Correspondence
Hepatitis C: the path towards effective universal therapy The worldwide burden of hepatitis C virus (HCV) infection is a major public health concern. New direct antiviral agents (DAAs) have revolutionised the management of HCV infection, with eradication rates higher than 90%. However, their high cost has precluded their widespread use, leading to restrictive conditions of prescription in many countries. DAAs have been available to all people living in France who are infected with HIV for 2 years (first via temporary authorisation and then via marketing authorisations) regardless of their liver fibrosis stage. The cost of this treatment is supported by the French Social Security. Knowledge of whether and why some patients did not benefit from this universal access could help achieve the new French goal of universal treatment for all (regardless of HIV
status) that was set in May, 2016, and in adjustment of public health policies. A survey was done in June, 2016, in north-eastern France on a cohort of 10 087 patients infected with HIV, who were all screened for HCV. 1041 (10·3%) of these patients were HCV seropositive, and of the 742 who did not clear HCV spontaneously, 308 (41·5%) were successfully treated with previous standard bitherapy (pegylated interferon and ribavirin). Of the 434 patients who should have received new DAAs, 235 (54·1%) had been given or were on DAAs at the time, whereas 199 (45·9%) were not. The reasons why patients did not have treatment, assessed via a standardised questionnaire in 183 patients, are reported in the figure. 2 years after the possibility of treatment for all in HIV-infected patients, nearly half of patients had been effectively treated with DAAs. One-quarter of the patients who were not lost to follow-up and who should have been offered DAAs are still not
planned to receive them. Physicians felt that DAA therapy was not urgently needed for 41% of patients. Addictions are still barriers to treatment, and the fact that 11% of patients were unwilling to be treated might reflect a scarcity of information or a fear of losing welfare allowances associated with chronic HCV disease, thus adding to social difficulties, which are a main barrier to treatment. Although HCV screening is not a concern in people living with HIV, a gap between universal access and universal effective treatment remains, partly caused by the difference between the need to treat and the urgency or the possibility of doing so, and underlying economic considerations. Reducing the cost of DAAs, therapeutic education, social support, a different attitude to addictions, and coherent health policies towards migrants should increase the rate of treatment, reduce the viral burden, and contribute to the eradication of epidemics.
For the Lancet Article on global burden of viral hepatitis see http://dx.doi.org/10.1016/ S0140-6736(16)30579-7
40
35
30
Patients (%)
25
20
15
10
5
0 HCV therapy HCV therapy Ongoing planned in not urgent addictions the next (alcohol, 6 months drugs)
Lost to follow-up or moved away
Anticipated nonadherence
Patient unwilling to be treated
Social difficulties
Figure: Main reasons for patients not having treatment in the InterCorevih Nord-Est (ICONE) Several reasons are possible for each patient. HCV=hepatitis C virus
www.thelancet.com Vol 388 September 10, 2016
Migrant
Ongoing somatic disorders
Ongoing psychiatric disorders
Antiretroviral therapy
Other reasons Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
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Correspondence
LP reports personal fees and non-financial support from Bristol-Myers Squibb; personal fees from Gilead and Pfizer; and non-financial support from Viiv Healthcare, MSD, and Janssen Cilag, outside the submitted work. CR is a member of the board for Gilead and MSD. DR reports personal fees from Gilead, MSD, Bristol-Myers Squibb, and ViiV, outside the submitted work. J-LR, CC, GB-W, OR, and FB-S declare no competing interests.
*Lionel Piroth, Christian Rabaud, David Rey, Jean-Luc Schmit, Catherine Chirouze, Geneviève Beck-Wirth, Olivier Robineau, Firouze Bani-Sadr, for the ICONE Study Group
[email protected] Infectious Diseases Department, CHU Dijon, 21079 Dijon Cedex, France (LP); Infectious Diseases Department, CHU Nancy, Nancy, France (CR); HIV Infection Care Centre, CHU Strasbourg, Strasbourg France (DR); Infectious Diseases Department, CHU Amiens, Amiens France (JLS); Infectious Diseases Department, CHU Besançon, Besançon, France (CC); Internal Medicine Department, Groupe Hospitalier Régional, Mulhouse, France (GB-W); Infectious Diseases Department, Centre hospitalier Gustave Dron, Tourcoing, France (OR); and Infectious Diseases Unit, CHU Reims, Reims, France (FB-S)
Ethnicity and HIV epidemiology research in China Ethnic affiliation can be a powerful predictor of HIV infection, diagnosis, and disease progression. This is partly because ethnic affiliation can reflect exposure to specific cultural standards, Odds ratio (95%CI) Dichotomised ethnic affiliations Han majority
1·00
Other
1·14 (0·64–2·01)
Disaggregated ethnic affiliations Han majority
1·00
Manchu
0·21 (0·03–1·56)
Mongol
0·29 (0·04–2·25)
Hui
2·97 (1·49–5·92)*
Other ethnic minority from south China
0·31 (0·04–2·38)
Other ethnic minority from north China
1·24 (0·26–5·93)
* p
