Toronto Liver Centre

As the result of systemic and structural barriers, hepatitis C virus (HCV) continues to disproportionately affect people who inject drugs, those in prison, Indigenous peoples, immigrants from HCV-endemic countries, and gay, bisexual and othermen who have sex with men in Canada. Point-of-care antibody and RNA testing improve access to HCV testing and enable single-visit diagnosis and treatment initiation, yet robust, context-specific strategies are needed to scale these technologies nationally. This protocol describes the SCALE-POCT study, which aims to: (i) map current HCV care pathways and future point-of-care workflows across community and carceral settings; (ii) identify multilevel barriers and facilitators to the adoption and sustainment of point-of-care HCV testing and treatment; (iii) co-design and operationalise theory-informed implementation strategies, protocols, and materials; and (iv) evaluate the acceptability, feasibility, and economic impacts of the co-designed strategies. Guided by Implementation Mapping and a healthequity lens, the study will enroll 20 to 25 sites, includingneedle and syringe programs,overdose prevention programs, drug treatment clinics, outreach services, community health centers, Indigenous health organizations, and provincial prisons in British Columbia, Ontario, and Québec. Phase 1 will use process mapping focus groups, supplemented by aggregated HCV carecascade indicators, to document site-specific workflows and pinpoint bottlenecks. Phase 2 will employ semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR), Kingdon's Multiple Streams Framework, and the Theoretical Domains Framework to characterize barriers and enablers at the outer setting, inner setting, intervention, individual, and process levels. Triangulated heat-mapping will enable cross-site comparisons. Phase 3 will link these determinants to implementation strategies using the Expert Recommendations for Implementing Change (ERIC) compilation and CFIR-ERIC Matching Tool. User-centered co-design workshops will then refine each strategy's actor, action, target, temporality, and dose, while also developing standard operating procedures, training modules, and quality assurance tools. Phase 4 will apply amixed-methods evaluation of the implementation strategies developed, using validated instruments to quantify acceptability, appropriateness, and feasibility; feedback sessions to qualitatively assess contextual fit; and time-driven activity-based costing to estimate implementation resource requirements over pre-implementation, implementation, and sustainment periods. SCALE-POCT will deliver a rigorously co-designed implementation package, establishing the operational blueprint for large-scale, pragmatic implementationtrialsof point-of-care testing. It will support national HCV elimination targets while offering a transferable model for other sexually transmitted and blood-borne infections. This study is registered at ClinicalTrials.gov, NCT07095192.

ABSTRACTThis was a nonblinded randomised controlled trial comparing pharmacist‐led hepatitis C virus (HCV) treatment in the community, to tertiary care hepatology. Of 34 antibody‐positive individuals, 28 completed a rapid HCV RNA test in the pharmacy. The study was terminated after randomising 11 participants over 15 months (recruitment continued until ~27 months), as a result of feasibility concerns of pharmacist‐led care, and here we highlight important lessons learned to consider for future efforts.

ABSTRACTBackgroundTenofovir alafenamide (TAF) has shown non‐inferior efficacy to tenofovir disoproxil fumarate (TDF), with superior bone and renal safety.AimTo characterise 5‐year TAF efficacy and safety in patients of East Asian ethnicity from pivotal Phase 3 studies.MethodsPatients were randomised (2:1) to receive TAF or TDF for up to 3 years of double‐blind treatment, followed by open‐label TAF. Patients either continued TAF or switched from TDF to TAF at Week 96 (TDF → TAF 3 years) or Week 144 (TDF → TAF 2 years) of treatment. Efficacy endpoints (virologic, biochemical and serologic) and safety were assessed.ResultsAmong 591 patients of East Asian ethnicity (TAF, n = 401; TDF → TAF 3 years, n = 84; TDF → TAF 2 years, n = 106), high rates of virologic control were achieved (89%, 94% and 92%, respectively) at Year 5 (missing = failure analysis). At Year 5, rates of alanine aminotransferase normalisation (85%, 90% and 78%) and hepatitis B e antigen loss (36%, 43% and 44%) were similar. Following the switch from TDF to TAF, changes in fasting lipid parameters were consistent with removal of the known lipid‐lowering effect of TDF. However, changes in the total cholesterol to high‐density lipoprotein ratio (marker of cardiovascular risk) were minimal and comparable in all groups by Year 5. Renal and bone parameters improved after switching.ConclusionsThrough 5 years, rates of virologic suppression were high in East Asian patients treated with TAF or switched from TDF to TAF. TAF and TDF were well tolerated, with improved renal and bone safety observed in patients switching from TDF to TAF.

Suboptimal awareness and low rates of hepatitis delta virus (HDV) testing contribute to underdiagnosis and gaps in accurate estimates of U.S. HDV prevalence. We aim to provide an updated assessment of HDV prevalence in the U.S. using a comprehensive literature review and meta-analysis approach. A comprehensive literature review of articles reporting HBsAg seroprevalence and anti-HDV prevalence was conducted to calculate country-specific rates and pooled prevalence of CHB and HDV using meta-analyses. Country-specific CHB and HDV rate estimates were combined with number of foreign-born (FB) persons in the U.S. in 2022 from U.S. Census Bureau to estimate total numbers of FB with CHB and HDV, respectively. These estimates were further combined with updated estimates of U.S.-born persons with CHB and HDV to yield the total number of persons with CHB and HDV. In 2022, we estimated 1.971 million (M) (95% CI 1.547-2.508) persons with CHB; 1.547 M (95% CI 1.264-1.831) were FB and 0.424 M (95% CI: 0.282-0.678) were U.S.-born. The weighted average HDV prevalence among FB persons in the U.S. was 4.20% (64 938 [95% CI 33055-97 392] persons), among whom 45% emigrated from Asia, 25% from Africa, and 14% from Europe. When combined with updated estimates of U.S.-born persons with HDV, we estimate 75 005 (95% CI: 42187-108 393) persons with HDV in the U.S. Including both FB and U.S.-born persons, we estimated that 1.971 M and 75 005 persons were living with CHB and HDV, respectively, in the U.S. in 2022.

Despite the availability of highly effective direct-acting antiviral therapy, chronic hepatitis C (CHC) continues to cause a major public health burden. In many high-income countries, treatment rates have been declining, which was exacerbated by the impact of the COVID-19 pandemic, threatening the ability to meet the World Health Organization (WHO)'s targets for eliminating HCV as a public health threat by 2030. We sought to model the impact of CHC in Canada, a resource-rich country with ongoing immigration from HCV-endemic regions; which relies exclusively on risk-based screening for case identification. We developed an agent-based model to characterize the HCV epidemic in a high-income country with ongoing immigration. Combinations of prevention such as harm reduction, screening, and treatment strategies were considered. Model parameters were estimated from the literature and calibrated against historical HCV data. Sensitivity analyses were performed to assess uncertainty. Under the current status quo of risk-based screening, we predict the incidence of CHC-induced decompensated cirrhosis, HCC, and liver-related deaths would decrease by 79.4%, 76.1%, and 62.1%, respectively, between 2015 and 2030, but CHC incidence would only decrease by 11.1%. The results were sensitive to HCV transmission rate and an annual number of people initiating treatment. Current risk-based screening, and subsequent treatment, will be inadequate to achieve WHO goals. With extensive scale-up in screening, and treatment, the mortality target may be achievable, but the target for preventing new CHC cases is unlikely reachable, highlighting the importance of developing enhanced harm-reduction strategies for HCV elimination.

Background and aimsHistorical paired liver biopsy studies are likely to underestimate current progression of disease in patients with chronic hepatitis C virus (HCV) infection. We aimed to assess liver disease progression according to the non-invasive Fibrosis-4 (FIB-4) index in patients with chronic HCV and early disease.Methods and resultsPatients diagnosed with chronic HCV and FIB-4 <3.25 from four international liver clinics were included in a retrospective cohort study. Follow-up ended at start of antiviral therapy resulting in sustained virological response, at time of liver transplantation or death. Primary outcome of advanced liver disease was defined as FIB-4 >3.25 during follow-up. Survival analyses were used to assess time to FIB-4 >3.25.In total, 4286 patients were followed for a median of 5.0 (IQR 1.7–9.4) years, during which 41 071 FIB-4 measurements were collected. At baseline, median age was 47 (IQR 39–55) years, 2529 (59.0%) were male, and 2787 (65.0%) patients had a FIB-4 <1.45. Advanced liver disease developed in 821 patients. Overall, 10-year cumulative incidence of advanced disease was 32.1% (95% CI 29.9% to 34.3%). Patients who developed advanced disease showed an exponential FIB-4 increase. Among patients with a presumed date of HCV infection, cumulative incidence of advanced disease increased 7.7-fold from 20 to 40 years as opposed to the first 20 years after HCV infection.ConclusionsThe rate of advanced liver disease is high among chronic HCV-infected patients with early disease at time of diagnosis, among whom liver disease progression accelerated over time. These results emphasise the need to overcome any limitations with respect to diagnosing and treating all patients with chronic HCV across the globe.

Gastroenterology 2 Mins 28th November Deleted in Colorectal Cancer Salivary Methylation Analysis Is a Non-invasive and Useful Method for Screening Patients with Superficial Hypopharyngeal Cancer

BackgroundThe efficacy of a single dose of pegylated interferon lambda in preventing clinical events among outpatients with acute symptomatic coronavirus disease 2019 (Covid-19) is unclear.MethodsWe conducted a randomized, controlled, adaptive platform trial involving predominantly vaccinated adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Brazil and Canada. Outpatients who presented with an acute clinical condition consistent with Covid-19 within 7 days after the onset of symptoms received either pegylated interferon lambda (single subcutaneous injection, 180 μg) or placebo (single injection or oral). The primary composite outcome was hospitalization (or transfer to a tertiary hospital) or an emergency department visit (observation for >6 hours) due to Covid-19 within 28 days after randomization.ResultsA total of 933 patients were assigned to receive pegylated interferon lambda (2 were subsequently excluded owing to protocol deviations) and 1018 were assigned to receive placebo. Overall, 83% of the patients had been vaccinated, and during the trial, multiple SARS-CoV-2 variants had emerged. A total of 25 of 931 patients (2.7%) in the interferon group had a primary-outcome event, as compared with 57 of 1018 (5.6%) in the placebo group, a difference of 51% (relative risk, 0.49; 95% Bayesian credible interval, 0.30 to 0.76; posterior probability of superiority to placebo, >99.9%). Results were generally consistent in analyses of secondary outcomes, including time to hospitalization for Covid-19 (hazard ratio, 0.57; 95% Bayesian credible interval, 0.33 to 0.95) and Covid-19–related hospitalization or death (hazard ratio, 0.59; 95% Bayesian credible interval, 0.35 to 0.97). The effects were consistent across dominant variants and independent of vaccination status. Among patients with a high viral load at baseline, those who received pegylated interferon lambda had lower viral loads by day 7 than those who received placebo. The incidence of adverse events was similar in the two groups.ConclusionsAmong predominantly vaccinated outpatients with Covid-19, the incidence of hospitalization or an emergency department visit (observation for >6 hours) was significantly lower among those who received a single dose of pegylated interferon lambda than among those who received placebo. (Funded by FastGrants and others; TOGETHER ClinicalTrials.gov number, NCT04727424.)

Background & Aims:Currently available non-invasive tests, including fibrosis-4 index (FIB-4) and liver stiffness measurement (LSM by VCTE), are highly effective at excluding advanced fibrosis (AF) (F ≥3) or cirrhosis in people with non-alcoholic fatty liver disease (NAFLD), but only have moderate ability to rule-in these conditions. Our objective was to develop and validate two new scores (Agile 4 and Agile 3+) to identify cirrhosis or AF, respectively, with optimized positive predictive value and fewer indeterminate results, in individuals with NAFLD attending liver clinics.Methods:This international study included seven adult cohorts with suspected NAFLD who underwent liver biopsy, LSM and blood sampling during routine clinical practice or screening for trials. The population was randomly divided into a training set and an internal validation set, on which the best-fitting logistic regression model was built, and performance and goodness of fit were assessed, respectively. Furthermore, both scores were externally validated on two large cohorts. Cut-offs for high sensitivity and specificity were derived in the training set to rule-out and rule-in cirrhosis or AF and then tested in the validation set and compared to FIB-4 and LSM.Results:Each score combined LSM, AST/ALT ratio, platelets, sex and diabetes status, as well as age for Agile 3+. Calibration plots for Agile 4 and Agile 3+ indicated satisfactory to excellent goodness of fit. Agile 4 and Agile 3+ outperformed FIB-4 and LSM in terms of AUROC, percentage of patients with indeterminate results and positive predictive value to rule-in cirrhosis or AF.Conclusions:The two novel non-invasive scores improve identification of cirrhosis or AF among individuals with NAFLD attending liver clinics and reduce the need for liver biopsy in this population.