February 2, 2012


David Nelson/MEDILL

The AIDS Foundation of Chicago is working to bring testing to an array of sites.

by David B. Nelson
Feb 02, 2012

Medical researchers continue to hunt for a cure for what some might call the polio of our time: HIV/AIDS. But innovative testing and health programs to prevent HIV/AIDS are launching in Chicago and other cities.

“I think what all these initiatives are trying to do is normalize testing,” said Johnathon Briggs, vice president of communications at the AIDS Foundation of Chicago. “We’re focusing on non-traditional venues, places like clubs, businesses, barber shops, fairs,” he said.
The foundation organized testing events at three Walgreens in the Chicago area to coordinate with National HIV Testing Day on June 27th. The project will return this June and beyond.

“We didn’t expect that there’d be people who were already positive coming to us,” Briggs said. “These people knew they were HIV positive but wanted to finally get proper care." Briggs said foundation volunteers refer people all year long to healthcare specializing in HIV/AIDS treatment.

The AIDS Foundation is also arranging for testing at public aid sites, such a food stamp offices in the Chicago area.

In Washington, D.C. drivers waiting for services at the Department of Motor Vehicles can get an oral rapid test, which gives results within 20 minutes.

“We’re also equipped with trained HIV counselors in case a person is found to be infected,” said Michael Kharfen, bureau chief of community outreach at the D.C. department of health.
The testing, a public-private partnership between the department of health and the department of motor vehicles, has proven extremely successful.

“Our initial goal was to provide testing for up to 3,000 individuals,” Kharfen said, “or roughly 15 percent of individuals who visit our branch. In the first full year, we provided testing to over 5,000 people.”

“You can save other people's lives, but you can also save your own,” said Briggs.

People infected with HIV who don’t know they have the virus create a risk for doctors and the public as well as themselves, he said.
“They’ve never been tested because they’ve never perceived themselves at risk,” said Dr. Robert Hirschtick of Northwestern Memorial Hospital, a part-time specialist in HIV/AIDS. Hirschtick, who specializes in infectious disease, said, “When most people first get infected, they brush off the symptoms by saying they have the flu. These can be fatigue, fever, achiness, sore throat, and people think they just had a simple virus. They may not have those symptoms again for 10 years.”

The Chicago Department of Public Health also has begun a Get Tested Chicago program which promotes testing for not only HIV, but also various STIs (Sexually Transmitted Infections). The publicity blitz has hit the city in the form of public service announcements on both English and Spanish-speaking radio and television channels, as well as billboards on Clark Street and Diversey Avenue and 95th Street and Stony Island Avenue.

“Usually if you have on STI, it puts you at greater risk because of the sores associated with herpes, or the lesions with syphilis or gonorrhea,” said Briggs.

“Behaviorally, if you’re already having sexual activity that’s less than safe, you’re going to be exposed to multiple infections,” added Dr. Hirschtick. “But biologically you’re at risk without that natural protective barrier.”

An estimated 34 million people around the world currently live with HIV/AIDS, according to a study by AVERT, an international charity. In the same year, 2.7 million more people were infected, and 1.8 million lost their lives.

Despite these staggering numbers and with no real cure or vaccine in sight, activists remain optimistic.

“We’ve started to see that once people are infected, and know they are, they change their behavior,” said Briggs. “They want to make sure they don’t spread it to anyone else. And if they start early and adhere to a treatment regiment, they can reduce that spread. And this is a wonderful thing.”


Stem Cells Could Advance Hepatitis Research


An image of hepatitis C Image Source: MIT

Drug Discovery & Development - February 02, 2012

Researchers from Massachusetts Institute of Technology (MIT), Rockefeller University, and the Medical College of Wisconsin have developed a way to establish a hepatitis infection in liver-like cells from induced pluripotent stem cells (iPSCs), enabling scientists to study how genetic differences produce varying responses in patients infected with hepatitis C.

Sangeeta Bhatia, a professor of health sciences, technology and electrical engineering, and computer science at MIT and Charles Rice, a professor of virology at Rockefeller University, reported that they could induce liver cells to grow outside the body by growing them on micropatterned plates that direct their organization. The liver cells can be infected with hepatitis C, but they cannot be used to proactively study the role of genetic variation in viral responses because they come from organs that have been donated for transplantation and represent only a small population.

To make cells with more genetic variation, Bhatia and Rice teamed up with Stephen Duncan, a professor of human and molecular genetics at the Medical College of Wisconsin who showed he could transform iPSCs into liver-like cells.

MIT postdoc Robert Schwartz and graduate student Kartik Trehan took the liver-like cells and infected them with hepatitis C. To confirm that infection had occurred, the researchers engineered the viruses to secrete a light-producing protein every time they went through their life cycle.

The researchers’ goal is to take cells from patients who had unusual reactions to hepatitis C infections, transform those cells into liver cells, and study their genetics to see why they responded the way they did. “Hepatitis C virus causes an unusually robust infection in some people, while others are very good at clearing it. It’s not yet known why those differences exist,” Bhatia says.

One potential explanation is genetic differences in the expression of immune molecules such as interleukin-28, a protein that has been shown to play a role in the response to the hepatitis infection. Other possible factors include cells’ expression of surface proteins that enable the virus to enter the cells, and cells’ susceptibility to having viruses take over their replication machinery, and other cellular structures.

The research was published in the Proceedings of the National Academy of Sciences.

Release Date: Feb. 1, 2012
Source: Massachusetts Institute of Technology


By Kim Irwin  February 02, 2012

Researchers from UCLA's Jonsson Comprehensive Cancer Center have identified a cell-permeable peptide that inhibits a hepatitis C virus protein and blocks the viral replication that can lead to liver cancer and cirrhosis.

The finding by Dr. Samuel French, a UCLA assistant professor of pathology and senior author of the research, builds on previous work by French's laboratory that identified two cellular proteins that are important factors in hepatitis C virus infection.

In that earlier research, French and his team set out to identify the cellular factors involved in hepatitis C replication. Using mass spectrometry, they found that heat-shock proteins (HSPs) 40 and 70 were important for viral infection. HSP 70 was previously known to be involved, but the study linked HSP 40 for the first time to hepatitis C infection. The researchers further showed that the natural compound quercetin, which inhibits the synthesis of these proteins, significantly inhibited viral infection in tissue culture.

In the current study, published Jan. 30 in the peer-reviewed journal Hepatology, French and his team demonstrated that the viral, non-structural protein 5A (NS5A) directly binds to HSP 70, and they mapped the site of the NS5A–HSP 70 complex on NS5A. While HSP 70 was previously shown to bind to NS5A in cells, a direct NS5A–HSP70 interaction and complex formation was established in this study. In an effort to stop this interaction, the researchers tested peptides that might inhibit HSP 70.

"This is important because we've developed a small peptide which binds to that site and blocks the interaction between the proteins that is important for viral replication," French said. "This is another, potentially highly efficacious way to block replication of hepatitis C."

An estimated 160 million people worldwide are infected with hepatitis C, and the conventional treatments — interferon and ribavirin — can have significant side effects. A new drug targeting cellular proteins rather than viral proteins would be a valuable addition to the treatment arsenal, French said.

"We were surprised that this peptide works this well," he said. "While its mechanism is different, the activity of this peptide is comparable to other newly developed antivirals."

The study, done in tissue culture, shows that the peptide gains entry into the cell easily and blocks the cascade of cellular events that allows the virus to replicate, French said. Blocking the HSP 70 protein rather than a viral protein also reduces the chance of patients with the hepatitis C virus developing resistance to the peptide.

"There's no direct pressure on the virus, so it is less likely to mutate and develop resistance," French said. "The goal is to achieve a sustained response, essentially a cure, meaning there is no more virus replication. There are a lot of drugs coming out now that are designed to stop hepatitis C replication, but resistance is still an issue. About 10 to 20 percent of patients on the new drugs become resistant. This new peptide may help combat resistance."

Going forward, French and his team are testing variants of the newly discovered peptide to see if they can develop one with an even higher affinity and can decrease the size of the peptide to improve cellular penetration and liver targeting. The new and improved peptides will be tested in animal models.

This peptide "may be a candidate for hepatitis C therapy," the study states. "Considering the potency of the peptide in suppressing viral translation levels, treatment with this peptide may significantly improve the efficacy of conventional treatments in patients who become resistant to conventional therapies."

The study was supported in part by the National Institutes of Health and by the California Center for Antiviral Drug Discovery at the University of California.

UCLA's Jonsson Comprehensive Cancer Center has more than 240 researchers and clinicians engaged in disease research, prevention, detection, control, treatment and education. One of the nation's largest comprehensive cancer centers, the Jonsson Center is dedicated to promoting research and translating basic science into leading-edge clinical studies. In July 2011, the center was named among the top 10 cancer centers nationwide by U.S. News & World Report, a ranking it has held for 11 of the last 12 years.

For more news, visit the UCLA Newsroom and follow us on Twitter.


What is Killing People With Hepatitis C Virus Infection?

From Seminars in Liver Disease

JasonGrebely, B.Sc., Ph.D.; Gregory J.Dore, M.B.B.S., Ph.D., F.R.A.C.P., M.P.H.

Posted: 02/01/2012; Semin Liver Dis. 2011;31(4):331-339. © 2011 Thieme Medical Publishers

Abstract and Introduction

The burden of hepatitis C virus (HCV)-related morbidity and mortality continues to rise. Progression to advanced liver disease among HCV-infected individuals generally requires decades, but we are entering an era where those infected with HCV in the 1970s and 1980s are at significant risk of mortality. Liver disease has overtaken drug-related harm as the major cause of mortality in HCV-infected individuals in many settings. Direct-acting antiviral therapies have provided renewed optimism, but HCV treatment uptake will need to increase markedly to reduce liver disease mortality. This review provides updated information on the natural history of HCV, disease-specific causes of mortality among people with HCV, estimates and projections of HCV-related disease burden and mortality and individual and population-level strategies to reduce mortality. The considerable variability in mortality rates within subpopulations of people with HCV will be outlined, such as in people who inject drugs and those with HIV co-infection.


The next decade will be a crucial period in the public health response to hepatitis C virus (HCV) infection. The rapid development of direct-acting antiviral (DAA) therapy for chronic HCV infection has brought considerable optimism to the HCV sector,[1] with the realistic hope that therapeutic intervention will soon be more effective and offer shorter treatment duration. The initial phase of combination pegylated interferon (PEG-IFN), ribavirin, and one or more DAA agents will be associated with increased toxicity and complexity of therapeutic management,[1] but over the course of this decade, strategies including interferon-free regimens with enhanced tolerability, dosing schedules, and simplified monitoring protocols should emerge.

These therapeutic advances are urgently required, as a high HCV incidence 20 to 30 years ago is now reflected in a growing burden of advanced HCV-related liver disease.[2–8] Without effective therapeutic intervention, the projected liver disease burden will continue to rise in many countries,[9–14] for at least the next one to two decades, and beyond in those settings that have experienced ongoing high-level HCV transmission.

Despite the prospect of greatly improved therapies, the challenges ahead for HCV infection are considerable. HCV treatment uptake is very low in many countries[12,15,16] and within marginalized subpopulations in countries with higher treatment uptake.[16–20] The explanations for low uptake are multifactorial[21] and not the focus of this review, but interferon-related toxicity, lack of HCV treatment infrastructure, suboptimal government subsidization programs and medical insurance coverage, as well as competing patient health and social priorities are likely to remain as contributing factors in the near future.

An improved understanding of morbidity and mortality among people with HCV infection will guide clinical management and therapy decision-making, both at the individual patient and population strategic levels. This review will provide updated information on the natural history of HCV infection, disease-specific causes of mortality among people with HCV infection, estimates and projections of HCV-related disease burden and mortality, the potential impact of HCV treatment on disease burden, and individual and population-level strategies to reduce mortality. The considerable variability in mortality rates within subpopulations of people with HCV will be outlined, and a particular focus given to the issue of competing mortality risk among people who inject drugs and those with human immunodeficiency virus (HIV) co-infection.

Natural History of Chronic HCV Infection

An estimated 75% of people who acquire HCV infection progress to development of persistent of chronic HCV infection,[22] with associated risk of progressive liver disease, cirrhosis, liver failure, or hepatocellular carcinoma.[23] The remaining 25% of people achieve spontaneous HCV clearance;[22] however, these individuals may be reinfected in the setting of ongoing HCV exposure. Although many of those with reinfection undergo subsequent spontaneous viral clearance, others develop persistent infection.[24–30]

As reviewed elsewhere,[31] the risk of HCV-related liver disease morbidity and mortality depends on several factors: (1) the duration of HCV infection;[32–34] (2) the presence of cofactors for development of liver fibrosis (such as male gender,[35–37] ethnicity,[38,39] older age at infection,[37,40–42] heavy alcohol intake,[43–45] HIV[46–49] or chronic hepatitis B virus (HBV) co-infection,[50,51] diabetes,[52,53] obesity,[54,55] and hepatic steatosis[56,57]); (3) access to HCV therapy and a favorable treatment response;[58] and (4) competing mortality risk (such as HIV[7,49] and illicit drug-related overdose[2,6,7,8,49]). The generally slowly progressive nature of chronic HCV, with limited advanced liver disease in the initial 10 to 15 years of infection (even in those individuals with cofactors for fibrosis development), means that duration of HCV infection and its surrogate, age, are key determinants of mortality risk.[31] Thus, a 50-year-old individual with 30 years chronic HCV is likely to have a higher HCV-related mortality risk, even in the absence of liver disease cofactors, than a 30-year-old individual with 5 to 10 years infection and several cofactors. However, the 50-year-old individual with 30 years infection, with heavy alcohol intake, obesity, and regular cannabis smoking (recently shown to be a liver fibrosis cofactor[59]) will be at particularly high risk.

The risk of HCV-related cirrhosis based on duration of infection has recently been estimated through large systematic reviews of disease progression studies in HCV mono-infected and HIV/HCV co-infected populations (Fig. 1).[33,34] The exponential relationship between duration of infection and cirrhosis relates to the generally protracted disease course (few very fast progressors), the cumulative nature of cirrhosis prevalence (even linear rates of progression lead to a nonlinear/upward curve for cirrhosis), and the potential for more rapid fibrosis progression at older age.


Figure 1. Risk of hepatitis C virus- (HCV-) related cirrhosis based on duration of infection as estimated through large systematic reviews of disease progression studies in HCV mono-infected and human immunodeficiency virus (HIV)/HCV co-infected populations.33,34

Without therapeutic intervention, an estimated 7 to 18% of HCV mono-infected individuals will develop cirrhosis over a 20-year infection period,[31,34] and be at considerable risk of HCC (1–6% per annum) or liver failure (2–3% per annum).[31] Thus, a significant minority of people with chronic HCV (possibly 10–20%) are likely to have shortened life expectancy through HCV-related mortality. A further large proportion will have HCV-related morbidity with reduced quality of life.[60]

Causes of Mortality Among People With HCV Infection

The distribution of causes of death within a population with a chronic disease will depend on several factors: (1) disease-specific natural history and mortality risk, (2) distribution of duration of chronic disease within the population, (3) access to effective therapeutic intervention that alters natural history, and (4) age distribution and competing mortality risk within the population.

The three major disease-specific groupings for mortality among people with HCV infection are drug-related, liver disease-related, and HIV-related. Drug-related mortality includes drug overdose and suicide. Liver disease-related mortality includes decompensated cirrhosis and HCC. The mortality distribution based on these major groupings in population-based HCV notification—death registry linkage studies in Australia (New South Wales),[8] Sweden,[6] Scotland[7] and Denmark[2] (Lars Omland, personal communication, August 11, 2011) is shown in Fig. 2. In these four countries, the proportion of liver disease-related deaths varied from 19 to 24%, and for drug-related from 18 to 27%. A high proportion of drug-related mortality is consistent with injection drug use (IDU) being the major mode of HCV acquisition in all four settings. The proportion of HIV-related deaths was highest in Scotland (7.9%)[7] where 4% of the HCV-notified population was HIV co-infected, and lowest in Australia (0.4%)[8] where only 0.5% was HIV co-infected. Settings in which the HIV co-infection rate is even higher than Scotland, such as in developed countries in North America and Europe, would be expected to have larger proportions of deaths related to HIV disease.


Figure 2. Contribution of human immunodeficiency virus- (HIV-) related, liver-related, drug-related, and other cause-related mortality (percentage of total number of deaths) in large population-based studies of people diagnosed with HCV infection in Australia (New South Wales),8 Sweden,6 Scotland,7 and Denmark2 (Lars Omland, personal communication, August 11, 2011).

Temporal trends in mortality rates and distribution among people with HCV infection are clearly important to monitor. From 1992 to 2006 in New South Wales, Australia, there has been a steady increase in the number of people with HCV dying from liver-related causes (Scott Walter, personal communication, August 11, 2011) (Fig. 3). In contrast, the number of deaths from drug-related causes increased rapidly during the 1990s, but has declined since 1999 due to the well-documented heroin "drought" starting in late 1999 and its likely subsequent reductions in IDU. The number of liver disease-related deaths reflects the expanding pool of chronic HCV including larger numbers with prolonged duration of infection (aging cohort effect). From 1997 to 2006 the age-adjusted liver disease mortality rate was stable (around 15 deaths per 10,000 person years), indicating no impact of improved HCV therapy.[8] The lack of an effect of HCV treatment on individual risk of liver-disease mortality probably relates to the generally low-treatment uptake rate, suboptimal efficacy (particularly among those with advanced liver disease), and the relatively short period of follow-up since improvements.


Figure 3. Total number of deaths due to liver-related, drug-related, and other causes in a large population-based study of people diagnosed with hepatitis C virus (HCV) infection in New South Wales, Australia, from 1992 to 2006 (Scott Walter, personal communication, August 11, 2011).

Consistent with increasing numbers of people with HCV dying from liver-related causes, the proportion of all liver disease deaths with underlying HCV is increasing in many settings, as demonstrated in a population-based study in Scotland.[4] The burden of HCV-related advanced liver disease is also seen in increasing numbers of HCV-related liver transplants in many countries.[16]

Mortality Among Injection Drug Users With HCV Infection

The prevalence of HCV among regular IDUs and people receiving opioid substitution therapy (OST) is 60 to 80%;[61] thus, mortality studies in these populations are likely to reflect mortality among IDUs with HCV infection. Overall, mortality rates in these two populations are 1 to 2 per 100 person years,[62,63] although there is evidence that OST reduces drug-related mortality.[64,65] A study among the OST population in Australia demonstrated a considerably higher drug-related mortality rate compared with liver-disease mortality, with the ratio varying from threefold when receiving OST to 18-fold when not receiving OST.[65] However, this study covered a period during the 1990s with very high rates of drug-related mortality. A more recent mortality linkage study in New South Wales that included people on OST in 1980 to 1984 has demonstrated increasing rates of liver disease mortality, which in recent years is the leading cause of death overtaking drug-related mortality.[66] This study is of great importance as it demonstrates the impact of liver disease on mortality within an aging cohort, particularly when rates of IDU decline.

In Canada, the Vancouver community-based CHASE cohort (81% and 42% have used illicit and injection drugs in the past 6 months; HCV prevalence is 64%) has also examined all-cause and liver-related mortality through data linkage to a death registry.[49] Between 2003 and 2007, the rate of mortality was 1.9 per 100 person-years, with causes of death being 7% liver-related, 20% drug-related, 21% HIV-related, and 52% other cause-related. All-cause mortality was associated with age >50 years and HIV infection. Further, those >50 years of age were at significant risk of liver-related mortality. Given that many communities of IDUs were infected with HCV in the 1970s and 1980s, there will inevitably be greater incidence of liver disease over the next decade.

The potential future burden of advanced liver disease within aging cohorts is also reflected in an autopsy study among individuals dying from opioid toxicity in New South Wales, Australia.[67] Among 841 deaths over a 5-year period (1998–2002), the HCV prevalence was 71% and cirrhosis was present in 7%.[67] However, in those aged >44 years at death (n = 75), cirrhosis prevalence was 25%.

Mortality in Other Populations With HCV Infection

Injection drug use has been the major mode of HCV acquisition in North America, Europe, and Australia. However, in other settings, HCV transmission has largely been through non-IDU modes and the contribution of drug-related mortality is therefore considerably reduced. Thus, the impact of HCV-related disease on mortality rates and distribution is more evident.

In one study from the United Kingdom, 924 individuals who had acquired HCV infection via blood transfusion were traced during a look-back program.[68] By the end of 2004, 28% had died (255 of 924), with 26% dying of liver-related causes. The risk of liver-related mortality in those with HCV infection was three times higher than the control group of anti-HCV negative transfusion recipients. In Taiwan, 23,785 persons (aged 30 to 65 years, HCV prevalence 4.5%) were recruited from seven townships between 1991 and 1992 and followed through 2004.[69,70] Among participants with HCV mono-infection (n = 1,040), 171 died by 2004; 28% of deaths were liver-related. After adjusting for gender, age, cigarette smoking, and alcohol consumption, those with HCV mono-infection were two times more likely to die of any cause and five times more likely to die of chronic liver disease and cirrhosis compared with those without HCV. These data suggest that HCV still leads to excess mortality when drug-related and HIV effects are removed.

Mortality in People With HIV/HCV Co-infection

As reviewed elsewhere,[71] co-infection with HIV decreases spontaneous clearance of HCV infection,[72] increases HCV RNA levels,[73] increases HCV-related liver disease progression,[46,74] and reduces response to IFN-based therapy.[75,76] Since the introduction of triple-combination antiretroviral therapy in the mid-1990s, overall mortality rates among HIV-infected populations have declined dramatically.[77] Further, the distribution of causes of death have altered considerably, with a declining proportion of acquired immunodeficiency syndrome- (AIDS-) related mortality and increasing proportions of cardiovascular and liver disease mortality.[78,79] The contribution of liver disease to mortality is particularly high in settings with a high HIV/HCV co-infection prevalence;[78] however, even in Australia where only 10 to 15% of people with HIV are HCV co-infected, liver disease contributes to 11% of deaths (Kathy Petoumenos, personal communication, August 12, 2011).

Within the HIV/HCV co-infected population, factors that influence rates and distribution of mortality are access to antiretroviral therapy, access to and effectiveness of HCV therapy, drug use, and age distribution.[71] In Australia, within the HIV/HCV co-infected population there is universal access to antiretroviral therapy and high levels of uptake, relatively limited regular ICU (the vast majority are men who have sex with men), and an aging population. Among HIV/HCV co-infected patients enrolled in the Australian HIV Observational Database (AHOD; n = 3,531), liver disease has been the underlying cause in 26% of deaths (14 of 55 deaths) as compared with only 9% of deaths (16 of 181) in those with HIV alone (Kathy Petoumenos, personal communication, August 12, 2011).

Further, although the lifespan of those with HIV infection has been improved through the availability of contemporary antiretroviral therapy, the lives of those with HCV/HIV co-infection remain much shorter.[71] In Denmark, one study compared the mortality rates of 3,990 HIV-infected persons and the general population.[80] The study demonstrated that although mortality has dropped significantly in HIV-infected persons (from a high of 124 per 1000 person years in the era preceding HIV antiviral therapy to 25 per 1000 person years in 2000–2005), the impact was less pronounced among those co-infected with HCV (57 per 1000 person-years in those with HCV/HIV vs 19 per 1000 person-years among those with HIV alone). In a large study of 23,441 HIV-infected persons (76,893 person-years of follow-up), the frequency of and risk factors associated with liver-related deaths were assessed (66% with HCV co-infection, 17% active HBV co-infection).[78] Among 1246 deaths (5.3%; 1.6 per 100 person-years), liver-related death was the most frequent cause of non-AIDS related death (14.5% were from liver-related causes). Predictors of liver-related deaths were latest CD4 cell count, older age, IDU, HCV infection, and active HBV infection. Given the underreporting of liver-related disease, the actual impact is probably even greater.[71]

The Potential Impact of Improving HCV Therapy on Mortality Rates

The burden of HCV-related advanced liver disease is projected to increase further in many countries.[9,10,11,12,13,14] A major public health issue is the potential impact of improving HCV therapy on these projected increases in mortality. In HIV, the availability of effective combination antiretroviral therapy from the mid-1990s dramatically reduced the overall mortality rate and altered the distribution of causes of death (increasing proportion of non-AIDS related deaths).[78–80] The lower overall disease-specific HCV mortality risk compared with HIV and more protracted disease progression (life expectancy for chronic HCV infection is on average reduced by several years rather than decades for HIV) mean that a more-effective and more broadly implemented therapeutic intervention will be unable to have the dramatic impact that was seen for antiretroviral therapy. However, there is considerable potential for improved HCV therapeutic intervention to alter expected HCV-related mortality, particularly when the temporal "ageing cohort" effect is most pronounced.

The recent introduction of DAA therapy in combination with PEG-IFN and ribavirin will enhance treatment response rates for those with chronic HCV genotype 1 infection and shorten duration of therapy for many patients.[1] However, low HCV treatment (PEG-IFN/ribavirin) uptake rates for those with chronic HCV genotype 2/3,[12,15–20] despite treatment success of 70 to 80% and shorter duration therapy (generally 24 weeks), suggest that initial DAA-based response rate improvements will have a modest impact at the population level. Recent evidence suggests that IFN-free combination DAA therapy with high rates of treatment response is feasible.[81] Improvements in DAA therapy tolerability and dosing schedules are highly likely given agents in phase II/III development.[1] Large population-level impacts on HCV-related liver disease mortality will likely require IFN-free combination therapy that is tolerable, has a favorable dosing schedule, and is effective over a relatively short duration. Such HCV therapeutic advances are within reach over the next decade.

How can we Currently Prevent People With Hcv Infection From Dying?

The availability of PEG-IFN/ribavirin-free regimens for the treatment of HCV infection are still 5 to 10 years away and other strategies will be required if we are to stem the projected rise in liver-disease burden.[9–14] Strategies that increase the proportion of individuals diagnosed, assessed, and treated for HCV infection with currently available treatment regimens are required.

Increasing the number diagnosed with HCV infection will be important as we move forward. In the United States, the true number of people infected with HCV is likely underestimated (5.2 million as compared with previous estimates of 3.3 million from household surveys), given that homeless people, prisoners, IDUs, and other marginalized populations at high-risk of HCV are often not included in national household surveys.[82] Strategies to enhance diagnosis of HCV may include the promotion of national HCV testing guidelines,[83] and enhanced education and training of general practitioners about HCV testing and diagnostic criteria to enhance diagnosis and referral. Further strategies include the provision of mentoring diagnosis programs among general practitioners with higher case loads of HCV-infected patients,[84] an improved awareness of programs offering comprehensive multidisciplinary HCV care (particularly for IDUs), and improved pathways for referral. Incorporation of HCV assessment and treatment services into drug and alcohol treatment settings is also required.

Enhancing the proportion assessed for HCV is crucial. Non-invasive tests of fibrosis (e.g., FibroScan and FibroTest) offer considerable opportunities for enhanced screening and assessment of liver disease. In a study at one hospital in France, a cohort of 1457 consecutive patients with chronic HCV were assessed for liver fibrosis by liver biopsy, FibroScan, FibroTest, aspartate aminotransferase to platelet ratio index (APRI), and FIB-4 score to evaluate all-cause and liver-related mortality during a 5-year follow-up period.[85] Survival was significantly decreased among patients diagnosed with severe fibrosis (regardless of the noninvasive method employed) and all noninvasive methods were able to predict shorter survival times, although FibroScan and FibroTest had higher predictive values. These tools will help physicians determine prognosis at earlier stages and therefore allow enhanced targeting of therapy to those with significant liver disease.

Strategies are needed to enhance HCV assessment and treatment in the community to reduce mortality among people with HCV. Barriers to expanding HCV treatment in the community are multifactorial and include issues of access to therapy and barriers at the level of the patient, practitioner, and system.[86] HCV-infected patients often have complex social, medical, and psychiatric comorbidities, complicating decisions around care. Currently, there is limited infrastructure for the provision of HCV assessment and treatment delivery beyond well-established, hospital-based liver clinics. However, successful strategies to improve engagement with HCV services and enhance HCV assessment have been explored.[21] One model to enhance access to HCV care for underserved populations focused on the integration of community-based health centers in New Mexico using state-of-the-art telehealth technology to provide training and support for primary care providers to deliver best-practice HCV care.[87] This model was effective, with similar responses to HCV treatment observed among community-based clinics as compared with a university-based hospital.[87] This approach represents a needed change from the conventional approaches in which specialized care and expertise are concentrated in academic medical centers in urban areas.

Lastly, given that 70 to 80% of current HCV infections occur among IDUs,[88] it is clear that strategies to reduce mortality among those living with HCV will require specific strategies for this marginalized group. There is now overwhelming evidence that the treatment of HCV infection in this population is safe and effective across multiple models of care.[89] As such, older IDUs in particular will be an important group to follow clinically (perhaps with noninvasive liver fibrosis screening) and perhaps offer intensified HCV assessment and treatment in an effort to reduce liver-related mortality.


Our understanding of morbidity and mortality among people with HCV infection has greatly improved over the past several decades. In large population-based studies, liver-related and drug-related causes of death account for approximately one-half of all deaths (one-quarter each) among people with HCV infection. Liver disease burden continues to rise in many countries,[9–14] particularly given the low HCV treatment uptake in many countries[12,15,16] and subpopulations.[16–20] Although novel HCV treatments (particularly PEG-IFN/ribavirin-free regimens) offer great hope for reducing the future mortality associated with HCV, combinations with improved tolerability and shorter duration are still 5 to 10 years away. Current efforts will need to focus on enhancing the diagnosis, assessment, and treatment of HCV-infected patients at greatest risk of liver disease progression to reduce mortality among those living with HCV infection.


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AHF Calls for Congressional Investigation and Shake up at FDA



Feb. 2, 2012, 6:30 a.m. EST

As Washington Post reports that, "...the Food and Drug Administration secretly monitored the personal e-mail of a group of its own scientists and doctors after they warned Congress that the agency was approving medical devices that they believed posed unacceptable risks to patients," AIDS Healthcare Foundation calls for top to bottom shake-up--and a congressional investigation--of the FDA

WASHINGTON, Feb 02, 2012 (BUSINESS WIRE) -- --AIDS group had separately sued the FDA over its denial of AHF's Freedom of Information Act requests regarding correspondence between the FDA and Gilead Sciences re: its potential application to expand the use of its AIDS drug, Truvada, for use as an HIV prevention pill in uninfected individuals

AIDS Healthcare Foundation (AHF) today called for a top to bottom shake-up of the management at the Food and Drug Administration (FDA) as well as a Congressional investigation following the publication of a Washington Post news article (1/31/12) that reported, "...the Food and Drug Administration secretly monitored the personal e-mail of a group of its own scientists and doctors after they warned Congress that the agency was approving medical devices that they believed posed unacceptable risks to patients." Last week, a group of six of the current and/or now former FDA scientists sued the agency by filing whistleblower complaints over the agency's illegal surveillance of their personal email accounts. The group asserts they have a legal right to air their concerns to Congress or journalists regarding the safety and efficacy of devices for cancer screening and other purposes that they reviewed.

Last September, AHF had separately sued the FDA over its denial of the AIDS group's Freedom of Information Act requests regarding any correspondence between the FDA and Gilead Sciences regarding the drug company's potential application to expand the use of its blockbuster AIDS treatment, Truvada, for use as an HIV prevention pill in uninfected individuals. AHF officials had been told by sources that Gilead was being encouraged by government officials to apply for the expanded use of the drug as an HIV prevention tool--despite the fact that one widely-reported research study cited in support of such expanded use showed a modest 44% effectiveness rate in preventing HIV transmission.

"The inappropriate and illegal surveillance of FDA employees' personal email accounts by FDA brass demands a top to bottom shake up of management at the FDA as well as a full Congressional investigation into the matter," said Michael Weinstein, AIDS Healthcare Foundation President. "The mission of the FDA is to protect the public health by ensuring that our food, drugs and medical equipment and devices are safe and do not cause harm to the public. In our own situation, AHF heard from reliable sources that FDA officials were encouraging Gilead to apply for expanded use of its AIDS drug, Truvada, as a form of pre-exposure prophylaxis for prevention of HIV transmission despite significant questions about its potential effectiveness at that. We were concerned that the FDA failed to comply with our FOIA requests and as a result, we filed a legal action late last September after repeated failed attempts to get any answers from the FDA. Through that action, we also hoped to determine the extent of collusion, if any, between Gilead and the FDA with regard to this potential expanded use for Truvada."

Gilead's likely pursuit of FDA-approval for expanding the use of its best-selling $35 per day AIDS drug to include use as a form of HIV prevention--commonly known as pre-exposure prophylaxis (PrEP) for uninfected individuals--comes following a widely-reported study released earlier last year of 2,500 high risk gay men using Truvada as prevention which showed a 44% effectiveness rate in preventing HIV transmission. AHF believes such modest results are insufficient to support FDA approval of Truvada as an HIV prevention tool--and a move that AHF and other AIDS advocates believe would set a dangerous precedent.

AHF's legal action was filed in the United States District Court, Central District of California, seeking to "...enjoin the FDA from withholding FDA records," and "To order the production of any FDA records improperly withheld from AHF."

Background on AHF's Freedom of Information Requests

According to AHF's September 2011 lawsuit, AHF filed the following FOIA requests and correspondence with the FDA:

-- AHF Freedom of Information Request 2/25/2011 "AHF filed with the FDA's Freedom of Information Office on February 25, 2011 a letter requesting access to certain documents, under the Freedom of Information Act, ...that show whether, from January 1, 2010 to the present, Gilead Sciences Inc. has submitted an Investigational New Drug application and/or a New Drug Application and/or a request for a new use or indication for the use of the drug Truvada (Tenofovir/Emtricitabine) as a means of 'pre-exposure prophylaxis' to prevent transmission of Human Immunodeficiency Virus (HIV)."

-- AHF Freedom of Information Request 3/31/2011 "... Access was requested to "documents pertaining to or showing any communications or discussions, either within the FDA or between the FDA and Gilead Sciences Inc. concerning the possible indication for the use of the drug Truvada (Tenofovir/Emtricitabine) as a means of 'pre-exposure prophylaxis' to prevent transmission of Human Immunodeficiency Virus (HIV)."

-- FDA Denial of AHF's Freedom of Information Requests " By letter dated July 18, 2011, the FDA responded to AHF's two requests and assigned case numbers 2011-2612 and 2011-1543. ... The FDA denied the requests, claiming that it "cannot acknowledge receipt of such applications until they are otherwise publicly disclosed, e.g., by the applicant or when an approvable or approval letter is issued to the firm."

-- AHF Appeal " By letter dated August 25, 2011, AHF explained to the FDA that Gilead has made the status of any application public in a forum that included employees of the FDA and therefore the FDA's purported basis for denying the Freedom of Information Act requests no longer exists...."

"We believe pursuant to the Freedom of Information Act that AHF has the right to obtain the documents requested, and the FDA has no sound legal basis for its actions in withholding access to such documents," said Tom Myers, General Counsel and Chief of Public Affairs for AIDS Healthcare Foundation. "As a result of such ongoing avoidance and delay tactics and non-responses from the FDA, AHF decided its best course was to file the legal action in order to get the information we requested."

Separately, a recent New York Times article (Sunday January 29,2012) reported on a pattern of various U.S. government agencies' responses--or lack thereof--to outstanding FOIA requests. The article posed the question: "Is a FOIA delayed a FOIA denied?" reporting that, "On Jan. 4, (2012) The New York Times received a final response from the Defense Department to a FOIA request made on June 1, 1997," wryly noting, "The department sent it by Federal Express, Priority Overnight."

For more information, please visit www.nomagicpills.org or www.aidshealth.org 

AIDS Healthcare Foundation (AHF), the largest global AIDS organization, currently provides medical care and services to more than 125,000 individuals in 26 countries worldwide in the US, Africa, Latin America/Caribbean, the Asia/Pacific region and Eastern Europe. www.aidshealth.org 

SOURCE: AIDS Healthcare Foundation


Bacterial imbalance may be behind liver disease


Updated: 2012-02-01 16:45:00 CST

Unhealthy liver panel test results are generally thought to be the consequence of lifestyle factors. Obesity and excessive alcohol consumption can damage the organ and impair its function.

However, a new study from a team of Yale University researchers suggests that liver damage and obesity may frequently be caused by contagious microbial imbalances.

The research team showed that mice that lacked two key proteins that regulate inflammatory responses developed imbalances of microorganisms in their guts. This led to an increase in obesity and liver disease.

Furthermore, the study showed that when mice with these microbial imbalances were placed in confinements with normal mice, the healthy animals ended up developing the same disturbances, suggesting that the problem may be contagious.

On the bright side, the problems appeared to be relatively easy to treat and to reverse.

"We found, in mice, that targeted antibiotic treatment brought the microbial composition back to normal, and thus eased the liver disease," said lead researcher Richard Flavell. "Our hope is that our findings may eventually lead to a treatment for humans."

The findings could lead to a new understanding of the causes of obesity and unhealthy liver panel tests, which may lead to improved treatments.


Also See: Straight from the gut: Microbes can cause obesity

Public release date: 2-Feb-2012

Contact: Dawn Peters

Drug found to be safe in PBC patients not responsive to ursodeoxycholic acid

An open-label study of rituximab, a monoclonal antibody for human CD20, was shown to be safe in patients with primary biliary cirrhosis (PBC) who had an incomplete response to the standard ursodeoxycholic acid (UDCA) therapy, also known as Ursodiol. Study details available in the February issue of Hepatology, a journal published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases, report that rituximab was successful in reducing the level of alkaline phosphatase (ALP)—a protein used to measure liver injury.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), PBC—an autoimmune liver disease characterized by inflammation of the bile ducts that ultimately causes bile to build up and damage the liver—typically occurs between the ages of 40 and 60, primarily affecting women. Medical studies have identified the presence of anti-mitochondrial autoantibodies (AMA) to enzymes involved in the production of the body's energy (pyruvate dehydrogenase complex-PDC-E2) in up to 95% of PBC cases.

Currently, the standard therapy for PBC is UDCA or liver transplantation in patients who have progressed to end-stage liver disease. However, previous studies have shown that UDCA may be ineffective in up to 40% of PBC patients and 10% could require transplantation or die from the disease. "Small trials using immunosuppressants have failed to demonstrate significant clinical benefit or carry unacceptable safety profiles," said Dr. Christopher Bowlus with UC Davis Health System in California and lead author of the current study.

Dr. Bowlus added, "Given our previous work implicating B cells to the development of this disease, we hypothesized that a therapy such as rituximab, which depletes B cells, could offer a potentially effective treatment option with acceptable adverse effects." The team enrolled 6 patients between the ages of 18 and 65 years of age who were diagnosed with PBC and had an incomplete response to UDCA despite 6 months of therapy. Participants in this open-label study received an intravenous infusion of 1000 mg of rituximab on day 1 and day 15, with follow-up for 52 weeks. Two patients received one dose of rituximab due to latent varicella (chickenpox) activation in one and viral respiratory infection in the other.

The trial results found that rituximab was safe and well tolerated by PBC patients, with no serious adverse events reported. By 16 weeks post-treatment patients had significantly lower levels of immunoglobulins IgG, IgM, and IgA, which are the antibodies normally present in blood, but in the case of IgM are often elevated in PBC. In addition, the abnormal antibodies directed against mitochondria (AMA), were also reduced after treatment. However, levels returned to baseline by 36 weeks. Further, serum alkaline phosphatase decreased up to 36 weeks post-treatment.

The authors noted that rituximab therapy could clinically improve PBC through multiple pathways that include the reduction of anti-mitochondrial antibodies through depletion of memory B cells, increases in regulatory T cells associated with immune response, and modulation of cytokine production involved with inflammation. "Further investigation of B cell targeting strategies is necessary to develop potentially novel therapeutic options for patients with PBC," concludes Dr. Bowlus.


Full Citation: Biochemical and Immunologic Effects of Rituximab in Primary Biliary Cirrhosis Patients with an Incomplete Response to Ursodeoxycholic Acid." Masanobu Tsuda, Yuki Moritoki, Zhe-Xiong Lian, Weici Zhang, Katsunori Yoshida, Kanji Wakabayashi, Guo-Xiang Yang, Toshio Nakatani, John Vierling, Keith Lindor, M. Eric Gershwin and Christopher L. Bowlus. Hepatology; Published Online: January 27, 2012 (DOI: 10.1002/hep.24748); Print Issue Date: February 2012. http://onlinelibrary.wiley.com/doi/10.1002/hep.24748/abstract.

Author Contact: To arrange and interview with Dr. Bowlus, please contact Charles Casey with the Office of Public Affairs at UC Davis Health System at charles.casey@ucdmc.ucdavis.edu or 916-734-9048.

This study is published in Hepatology. Media wishing to receive a PDF of the article may contact healthnews@wiley.com.

About the Journal

Hepatology is the premier publication in the field of liver disease, publishing original, peer-reviewed articles concerning all aspects of liver structure, function and disease. Hepatology's current impact factor is 10.885.Each month, the distinguished Editorial Board monitors and selects only the best articles on subjects such as immunology, chronic hepatitis, viral hepatitis, cirrhosis, genetic and metabolic liver diseases and their complications, liver cancer, and drug metabolism. Hepatology is published on behalf of the American Association for the Study of Liver Diseases (AASLD). For more information, please visit http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1527-3350 .

About Wiley-Blackwell

Wiley-Blackwell is the international scientific, technical, medical, and scholarly publishing business of John Wiley & Sons, with strengths in every major academic and professional field and partnerships with many of the world's leading societies. Wiley-Blackwell publishes nearly 1,500 peer-reviewed journals and 1,500+ new books annually in print and online, as well as databases, major reference works and laboratory protocols. For more information, please visit http://www.wileyblackwell.com or our new online platform, Wiley Online Library (http://www.wileyonlinelibrary.com), one of the world's most extensive multidisciplinary collections of online resources, covering life, health, social and physical sciences, and humanities.



February 2, 2012

Caffeine consumption has long been associated with decreased risk of liver disease and reduced fibrosis in patients with chronic liver disease. Now, newly published research confirms that coffee caffeine consumption reduces the risk of advanced fibrosis in those with nonalcoholic fatty liver disease (NAFLD). Findings published in the February issue of Hepatology, a journal of the American Association for the Study of Liver Diseases, show that increased coffee intake, specifically among patients with nonalcoholic steatohepatitis (NASH), decreases risk of hepatic fibrosis.

The steady increase in rates of diabetes, obesity, and metabolic syndrome over the past 20 years has given rise to greater prevalence of NAFLD. In fact, experts now believe NAFLD is the leading cause of chronic liver disease in the U.S., surpassing both hepatitis B and C. The majority of patients will have isolated fatty liver which has a very low likelihood of developing progressive liver disease. However, a subset of patients will have NASH, which is characterized by inflammation of the liver, destruction of liver cells, and possibly scarring of the liver. Progression to cirrhosis (advanced scarring of the liver) may occur in about 10-11% of NASH patients over a 15 year period, although this is highly variable.

To enhance understanding of the correlation between coffee consumption and the prevalence and severity of NAFLD, a team led by Dr. Stephen Harrison, Lieutenant Colonel, U.S. Army at Brooke Army Medical Center in Fort Sam Houston, Texas surveyed participants from a previous NAFLD study as well as NASH patients treated at the center's hepatology clinic. The 306 participants were asked about caffeine coffee consumption and categorized into four groups: patients with no sign of fibrosis on ultrasound (control), steatosis, NASH stage 0-1, and NASH stage 2-4.

Researchers found that the average milligrams in total caffeine consumption per day in the control, steatosis, Nash 0-1, and Nash 2-4 groups was 307, 229, 351 and 252; average milligrams of coffee intake per day was 228, 160, 255, and 152, respectively. There was a significant difference in caffeine consumption between patients in the steatosis group compared to those with NASH stage 0-1. Coffee consumption was significantly greater for patients with NASH stage 0-1, with 58% of caffeine intake from regular coffee, than with NASH stage 2-4 patients at only 36% of caffeine consumption from regular coffee.

Multiple analyses showed a negative correlation between coffee consumption and risk of hepatic fibrosis. "Our study is the first to demonstrate a histopatholgic relationship between fatty liver disease and estimated coffee intake," concludes Dr. Harrison. "Patients with NASH may benefit from moderate coffee consumption that decreases risk of advanced fibrosis. Further prospective research should examine the amount of coffee intake on clinical outcomes."

More information: "Association of Coffee and Caffeine Consumption with Fatty Liver Disease, Non-alcoholic Steatohepatitis, and Degree of Hepatic Fibrosis." Jeffrey W Molloy, Christopher J Calcagno, Christopher D Williams, Frances J Jones, Dawn M Torres, Stephen A Harrison. Hepatology; December 22, 2011 (DOI: 10.1002/hep.24731); Print Issue Date: February 2012.

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