Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
S Afr Med J. 2020 Jan 29;110(2):106-111. doi: 10.7196/SAMJ.2020.v110i2.14208.
Hepatitis C virus (HCV) in South Africa (SA) is incompletely characterised and understood. Epidemiological and clinical data will better inform our understanding and assist national policy decision-making. Against the background of more than two decades of clinical challenges in HCV management, the advent of direct-acting antivirals (DAAs) now makes HCV elimination plausible.
To better understand the base from which we come, we elected to review and characterise our HCV experience at Groote Schuur Hospital (GSH), Cape Town, SA, in the pegylated interferon (Peg-IFN) and ribavirin (RBV) management era.
Patients with chronic HCV infection attending the GSH Liver Clinic from 2002 to 2014 were included in the analysis. Relevant data were extracted from a registry and existing clinical records were accessed. Two brands of Peg-IFN were available, and patients treated with the first-generation add-on protease inhibitor telaprevir were included.
A total of 238 patients were included in the analysis (median (interquartile range) 47 (37 - 58) years, 60.5% males). Males were significantly younger than females (43.5 (35 - 52) years v. 55 (42 - 64) years, respectively) (p<0.0001). The majority were white (55.9%) or of mixed ancestry (21.8%), 16.4% were HIV co-infected, 3.7% were hepatitis B virus (HBV) co-infected, and 1 patient (0.4%) was triple-infected with HCV, HBV and HIV. The most likely mode of HCV acquisition was blood or blood product exposure prior to 1992 (32.8%) and injecting drug use (17.6%), while 30.3% of patients had no clear risk factor identifiable. Genotypes (GTs) 1 - 5 were observed, with GT-1 (34.9%) predominating. Of patients who were biopsied (n=90), 30.0% had ≥F3 fibrosis, with 15.6% cirrhotic. With IL28B polymorphisms, the heterozygous CT (23.9%) and CC (15.5%) genotypes were most frequent. Of the patients, 32.6% accessed Peg-IFN/RBV-based therapy, 6.5% (n=5) with add-on telaprevir. GT-1 (35.1%) was most prevalent in the treatment group, followed by GT-3 (26.0%) and GT-5 (18.2%); 10.0% were HIV co-infected. The overall sustained virological response (SVR) rate was 75.3%, with 37.0% of GT-1 patients not achieving SVR. Of the patients treated, 49.4% experienced adverse events, including cytopenias (32.5%) and depression (15.6%), and 23.4% required cell support in the form of erythropoietin and/or granulocyte-macrophage colony-stimulating factor.
HCV patients in the Peg-IFN/RBV management era typified the epidemiology of HCV. GT distribution was pangenotypic, and treatment outcomes were encouraging despite treatment challenges. Patient selection, IL28B and sensible support of cytopenias probably accounted for these favourable outcomes. However, numbers treated were limited, and the DAA era of therapy allows for rapid expansion of therapy with now growing numbers of patients and a changing local epidemiology.
南非（SA）的丙型肝炎病毒（HCV）尚未得到充分描述和了解。流行病学和临床数据将更好地帮助我们了解情况，并为国家决策提供信息。在 HCV 管理面临二十多年临床挑战的背景下，直接作用抗病毒药物（DAAs）的出现使 HCV 消除成为可能。
为了更好地了解我们的起点，我们选择回顾和描述我们在南非开普敦格罗特舒尔医院（GSH）在聚乙二醇干扰素（Peg-IFN）和利巴韦林（RBV）管理时代的 HCV 经验。
纳入 2002 年至 2014 年在 GSH 肝脏诊所就诊的慢性 HCV 感染患者进行分析。从登记处提取相关数据，并查阅现有的临床记录。有两种品牌的 Peg-IFN 可用，包括第一代添加蛋白酶抑制剂特拉普韦的患者。
共有 238 例患者纳入分析（中位数（四分位数范围）47（37-58）岁，60.5%为男性）。男性明显比女性年轻（分别为 43.5（35-52）岁和 55（42-64）岁）（p<0.0001）。大多数患者为白人（55.9%）或混血（21.8%），16.4%为 HIV 共感染，3.7%为乙型肝炎病毒（HBV）共感染，1 例（0.4%）患者同时感染 HCV、HBV 和 HIV。HCV 感染的最可能途径是在 1992 年之前通过血液或血液制品暴露（32.8%）和注射吸毒（17.6%），而 30.3%的患者无法确定明确的风险因素。观察到 1-5 型 HCV 基因型（GTs），其中 GT-1（34.9%）占主导地位。接受活检的患者（n=90）中，30.0%有≥F3 纤维化，15.6%有肝硬化。根据 IL28B 多态性，杂合 CT（23.9%）和 CC（15.5%）基因型最为常见。在接受治疗的患者中，32.6%接受了 Peg-IFN/RBV 为基础的治疗，其中 6.5%（n=5）添加了特拉普韦。GT-1（35.1%）在治疗组中最为常见，其次是 GT-3（26.0%）和 GT-5（18.2%）；10.0%为 HIV 共感染。总的持续病毒学应答（SVR）率为 75.3%，其中 37.0%的 GT-1 患者未达到 SVR。在接受治疗的患者中，49.4%出现不良反应，包括血细胞减少症（32.5%）和抑郁症（15.6%），23.4%需要以红细胞生成素和/或粒细胞巨噬细胞集落刺激因子的形式进行细胞支持。
在 Peg-IFN/RBV 管理时代的 HCV 患者代表了 HCV 的流行病学。GT 分布是泛基因型的，尽管存在治疗挑战，但治疗结果令人鼓舞。患者选择、IL28B 和明智地支持血细胞减少症可能是这些有利结果的原因。然而，接受治疗的人数有限，而 DAAs 治疗时代允许快速扩大治疗范围，现在有越来越多的患者和不断变化的当地流行病学。
