英國HIV協會會議獲悉，英國HIV 感染者中有80% 的C型肝炎感染率下降
資料來源：Gus Cairns / 2023 年 4 月 25 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
James Lester 博士在 BHIVA 2023 上發表演講。攝影：Roger Pebody。
2018 年，英國愛滋病毒協會 (BHIVA) 宣布了一個雄心勃勃的目標：到 2021 年 4 月，消除合併感染愛滋病毒的慢性C型肝炎感染。
BHIVA在蓋茨黑德舉行的春季會議上說，目標尚未實現。 但是，儘管在 COVID-19 大流行期間檢測中斷，但英格蘭同時感染C型肝炎病毒 (HCV) 的 HIV 感染者人數減少了 79%。 這意味著至少在 HIV/HCV 合併感染人群中，NHS England 已經超越過了世界衛生組織設定的到 2030 年將慢性感染減少 72%（診斷為 90%，治療為 80%）的全球目標。
這是透過「微量消除」運動實現的； 該術語表示集中努力消除特定群體或人口中的感染，而不是或先於整個人口。
這些群體可能是盛行率最高的人群，或者遭受最嚴重臨床後果的人群，或者最容易成為消除計畫目標的人群。 所有這些都適用於合併感染者：從歷史上看，HIV 感染者的 HCV 流行率是普通人群的 20 倍； 愛滋病毒控制不佳的人更有可能遭受嚴重的臨床後果，如肝癌； 參加 HIV 照護的人通常會接受C型肝炎檢測。
這項由英國衛生安全局的詹姆斯萊斯特博士提出的研究比較了自 2015 年 3 月開始，當時英國國家健康與臨床卓越研究所 (NICE) 首次開始推薦對HCV直接作用的抗病毒藥物 (DAA) 之聯合用藥的一年中 HIV 感染者慢性 HCV 感染的盛行率，相對應於 2022 年底之盛行率。
這聽起來像是一個很簡單的練習。 但在 HIV 診所診斷出患有C型肝炎的人不一定會在那裡接受治療。 因此，雖然 HIV 和愛滋病報告系統 (HARS) 在 2015-16 年記錄了三分之一的人同時感染，且他們也有接受 DAA 治療的記錄，但對於三分之二的人來說，他們的成功治療必須要從後來的臨床記錄顯示他們現在是 HCV 陰性來證實。
這往往會低估 DAA 的成功率，因為在 2022 年記錄為患有 HCV 的人中有少數會再次感染。
2015-16 年，在當年接受 HIV 照護的 68,974 人中，有 3,035 人被記錄為同時患有C型肝炎 (4.4%)。 在這 3,035 人中，1,045 人有接受 DAA 治療的記錄，其中 849 人（81%）有持續病毒學應答（SVR）的記錄，亦即 HCV 被治癒。 其餘 1,990 人沒有記錄到 HCV 治療，但 1,548 人 (78%) 被記錄為到 2022 年底C型肝炎持續清除。總共有 2,397 人 (79%) 不再感染 HCV。
共有 158 家診所提供了數據。 在大約 15% 的診所中，2015-2016 年曾感染過 HCV 的每位患者都不再感染，但這些主要是非常小的診所，每個診所的合併感染患者不超過 10 人。 但在 42 家診所 (27%) 中，超過 90% 的患者已清除 HCV，而在 71 家 (45%) 中，超過 80%； 從數字上看，這些包括兩個最大的診所，每個診所都有 450 多名合併感染的患者。 另一方面，少數其合併感染患者不超過 4% 的小型診所，則在 2022 年的 HCV 患者數量與 2015-16 年相同。
就風險組而言，最大的患者群體是男同性戀和雙性戀男性，共有 1,638 名患者，其中 1,385 名 (85%) 到 2022 年已清除 HCV。所有感染 HIV 的男同性戀中的 HCV 患病率從 6% 下降到 1% .
第二大群體是 514 名注射吸毒者。 此處攜帶 HCV 的人數下降到 179，代表 HCV 感染相對減少了 65%。 但絕對下降值——HIV 陽性注射吸毒者感染 HCV則從超過 50% 降到 18%——代表了這一人群健康狀況的重大改善。
透過異性接觸和透過血液製品感染 HCV 的較小人群的下降幅度介於其他兩組之間，約為 75%。
男同性戀和雙性戀男性相對較高的治癒率意味著他們在所有合併感染人群中的比例從 52% 下降到 40%，然而注射吸毒者，卻與HCV/HIV合併感染人口總體減少79%相反，其比例從 18% 上升到 28%，
這個數字可能被低估了。 HARS 沒有具體說明什麼是構成了C型肝炎感染的證據，因此 2015-16 人群中可能存在假陽怡誤報，並且如上所述，有些人可能已經再次感染。 那些再次感染的人可能已經治癒了兩次，或者對 21% 仍然 HCV 陽性患者的貢獻不成比例。
作者說：「儘管 COVID-19 大流行造成了破壞，但這代表了相當大的進步」，確實，HIV 診所的 HCV 檢測受到了大流行的嚴重影響。
80% fall in hepatitis C among people with HIV in England, British HIV Association conference hears
Gus Cairns / 25 April 2023 / aidsmap
Dr James Lester presenting at BHIVA 2023. Photo by Roger Pebody.
In 2018, the British HIV Association (BHIVA) announced an ambitious target: to clear chronic hepatitis C infection from people with HIV co-infection by April 2021.
The target hasn’t yet been reached, BHIVA’s Spring conference in Gateshead heard yesterday. But, despite interruptions in testing during the COVID-19 pandemic, the number of people in England with HIV who also have hepatitis C virus (HCV) has reduced by 79%. This means that in the HIV/HCV co-infected population at least, NHS England has already surpassed the global goal set by the World Health Organization of a 72% reduction in chronic infections (90% diagnosed, 80% treated) by 2030.
This has been achieved by a campaign of ‘microelimination’; this term indicates focusing efforts to eliminate an infection in a specific group or population, instead of or in advance of the whole population.
These groups may be the people with the highest prevalence, or who suffer from the most serious clinical consequences, or who can be most easily targeted for an elimination programme. All these are true of people with co-infection: historically, HCV prevalence in people with HIV has been 20 times that in the general population; people with poorly controlled HIV are more likely to suffer severe clinical consequences like liver cancer; and people who attend for HIV care will generally be tested for hepatitis C.
The study, presented by Dr James Lester of the UK Health Security Agency, compared the prevalence of chronic HCV infection in people with HIV in the year beginning March 2015, when the UK’s National Institute for Health and Clinical Excellence (NICE) first started recommending combination direct-acting antivirals (DAAs) for HCV, with prevalence at the end of 2022.
This sounds like quite a simple exercise. But people diagnosed with hepatitis C at their HIV clinic do not necessarily get treatment for it there. So while one-third of the people were recorded as having co-infection in 2015-16 by the HIV and AIDS Reporting System (HARS) also had a record of treatment with DAAs, for two-thirds their successful treatment had to be inferred from later clinical records that showed they were now HCV negative.
This would tend to underestimate the success rate of DAAs, because a minority of those recording as having HCV in 2022 would be cases of reinfection.
In 2015-16, there were 3035 people recorded as also having hepatitis C out of a total of 68,974 people seen for HIV care during that year (4.4%). Of the 3035, 1045 had a record of receiving DAA therapy of whom 849 (81%) had a record of having a sustained virologic response (SVR), i.e. being cured of HCV. The remaining 1990 did not have HCV treatment recorded but 1548 (78%) were recorded as having a sustained clearance of hepatitis C by the end of 2022. In total, 2397 people (79%) no longer had HCV.
Altogether, 158 clinics contributed data. In about 15% of them, every single patient who had had HCV in 2015-2016 no longer had it, but these were mainly very small clinics with no more than 10 patients with co-infection each. But in 42 clinics (27%), more than 90% of patients had cleared HCV, and in 71 (45%), more than 80%; numerically these included the two largest clinics, with more than 450 patients with co-infection each. At the other end of the scale, a handful of small clinics with no more than 4% of patients with co-infection had the same number of patients with HCV in 2022 that they did in 2015-16.
In terms of risk group, the largest patient group was gay and bisexual men, numbering 1638 patients, and of these 1385 (85%) were cleared of HCV by 2022. HCV prevalence among all gay men with HIV declined from 6% to 1%.
The second biggest group was 514 people who injected drugs. Here the number with HCV declined to 179, representing a smaller relative reduction of 65% in HCV infection. But the absolute decline – from over 50% to 18% of HIV-positive injecting drug users having HCV – represents a major improvement in the health of this population.
The decline in the smaller groups of people who’d caught HCV through heterosexual exposure and through blood products was midway between the two other groups, at around 75%.
The relatively larger cure rate in gay and bisexual men meant that their share of the co-infected population went down from 52% to 40%, while the share that were injecting drug users increased from 18% to 28%, but against the overall shrinkage of the population with HCV/HIV co-infection of 79%.
This figure is probably an underestimate. HARS does not specify what constitutes evidence of hepatitis C infection, so there may have been false positives included among the 2015-16 population, and as mentioned above, some people may have been reinfected. Those with reinfection may either have been cured twice or are contributing disproportionately to the 21% still HCV positive.
“This represents considerable progress despite disruption caused by the COVID-19 pandemic,” the authors say, and it is true that HCV testing in HIV clinics was severely affected by the pandemic.