Rachel Lutz

 is a challenge, even when participation rates are high among innovative testing and care centers such as the use of dried blood spot testing (DBS), according to a 

Investigators from Spain conducted a retrospective study in 2 phases in order to determine the barriers to diagnosis and treatment among people with hepatitis C virus. The study authors wrote that people who attend drug treatment centers have a high burden of hepatitis C, and this population faces barriers to both diagnosis and treatment. One proposed way to simplify diagnosis is DBS testing, but regardless, patients remain untreated.

 that evaluated DBS testing for hepatitis B, C, and HIV diagnosis described the test as a blood sampling test that can be performed outside of care facilities. The test involves a capillary puncture that is transferred and dried on a paper card which is then transported by mail in a simple and safe way. The World Health Organization recommends this method, they said, as it can be instrumental in reaching hard-to-reach populations and those living in low-income settings.

For the first phase, the study authors analyzed retention in care, adherence to treatment, and predictive factors in the DBS testing program. These findings among patients treated at the drug treatment centers were compared to a group of patients treated at the hospital outpatient clinic.

Of the 512 patients attending drug treatment centers, 467 agreed to be tested for hepatitis C, the study authors reported. From that group, 237 patients tested positive, the investigators added, noting that the mean age was 46 years and the group was majority male (87%).

Once the study authors determined which patients tested negative for RNA or were under surveillance, a total of 178 were scheduled to meet with a specialist. Of that group, 44 patients did not attend. Furthermore, 25 patients did not complete the pre-treatment evaluation and the only factor that was associated with retention in care was the patient’s knowledge of hepatitis C infection.

Patients attending the drug treatment centers had lower rates of treatment adherence compared to the hospital outpatient clinic group (68 patients vs. 135 patients, respectively).

The next phase of the study was centered on evaluating patients who were lost to follow-up from drug treatment centers and trying to determine the efficacy of one-step testing and telemedicine plus a decentralized dispensation of hepatitis C medication compared to standard of care.

There were 69 patients who attended the drug treatment centers but were lost to follow-up. The proportion of the patients who completed the program (about two-thirds) was significantly higher among those assisted by telemedicine than by standard of care (about 25%).

“Although there was a high participation rate in a DBS testing program in drug treatment centers, non-retention in care is a challenge,” the study authors concluded. “Importantly, telemedicine linked to a decentralized dispensation of hepatitis C treatment re-engages patients and may be effective for hepatitis C micro-elimination.”

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The study authors said that decentralizing dispensation of hepatitis C treatment re-engages patients. 

Can Dried Blood Spot Testing Increase Retention in Care for Hepatitis C?

Research has identified 3 main prongs for low medication adherence among hepatitis C patients, including low awareness of the importance of adherence, according to a 

Journal of Primary Care & Community Health

Investigators from Cairo retrospectively analyzed the health data for 496 hepatitis C patients in order to assess adherence rates and reasons for noncompliance in patients with hepatitis C who receive interferon-free treatment regimens. The investigators noted the records were completed between August 2014 and October 2019 and they then categorized the patients into 2 groups: adherent (432 patients) and non-adherence (64 patients).

Adherence was assessed by follow up phone calls, and defined as taking all prescribed medications. Many methods to assess medication adherence have been developed, including patient self-reporting, but it is not always accurate. It remains the most common assessment tool for adherence in Egyptian health care, though.

It is a known factor that there is poor adherence among hepatitis C patients using interferon-based therapies, the study authors said, but that direct-acting antivirals (DAAs) are orally administered and have higher efficacy against hepatitis C. The adherence to DAAs is expected to improve, they said, and evaluating this adherence is crucial to assessing the ability of achieving hepatitis elimination.

The study authors noted there were no statistical differences between the groups regarding gender, service availability, treatment history, treatment type, treatment duration, liver function tests, or liver imaging. They did find that the non-adherent group had a significantly higher BMI when compared to the adherent group.

The patients in the adherent group achieved 100 percent sustained virologic response (SVR) after 12 weeks.

Through asking patients in follow-up phone calls why they did not adhere to their medication regimen, the study authors organized the most common reasons, including the following:

Low awareness (44%). The study authors said that educational interventions diagnosed with hepatitis C are important to increasing the adherence rate for the treatment, and that type of medication and how it is administered can also be barriers to adherence. Awareness should be a cooperative, multidisciplinary effort that involves the hepatologist, family physician, and psychiatrist.

Unaffordable cost of follow-up labs (17%), especially for those who missed the date for free follow-up tests. Egyptian programs dispense medications for free which can boost adherence. The patient pays this cost if they miss the free scheduled lab investigators, however. The study authors also noted that other investigations have determined that the use of specialized hepatitis clinics compared to general hepatology centers can raise adherence rates.

All of these factors require proper evaluation and management, the study authors said. They said that the mean age of the non-adherence group was not significantly higher than the adherent group in their study but noted physical and cognitive dysfunction is considered the main factor for non-adherence in elderly patients.

The investigators also identified 3 mortality cases that they determined were not related to medication, they said.

“Overall, DAAs showed high efficacy, tolerability, and better adherence profile versus Interferon-based therapies in the Egyptian hepatitis C patients,” the study authors concluded. “Low awareness was the main cause of non-adherence in patients receiving DAAs. Raising awareness is mandatory for proper treatment adherence and, subsequently, good clinical outcomes.”

Raising awareness about proper treatment adherence is one method of working toward eliminating hepatitis C.

Barriers to Hepatitis C Medication Adherence

For hepatocellular carcinoma (HCC) patients, sCD163 may not be a reliable diagnostic marker but it can predict tumor response to locoregional therapies, according to a paper published in 

Investigators from Cairo conducted a study of 40 adult patients in order to determine the role of sCD163 in patients with HCC in addition to 

-related liver cirrhosis. HCC typically stems from chronically inflamed liver tissues, and the majority of patients having hepatitis B, hepatitis C, cirrhosis, high alcohol consumption, obesity, genetic disorders, or contaminated foods.

Hemoglobin-haptoglobin scavenger receptor CD163 and its soluble form, sCD163, the study authors explained, is a promising biomarker of macrophage activation because it is shed from the cell surface into circulation. Eventually, macrophages could be a therapeutic target for HCC, as well.

The patients, all who had hepatitis C-related liver cirrhosis and HCC (called the HCC group), were randomly selected and then subjected to locoregional therapies, either transarterial chemoembolization (TACE) or radiofrequency ablation (RFA). An additional 20 patients with liver cirrhosis only were included in the analysis to serve as controls (LC group). All of the patients were also subject to routine lab tests and abdominal ultrasound.

The HCC patients had a mean age of 57 years, with 28 being male (70%). In the LC group, had a mean age of 54 years and 12 were male (60%).

The investigators measured alpha-fetoprotein (AFP) and sCD163 at baseline and after 1-month post-intervention. They learned that at baseline, sCD163 had a higher value in the HCC group though noted that it was insignificant. The median AFP value was much higher in the HCC group compared to the LC group.

After discovery of portal vein invasion in 4 HCC patients, they were excluded from logoregional therapy, but no patients in the LC group had PVT, the study authors said. sCD163 was significantly higher in cases with PVT, the study authors added, but AFP showed no difference in terms of PVT. This is aligned with previous studies, the investigators noted, but they also said they discovered a study that contradicted their association between sCD163 and vascular invasion.

Both sCD163 and AFP were statistically significant markers for estimating diagnostic efficacy, the study authors learned after analysis.

The investigators also compared sCD163 and AFP in both recurrent and eradicated HCC cases before and after intervention, they said. sCD163 showed a significant decrease in the eradicated cases and a significant increase in the recurrent cases. There was also a significant difference in pre-intervention mean sCD163 values between recurrent and eradicated HCC cases, the investigators added.

The study authors called age of patients, Child-Pugh score, s. albumin, and number and size of HCC focal lesions the most relevant demographic, clinical and biochemical data found in recurrent and eradicated HCC cases.

“It is concluded from this study that sCD163 has no reliable role as a diagnostic marker for HCC, yet it has a good prognostic role in predicting the tumor response to locoregional therapies as it showed a significant decline in eradicated cases of HCC after treatment,” the study authors concluded.

“[sCD163] showed a significant decline in eradicated cases of HCC after treatment,” the study authors wrote. 

Prognostic Biomarker after Therapy for HCC 

Despite changes that have been made during the coronavirus pandemic to manage acute severe 

, there seems to be low risk for COVID-19 infection post-hospitalization or severe COVID-19 for these patients, according to a 

Investigators from the UK conducted an observational case-control study across 60 acute secondary care hospitals in order to identify changes to care for severe ulcerative colitis during the ongoing COVID-19 pandemic and the effect on outcomes. The team wanted to determine the proportion of patients with severe disease who received rescue therapy or colectomy.

The 782 adult patients involved in the analysis presented either with ulcerative colitis or inflammatory bowel disease. There were 398 patients seen in the pre-pandemic period, defined as January-June 2019, and 384 patients seen in the pandemic period, defined as March-June 2020.

At baseline, the study authors described the 2 cohorts’ demographics and disease characteristics as similar. At the time of presentation with severe ulcerative colitis, a higher proportion of patients in the pandemic period were receiving oral steroids, rectal steroids, and biological or small molecule therapies compared to the historical, comparison cohort.

The median duration of oral steroids before meeting acute criteria was longer for the pandemic cohort compared to the statistical cohort, the investigators also learned (14 days vs. 13.5 days, respectively). The investigators wrote that there was no difference in the use of oral or topical mesalazines or thiopurines between the 2 cohorts, nor was there a difference among oral steroid users between the groups, such as prednisolone or poorly bioavailable steroid.

The 2 cohorts had no observable differences at days 1, 3, or 5 in terms of markers of acute severe ulcerative colitis severity, except for serum albumin levels, which were lower in the pandemic cohort. This group also demonstrated a higher proportion of patients who were managed initially on an ambulatory pathway compared to the historical group, but 84% of the ambulatory patients required inpatient admission compared to 95% of ambulatory patients during the historical cohort. The study authors found that patients were less likely to present emergently to the emergency room in the pandemic period compared to the historical cohort.

Rescue therapy was more common during the pandemic period compared to the historical group, primarily caused by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the pandemic group compared to the comparison group. The researchers also noted that there was no difference in the requirement for emergency surgery between the cohorts.

During the pandemic, rescue therapy or surgery happened at a higher rate and more quickly compared to the historical group. Additionally, time to rescue therapy or surgery was shorter in the pandemic, but overall response to rescue therapy was similar between the groups. There was also no difference in time to surgery between groups.

After 3 months, there was no observed difference between the proportion of patients in symptomatic, biochemical, or endoscopic remission, the study authors wrote based on follow-up data available for 697 total patients. There were also no serious COVID-19 outcomes.

“Although there have been some adaptations to conventional management of patients during the pandemic… these did not lead to different acute severe ulcerative colitis outcomes for patients,” the study authors concluded. “Use of cornerstone medications, such as high-dose intravenous steroids and biologicals, in acute severe ulcerative colitis appears to pose a low risk of nosocomial and post-discharge acquisition of SARS-CoV-2 and of developing severe COVID-19.”

Changes have been made to managing acute severe ulcerative colitis during COVID-19, including intravenous steroids, rescue therapy, and surgical approaches. 