英國的報告敦促重新考慮C型肝炎的再感染

資料來源：Keith Alcorn / 15 April 2022 / aidsmap news / 財團法人台灣紅絲帶基金會編譯

圖：伯明翰的針具交換/納洛酮供應 / nigelbrunsdon.com

C型肝炎信託基金及HCV 行動的一份報告結論道，在英國由於缺乏對C型肝炎治癒者在「減害」需求上的關注，以及缺乏對再感染的檢驗和監測，使得消除C型肝炎的進展受到了破壞。

該報告建議，需要更加重視再感染的檢測，以實現消除C型肝炎的目標，同時針對已完成一個療程的患者並應改進相關的預防措施。

『重新定義再感染：在英國實現永續的C型肝炎消除』係由C型肝炎感染者的全國家同儕支持組織「C型肝炎信託基金」和C型肝炎專業社區的聲音「C肝病毒行動 ( HCV Action) 」 所發表。報告中C型肝炎信託基金和 HCV 行動的研究人員，採訪了執行提供網絡的工作人員、提供同儕支持服務的人員以及最近接受C型肝炎治療者等人員，以深入了解服務的提供和其中未滿足的需求。

該報告強調了有關再感染率上零散不整的證據。儘管英國國家衛生安全局估計，英國有近 11% 的吸毒者可能在C型肝炎治癒後再次感染，但真實的再次感染之程度仍不清楚。報告之作者獲悉，某些地區在治癒兩年內所觀察到的比率高達 19%。

接受該報告採訪的幾位專業人士強調，檢測到再感染顯示資源正有效地用於篩查感染C型肝炎風險較高的人，並重新讓他們再接受治療。

鄧迪地區之泰賽德大學的約翰.狄龍教授對該報告的作者說：「如果你沒有看到再次感染，就表示你就沒有進行足夠的檢測，沒有治療到合適的病人」。「再感染是邁向疾病的消除中絕對會預期到的事件」。

受訪者強調，再感染不應成為拒絕或延遲治療的理由。

「我認為獲得再治療對那個群體來說非常重要，因為他們特別容易感染C型肝炎，因此也可能傳染給其他人，因此治療他們具有網絡效應」，倫敦的莫蒂默市場中心的 Stuart Flanagan 醫師告訴該報告之作者。

該報告建議應更加注重提供減害服務，特別是針頭和注射針具交換計畫，為藥愛行為制定減害以及提供注射設施和納洛酮以防止監獄出監時之藥物過量。應探索提供無菌注射設施的創新方法，包括自動販賣機、郵政投遞和提供藥物過量預防中心，以支持早期進入藥物和肝炎服務中。

還需要在C型肝炎治療期間和治療後提供減害模式，特別是支持減少注射、獲得無菌注射設備和參與鴉片類藥物之替代治療。

該報告還強調需要更多地利用C型肝炎治療所帶來的機會來滿足C型肝炎患者在治療期間和治療完成後的其他需求，例如住房和心理健康。六個月的預治療和治療期是向人們宣導再感染風險和減害措施的重要機會，以確保他們獲得適當的支持，並最大程度地減少完成治療後的再感染風險。

報告指出，確保在治療後為有再感染風險的人提供定期檢驗至關重要。

NHS信託基金會的紐卡斯爾醫院之 Stuart McPherson 醫師問道：「如果我們知道有十分之一的人再次感染，那麼我們不知道的則還有多少人呢？」， 「這是一個標誌，顯示對地區疾病的消除上我們比我們想像的還更遠離」。

在接受更頻繁檢測的人中，例如還押候審或在監的人，可能更容易發現再感染。但由於缺乏與服務機構的聯繫或未能為自認為已治癒C型肝炎的人提供檢測，可能會完全錯過其他人。

除了檢驗之外，還必須改進對再感染的監測，以便準確掌握全國再感染率之全景和再感染風險較高的人群，並調整修正當地的服務。

參考文獻：

C型肝炎信託與C肝病毒行動。重新定義再感染：在英國實現永續的C型肝炎消除。 

UK report urges re-think on hepatitis C reinfection

資料來源：Keith Alcorn / 15 April 2022 / aidsmap news / 財團法人台灣紅絲帶基金會編譯

Needle exchange/naloxone supply in Birmingham. Nigel Brunsdon/nigelbrunsdon.com

Progress towards the elimination of hepatitis C is being undermined by a lack of attention to the harm reduction needs of people cured of hepatitis C in the United Kingdom, as well as a lack of testing and surveillance for reinfection, a report by the Hepatitis C Trust and HCV Action concludes.

The report recommends that more attention needs to be paid to detecting reinfection in order to achieve hepatitis C elimination targets, as well as improving prevention measures for those who have completed a course of treatment.

Reframing reinfection: towards sustainable hepatitis C elimination in the UK was published by the Hepatitis C Trust, the national peer support organisation for people with hepatitis C, and HCV Action, the voice of the hepatitis C professional community. The Hepatitis C Trust and HCV Action researchers interviewed Operational Delivery Network staff, people providing peer support services and people recently treated for hepatitis C, to gain insights into service provision and unmet needs.

The report highlights the patchy evidence regarding reinfection rates. Although the National Health Security Agency has estimated that almost 11% of people who use drugs in England may have been reinfected after being cured of hepatitis C, the true extent of reinfection is unclear. Some areas have observed rates as high as 19% within two years of cure, the report authors learned.

Several professionals interviewed for the report stressed that detecting reinfection is a sign that resources are being used effectively to screen people at higher risk of hepatitis C infection and re-engage them in care.

“If you are not seeing reinfections, you are not testing enough, you are not treating the right people,” Professor John Dillon of Tayside University, Dundee, told the report’s authors. “Reinfection is an absolute expected event in a move towards elimination.”

Reinfection should not be used as a reason to deny or delay treatment, interviewees stressed.

“I think that access to re-treatment is really important for that group because they are at particular risk of hepatitis C transmission and therefore potentially may be transmitting to others as well, so treating them has a network effect,” Dr Stuart Flanagan of London’s Mortimer Market Centre told the report authors.

The report recommends a greater focus on the provision of harm reduction services, especially needle and syringe programmes, bespoke harm reduction for chemsex and provision of injecting equipment and naloxone for overdose prevention at prison exit. Innovative ways of providing sterile injecting equipment should be explored, including vending machines, postal delivery, and provision of overdose prevention centres to support early engagement with drugs and hepatitis services.

Models for the delivery of harm reduction during and after hepatitis C treatment are also needed, especially support to reduce injecting, obtain sterile injecting equipment, and engage in opioid substitution treatment.

The report also emphasises the need to make more of the opportunity that hepatitis C treatment brings for addressing other needs of people with hepatitis C, such as housing and mental health, during and after the completion of treatment. The six-month pre-treatment and treatment period is an important opportunity to educate people about reinfection risks and harm reduction measures and ensure that they have the support in place to minimise the risk of reinfection after completing treatment.

Ensuring that regular testing is offered after treatment for people at ongoing risk of reinfection will be critical, the report notes.

“If one in ten people are reinfecting, that we know about, then how many others do we not know about?”, asked Dr Stuart McPherson of Newcastle Hospitals NHS Foundation Trust. “It’s a marker that we are further away from elimination in our region than we maybe think we are.”

Reinfections may be identified more readily in people subject to more frequent testing, such as people on remand or in prison. But others may be missed entirely due to lack of contact with services or a failure to offer testing to people who consider themselves cured of hepatitis C.

Along with testing, surveillance for reinfection must improve, in order to establish an accurate national picture of reinfection rates and who is at greater risk of reinfection and to tailor local services.

References

Hepatitis C Trust & HCV Action. Reframing reinfection: towards sustainable hepatitis C elimination in the UK. (View pdf here).