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Senior Staff Physician
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich
University of Zurich
Dominique Laurent Braun, MD, has received consulting fees from AbbVie, Gilead Sciences, Merck, and ViiV.
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In May 2016, the World Health Organization (WHO) adopted the first global health sector strategy on viral hepatitis, a strategy aiming for elimination of viral hepatitis as a public health threat by 2030. This WHO call for action is a response to the ongoing epidemic of HCV; it is estimated that there are more than 1.5 million new HCV infections per year globally.
To reach this overarching elimination goal, microelimination interventions are proposed that focus on elimination in specific target populations with a high HCV prevalence and incidence. People with HIV form one such target population. An estimated 2.3 million HIV-positive people are coinfected with HCV. In addition, a particularly high incidence of HCV infection has been reported in HIV-positive MSM. For example, in the Swiss HIV Cohort Study, incident HCV infections in MSM increased 18-fold in the 13 years to 2011, whereas the incidence rate dropped in people who inject drugs and remained stable in heterosexual people.
Swiss HCVree Trial: A Model to Reach HCV Elimination Goals
The Swiss HCVree Trial, an HCV microelimination program targeting HIV-positive MSM in Switzerland, was conducted from 2015-2017. The aim of this study was to test whether WHO HCV elimination targets are achievable in clinical practice among HIV-positive MSM.
After a first HCV RNA–based screening phase from October 2015 to June 2016, all participants with replicating HCV infection were offered treatment with direct-acting antivirals. This treatment phase was accompanied by a behavioral intervention focused on HCV risk reduction. In brief, the authors adapted an evidence-based counseling intervention to improve self-regulation of risks associated with specific sexual behaviors and sexualized drug use, and implemented in parallel with HCV treatment. The trial finished with an HCV RNA–based rescreening from March until November 2017.
This HCV microelimination trial combining screening, treatment, and behavioral intervention resulted in a 57% decrease in incident HCV infections and 84% decrease in HCV prevalence within 2 years. Similarly, there was a 77% decline in the HCV incidence rate. The overall prevalence of replicating HCV infections dropped from 4.3% before the intervention to 0.4% after the intervention.
Of importance, one third of patients with an incident HCV infection had a negative HCV antibody test at the time of screening despite HCV replication. This reflects the fact that HCV antibodies can be negative during acute HCV infection due to the 4- to 10-week “window period’’ from the time of HCV exposure.
In a multivariate model, elevated liver enzymes, unprotected sex with occasional partners, intravenous drug use, noninjectable drug use, and previous syphilis were each associated with HCV RNA positivity.
What Have We Learned From the Swiss HCVree Trial?
The results from the Swiss HCVree Trial have several important implications for reaching the WHO target of a 90% reduction in new HCV cases by 2030 and could serve as a model for countries aiming at eliminating HCV among HIV-positive MSM.
First, HCV RNA–based screening should be considered in sexually active MSM at risk of HCV infection because delayed diagnosis and therapy substantially increase the time individuals spend with replicating HCV infection and, therefore, increase the risk of transmitting HCV to others. Second, to identify HCV reinfection, polymerase chain reaction–based screening should be performed in patients with successfully treated or self-cleared HCV infections. Third, unrestricted access to HCV treatment is crucial to follow the principles of treatment as prevention. Finally, counseling should be used to promote safer sex practices in HIV-positive MSM, as suppressive antiretroviral therapy does not provide protection from HCV and other sexually transmitted infections.
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