Welcome to HepCInfo Update 3.9 for April 21 – May 4, 2012. Read on to learn more about new and updated scientific findings in hepatitis C prevention, care, treatment and support.

New and newsworthy

Reducing widespread pipe sharing and risky sex among crystal methamphetamine smokers in Toronto: Do safer smoking kits have a potential role to play?
Many negative health effects, including potential hepatitis transmission, are associated with smoking crystal methamphetamine. In a new Canadian study published in the Harm Reduction Journal, the authors set out to determine whether a crystal methamphetamine smoking kit might help reduce the negative health effects of this practice.

Pipe sharing, which was widespread among study participants, was viewed as an integral part of the social experience of smoking crystal methamphetamine. Because of this, “changing pipe sharing behaviors may be difficult,” the researchers concluded. Though heated pipes were unlikely to cause direct injuries, many smokers reported having dry, cracked lips, “which may be a vector for disease transmission.” Many smokers reported sex with multiple partners and being less likely to use condoms while taking the drug. There was mixed demand for harm-reduction kits.

“Within the context of a broader health promotion and prevention program, pilot testing of safer smoking kits to initiate discussion and education on the risks associated with sharing pipes and unprotected sex for some communities (e.g., homeless/street-involved youth) is worth pursuing.” (US Centers for Disease Control, May 2012, in English)

Prison puzzle: Treating hepatitis C
According to figures obtained by CMAJ through a federal freedom of information request, Correctional Services of Canada’s (CSC) bill for hepatitis drug treatment was $4.7-million in 2010, roughly 4% of the agency’s health budget for inmates and an almost sevenfold increase since 2005. Demand for treatment continues to skyrocket and is beyond CSC’s current capacity.

Compounding the problem is the absence of harm reduction programs in prison. CSC’s “rejection of strategies such as needle exchange and safer tattooing programs in prisons is a well-known public health menace,” says Dr. Peter Ford, an Ontario-based physician who oversees HIV and hepatitis treatment in federal prisons. (Canadian Medical Association Journal News, May 2012, in English)

FDA Drug Safety Communication: Updated information on drug interactions between boceprevir (Victrelis) and certain boosted HIV protease inhibitor drugs
The U.S. Food and Drug Administration (FDA) is notifying the public that co-administration of the hepatitis C virus protease inhibitor boceprevir (Victrelis) along with certain ritonavir-boosted HIV protease inhibitors is not recommended at this time. This is because of the possibility of reducing the effectiveness of the medications. Ritonavir-boosted HIV protease inhibitors include ritonavir-boosted atanavir (Reyataz), ritonavir-boosted darunavir (Prezista), and lopinavir/ritonavir (Kaletra).

People should not stop taking any of their hepatitis C or HIV medicines without talking to their healthcare professional.
This announcement is an update to a Drug Safety Communication published in February 2012: Important drug interactions between Victrelis (boceprevir) and ritonavir-boosted human immunodeficiency virus (HIV) protease inhibitor drugs. (US Food and Drug Administration, May 2012, in English)

Telaprevir and boceprevir show high rate of serious side effects in hepatitis C patients with urgent need of treatment
A real-world study of new hepatitis C protease inhibitors in people with cirrhosis has shown a much higher rate of serious adverse events and treatment discontinuations than in clinical trials, Dr. Christophe Hézode reported at the 2012 International Liver Congress in Barcelona. Dr. Hézode presented on behalf of the French Compassionate Use of Protease Inhibitors in Cirrhotics cohort study.

Nonetheless, virologic response rates were high: up to 86% of cohort participants had undetectable hepatitis C viral load after 16 weeks of treatment. “These data strongly suggest that triple therapy must be administered cautiously with intensive safety monitoring inpatients [with cirrhosis],” conclude the investigators. (AIDSmap, May 2012, in English)

Straight to the source for new science

Tangible resources for preparing patients for antiviral therapy for chronic hepatitis C – Digestive Disease Sciences, April 2012, in English

Time to rethink antiviral treatment for hepatitis C in patients with coexisting mental health/substance abuse issues – Digestive Disease Sciences, April 2012, in English

Bipolar patients can safely and successfully receive interferon-based hepatitis C antiviral treatment – European Journal of Gastroenterology and Hepatology, May 2012, in English

The more you look, the more you find: Effects of hepatitis C virus testing interval on re-infection incidence and clearance and implications for future vaccine study design – Journal of Infectious Diseases, May 2012, in English

HIV-HCV co-infection facing HCV protease inhibitor licensing: implications for clinicians – Liver International, April 2012, in English

One complication of infection with hepatitis C virus (HCV) or hepatitis B virus (HBV) is liver cancer, and researchers in France continue to study this cancer both in people with either HCV or HBV or HIV co-infection. Their most recent study suggests that liver cancer occurs earlier and is more severe in some co-infected people who are at high risk for liver cancer. If the findings are confirmed, increased liver monitoring of co-infected people at high risk for liver cancer may be necessary.International liver cancer management guidelines suggest that people with cirrhosis (who are at high risk for liver cancer) should have ultrasound scans of their liver and have alpha-fetoprotein (AFP) tests to help their doctors look for tumours. If another team confirms the French results, more frequent monitoring of HIV-HCV co-infected people at high risk for liver cancer may be important. For instance, the French team suggests that ultrasound scans and other tests could be done every three months. This shorter time span might allow technicians and doctors to detect liver cancer when it is at an early stage. (CATIE, January 2012, in English)

Through this pilot project, Vancouver Coastal Health will evaluate whether or not we can use distribution of crack kits as an effective way to engage people and help them access other health services including addiction treatment. This turned out to be one of the major benefits of Insite, the supervised injection site. At the street level, introduction of this pilot project will prevent the type of harms associated with makeshift crack pipes that are in use right now by people who can’t afford to buy a suitable pipe, which frequently explode, leading to cuts, burns, and infections. (Huffington Post, January 2012, in English)

Vancouver Coastal Health is looking at offering supervised injection services for people who inject heroin at several of its clinics. Health officials are talking to potential partners in the medical community about a new way to provide the harm-reduction service, Chief Medical Officer Patricia Daly said Monday in an interview. The health authority has no plans in place at this time, she said, but offering supervised injection services at several facilities is the direction the health authority wants to go. “We want to really normalize it, so it becomes just another one of the harm-reduction services that you can offer to this group,” she said. “We need to be able to provide services throughout the region, wherever injection drug users may live.” (Globe and Mail, January 2012, in English)

Two new studies from the Mayo Clinic in the United States find that hepatitis C infection and obesity could be to blame for an increase in liver cancer cases, which have tripled over the last 30 years. “The studies illuminate the importance of identifying people with risk factors in certain populations to help catch the disease in its early, treatable stages,” said W. Ray Kim, principal investigator of one study. Two decades ago, liver cancer tended to be caused by liver-scarring diseases such as cirrhosis from alcohol consumption. The researchers say their findings could help doctors diagnose the disease earlier and save lives. (Mayo Clinic News, January 2012, in English)

The United States Centers for Disease Control and Prevention (CDC) issued a reminder for healthcare providers–reusing insulin pens on multiple people places people at risk for hepatitis viruses and HIV. Insulin pens are designed to be used multiple times, for a single person, using a new needle for each injection. The CDC recommends clearly labeling insulin pens with the person’s name or other identifying information to ensure that the correct pen is used only with the correct individual. (CDC, January 2012, in English)

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One complication of infection with hepatitis C virus (HCV) or hepatitis B virus (HBV) is liver cancer, and researchers in France continue to study this cancer both in people with either HCV or HBV or HIV co-infection. Their most recent study suggests that liver cancer occurs earlier and is more severe in some co-infected people who are at high risk for liver cancer. If the findings are confirmed, increased liver monitoring of co-infected people at high risk for liver cancer may be necessary.

International liver cancer management guidelines suggest that people with cirrhosis (who are at high risk for liver cancer) should have ultrasound scans of their liver and have alpha-fetoprotein (AFP) tests to help their doctors look for tumours. If another team confirms the French results, more frequent monitoring of HIV-HCV co-infected people at high risk for liver cancer may be important. For instance, the French team suggests that ultrasound scans and other tests could be done every three months. This shorter time span might allow technicians and doctors to detect liver cancer when it is at an early stage. (CATIE, January 2012, in English)

Through this pilot project, Vancouver Coastal Health will evaluate whether or not we can use distribution of crack kits as an effective way to engage people and help them access other health services including addiction treatment. This turned out to be one of the major benefits of Insite, the supervised injection site. At the street level, introduction of this pilot project will prevent the type of harms associated with makeshift crack pipes that are in use right now by people who can’t afford to buy a suitable pipe, which frequently explode, leading to cuts, burns, and infections. (Huffington Post, January 2012, in English)

Vancouver Coastal Health is looking at offering supervised injection services for people who inject heroin at several of its clinics. Health officials are talking to potential partners in the medical community about a new way to provide the harm-reduction service, Chief Medical Officer Patricia Daly said Monday in an interview. The health authority has no plans in place at this time, she said, but offering supervised injection services at several facilities is the direction the health authority wants to go. “We want to really normalize it, so it becomes just another one of the harm-reduction services that you can offer to this group,” she said. “We need to be able to provide services throughout the region, wherever injection drug users may live.” (Globe and Mail, January 2012, in English)

Two new studies from the Mayo Clinic in the United States find that hepatitis C infection and obesity could be to blame for an increase in liver cancer cases, which have tripled over the last 30 years. “The studies illuminate the importance of identifying people with risk factors in certain populations to help catch the disease in its early, treatable stages,” said W. Ray Kim, principal investigator of one study. Two decades ago, liver cancer tended to be caused by liver-scarring diseases such as cirrhosis from alcohol consumption. The researchers say their findings could help doctors diagnose the disease earlier and save lives. (Mayo Clinic News, January 2012, in English)

The United States Centers for Disease Control and Prevention (CDC) issued a reminder for healthcare providers–reusing insulin pens on multiple people places people at risk for hepatitis viruses and HIV. Insulin pens are designed to be used multiple times, for a single person, using a new needle for each injection. The CDC recommends clearly labeling insulin pens with the person’s name or other identifying information to ensure that the correct pen is used only with the correct individual. (CDC, January 2012, in English)