[Management of HCV and HBV infected patients]

2014

Chapter 4: Prevention of hepatitis B and C in drug users
Recommendations
Global and coordinated disease management, focused on prevention, should be offered to drug users. Harm reduction has been an integral part of healthcare policies for addictions since 2014, however funding is insufficient resulting in poor acceptance, inadequate implementation and efficacy.
- Support approaches that offer global and coordinated care to drug users in the same location (sociomedical treatment of addiction, harm reduction, diagnostic testing, non-invasive testing of liver fibrosis, antiviral treatment and monitoring of liver disease).
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Chapter 7 Evaluation of liver fibrosis in hepatitis B and C virus infections
Key points
- Several non-invasive blood tests (FibroTest, FibroMeter and Hepascore) as well as liver stiffness by FibroScan were validated in 2008 by the French national authority for Health ('HAS') for the assessment of the extent liver fibrosis and the presence of cirrhosis due to HCV.
- These non-invasive tests have been reimbursed by French national health insurance since 2012, but only once a year in untreated chronic hepatitis C without co-morbidities.
- The diagnostic accuracy of these different tests is basically similar for the diagnosis of moderate and severe fibrosis as well as cirrhosis.
- When tests results show that there is no significant fibroses, the risk of a false negative is approximately 20%.
- Non-invasive tests, in particular FibroScan, reliably exclude a diagnosis of cirrhosis (the risk of false negatives is less than 10%). On the other hand the positive predictive value is approximately 50%.
- The combination of a blood test and liver stiffness measurement increases the diagnostic accuracy of the results for significant fibrosis, but no cirrhosis. A biopsy is indicated in case of disagreement between the two methods.
- The predictive value of non-invasive tests for the risk of hepatic events and survival is high and seems to be better especially for compensated cirrhosis. Although changes in test results over time may be have an even stronger predictive value for the risk of complications, this approach is being validated.
- Although it has not been validated by the French national authority for health (HAS) and it is not reimbursed by French national health insurance, non-invasive tests are used in clinical practice for the evaluation of fibrosis in patients with chronic HBV. The Direction générale de la santé (DGS) requested that the use of these non-invasive tests in clinical practice for the diagnosis of HBV be evaluated by the French national authority for health ('HAS') to measure liver fibrosis in patients with chronic hepatitis B.
- Certain specificities of chronic HBV make interpretation of non-invasive tests more difficult: (a) a greater frequency of exacerbation of chronic HBV (increased transaminases that can interfere with results) and (b) an underestimation of fibrosis if the HCV thresholds are used.
- After viral suppression of HBV or viral eradication of HCV, the results of noninvasive tests improve in most patients.
Recommendations
- Make sure that non-invasive tests are interpretated by specialists in liver disease, taking into consideration the quality of the test, the patients clinical characteristics, and the results of other tests (biochemical, radiological and endoscopic).
- Obtain French national authority for health ('HAS') guidelines on the use of non-invasive tests in the diagnosis of fibrosis in HCV and HBV infection:
- in chronic HCV infection:
o continue evaluating the combination of different tests, to improve diagnostic accuracy,
o evaluate the role of non-invasive tests in post-treatment monitoring,
o extend the criteria for reimbursement of these tests,
o define the indications for liver biopsy.
- in chronic HBV infection:
o rapidly define the role of non-invasive tests in the diagnostic of fibrosis,
o propose a non-invasive diagnostic strategy reimbursed by French national health insurance,
o evaluate the role of non-invasive tests in the monitoring of patients after suppression of viral replication.
- Evaluate the interest of using non-invasive tests in the prognosis of chronic HBV and HCV infections in both treated and untreated patients, by integrating them into multiparametric models.
- Considering their ability to predict the risk of liver complications, express the results of non-invasive tests in quantitative values, and not simply by the F value of the METAVIR score.
- Support the development of new radiological techniques and new biological markers that take into account the dynamics of fibrogenesis, fibrolysis and co-morbidities.
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Chapter 8 Clinical consequences and treatment of hepatitis B infection
Recommendations
- Evaluate the severity of liver disease before making any therapeutic decision because of the adverse effects and/or the duration of existing treatments. The choice of available techniques depends on the patient's profile and the treatment strategy being considered:
o non-invasive tests may be indicated to identity asymptomatic chronic carriers who should not be treated but should be monitored, and patients with cirrhosis who need to be treated, whatever the viral load,
o liver biopsy which should be offered to patients with chronic hepatitis to evaluate necroinflammatory activity, the degree of fibrosis and to make therapeutic choices.
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Chapter 9 Clinical consequences and treatment of hepatitis C virus infection
Key points
- The indications for antiviral treatment are based on the severity of chronic hepatitis, in particular evaluated by the degree of fibrosis (using non-invasive tests and/or liver biopsy), the risk of short and intermediate term complications, the presence of extra-hepatic manifestations, as well as the motivation of the patient and his/her acceptance of treatment.
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Chapter 11 Liver transplantation and HBV and HCV infections
Recommendations
- Propose a yearly evaluation of fibrosis after liver transplantation for HCV-related liver disease. Non-invasive tests to evaluate fibrosis after transplantation should be further studied.
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Chapter 14 HIV/HCV/HBV coinfections
Recommendations
In patients with HCV coinfection
- Assess liver fibrosis with a blood test and transient elastography. If there is disagreement between non-invasive test results and in case of co-morbidities consider performing liver biopsy.
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Chapter 18: Care and support of vulnerable populations
Recommendations
Innovative approaches to be supported: mediation, appropriate housing, and advanced strategies
- Support mobile services that that offer a range of tools including vaccination against HBV, rapid diagnostic tests for hepatitis and FibroScan and develop training courses in counceling, in particular for rapid diagnostic tests.
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Chapter 20 Specific problems of chronic renal insufficiency, hemodialysis and kidney transplantation
Key points
Hepatitis C
- If HCV infection is diagnosed, the extent of fibrosis should be determined by liver biopsy until non-invasive tests have been validated in this population.
Hepatitis B
- If HBV infection is diagnosed, the extent of fibrosis should be determined by liver biopsy until non-invasive tests have been validated in this population.

Recommendations
- Evaluate non-invasive tests of fibrosis in patients with chronic renal insufficiency, under dialysis or not, and in kidney transplant patients and infected with HCV or HBV.