. Results: Each fibrosis subgroup had a distinctly different response. Most participants with cirrhosis (F4, TE ≥14.6 KPa) before HCV treatment did not show meaningful fibrosis regression-approximately 70% were predicted to remain >12 KPa 3 years after treatment ended. Participants with significant fibrosis (F2-F3, TE ≥7.2 and <14.6 KPa) showed appreciable regression in the first 2 years after treatment, falling on average to levels <7.2 KPa. Those without fibrosis before treatment (F0-F1) did not progress. Conclusions: Most coinfected people with cirrhosis before HCV cure will remain cirrhotic. For those with significant fibrosis, regression can be expected within 2 years to levels not normally associated with an increased risk of end-stage liver disease. A TE measurement 2 years after cure should give a reliable estimate of residual fibrosis.

Description:Hepatitis B virus vaccination is currently recommended in Australia for adults at an increased risk of acquiring infection or at high risk of complications from infection. This retrospective cohort study used data from an Australian sentinel surveillance system to assess the proportion of individuals who had a recorded test that indicated being susceptible to hepatitis B infection in six priority populations, as well as the proportion who were then subsequently vaccinated within six months of being identified as susceptible. Priority populations included in this analysis were people born overseas in a hepatitis B endemic country, people living with HIV, people with a recent hepatitis C infection, gay, bisexual and other men who have sex with men, people who have ever injected drugs, and sex workers. Results of the study found that in the overall cohort of 43,335 individuals, 14,140 (33%) were identified as susceptible to hepatitis B, and 5,255 (37%) were subsequently vaccinated. Between 26% and 33% of individuals from priority populations were identified as susceptible to hepatitis B infection, and the proportion of these subsequently vaccinated within six months was between 28% and 42% across the groups. These findings suggest further efforts are needed to increase the identification and subsequent vaccination of susceptible individuals among priority populations recommended for hepatitis B vaccination, including among people who are already engaged in hepatitis B care.

Description:Background: Long-acting injectable buprenorphine (LAIB) reduces the frequency of contact with opioid agonist therapy (OAT) service providers. Limited data exist on OAT prescribing in Australia after the introduction of subsidised LAIB prescribing in September 2019. This ecological study describes trends in OAT prescribing between 2015 and 2023 across a network of primary care services in Victoria, Australia. Methods: We utilised electronic medical records from 17 clinics in Victoria that provide services to people with opioid dependence to describe OAT prescribing patterns. We described the annual number and type (methadone, buprenorphine, LAIB) of OAT prescriptions issued, individuals prescribed, and individuals initiating OAT. Interrupted time series assessed changes in quarterly OAT prescribing following the introduction of LAIB. Results: Between 2015 and 2023, the average annual number of OAT prescriptions issued, and the average number of recipients prescribed OAT were 47,648 and 6470, respectively. Between 2020 and 2023, the proportion of individuals initiating on LAIB increased from 7% (73/1078) to 31% (357/1146). There was increasing quarterly OAT prescribing before the introduction of LAIB, after which methadone and buprenorphine prescribing declined by 2.6% (CR 0.974; 95% CI 0.968-0.980) and 3.2% (CR 0.968; 95% CI 0.963-0.973), respectively. After being introduced, quarterly LAIB prescribing increased by 13.1% (CR 1.131; 95% CI 1.096-1.167). Conclusions: We found substantial changes in OAT prescribing patterns in Victoria between 2015 and 2023, with shifts away from oral methadone and sublingual buprenorphine to LAIB. Alongside ongoing monitoring of prescribing patterns, future research should assess how LAIB impacts patient health and social outcomes.

Description:The hospital-led interventions yielding the best hepatitis C virus (HCV) testing and treatment uptake are poorly understood. We searched Medline, Embase, and Cochrane databases for studies assessing outcomes of hospital-led interventions for HCV antibody or RNA testing uptake, linkage to care, or direct-acting antiviral commencement compared with usual care, a historical comparator, or control group. We systematically reviewed hospital-led interventions delivered in inpatient units, outpatient clinics, or emergency departments. Random-effects meta-analysis estimated pooled odds ratios [pORs] measuring associations between interventions and outcomes. Subgroup analyses explored outcomes by intervention type. A total of 7872 abstracts were screened with 23 studies included. Twelve studies (222 868 participants) reported antibody testing uptake, 5 (n = 4987) reported RNA testing uptake, 7 (n = 3185) reported linkage to care, and 4 (n = 1344) reported treatment commencement. Hospital-led interventions were associated with increased antibody testing uptake (pOR, 5.83 [95% confidence interval {CI}, 2.49-13.61]; I 2 = 99.9%), RNA testing uptake (pOR, 10.65 [95% CI, 1.70-66.50]; I 2 = 97.9%), and linkage to care (pOR, 1.75 [95% CI, 1.10-2.79]; I 2 = 79.9%) when data were pooled and assessed against comparators. Automated opt-out testing (5 studies: pOR, 16.13 [95% CI, 3.35-77.66]), reflex RNA testing (4 studies: pOR, 25.04 [95% CI, 3.63-172.7]), and care coordination and financial incentives (4 studies: pOR, 2.73 [95% CI, 1.85-4.03]) showed the greatest increases in antibody and RNA testing uptake and linkage to care, respectively. No intervention increased uptake at all care cascade steps. Automated antibody and reflex RNA testing increase HCV testing uptake in hospitals but have limited impact on linkage to treatment. Other interventions promoting linkage must be explored.

Description:Background: People prescribed opioid agonist therapy (OAT) are a key population for hepatitis C virus (HCV) elimination. Health service engagement associated with OAT provision may facilitate hepatitis C testing and treatment. We aim to quantify the HCV care cascade among people receiving OAT in Australia. Methods: We extracted linked data from individuals attending any of 58 clinics participating in the ACCESS national sentinel surveillance network of primary care and sexual health clinics from 01-January-2016 to 31-December-2023. Outcomes included evidence of any HCV test (antibody or RNA) or direct-acting antiviral (DAA) prescription at an ACCESS clinic after their first OAT prescription. RNA positive individuals were inferred antibody positive; individuals with a DAA prescription were inferred RNA and antibody positive. We determined the number of individuals at each stage of the following cascade by the end of the study period: (1) positive antibody, (2) positive RNA, and (3) DAA prescription. Results: Among 15,382 individuals prescribed OAT, 44% (6817/15382) had an HCV antibody or RNA test after their first OAT prescription. Of these, 64% (4368/6817) were antibody positive by the end of the study period. Of these, 67% (2911/4368) were RNA positive, and of those, 69% (2,007/2911) were prescribed DAAs. Conclusions: A high proportion of people prescribed OAT were not engaged in care by their OAT provider or across ACCESS network clinics, but when diagnosed, rates of treatment were high. Given high HCV antibody and RNA prevalence, integrating HCV care into regular OAT care should be a priority for HCV elimination in Australia.