The adenine-rich tract in the 5ʹ-end of the hepatitis C virus ORF encodes a peptide regulating the binding of the C protein to RNA

Hepatitis C virus (HCV ) core (C) protein is thought to bind to viral RNA before it undergoes oligomerization leading to RNA encapsidation. Details of these events are so far unknown. The 5ʹ-terminal C protein coding sequence that includes an adenine (A)-rich tract is a part of an internal ribosome entry site(IRES). This nucleotide sequence but not the corresponding protein sequence is needed for proper initiation of translation of viral RNA by an IRES-dependent mechanism. In this study, we examined the importance of this sequence for the ability of the C protein to bind to viral RNA. Serially truncated C proteins with deletions from 10 up to 45 N-terminal amino acids were expressed in Escherichia coli, purified and tested for binding to viral RNA by a gel shift assay. The results showed that truncation of the C protein from its N-terminus by more than 10 amino acids abolished almost completely its expression in E. coli. The latter could be restored by adding a tag to the N-terminus of the protein. The tagged proteins truncated by 15 or more amino acids showed an anomalous migration in SDS-PAGE. Truncation by more than 20 amino acids resulted in a complete loss of ability of tagged C protein to bind to viral RNA. These results provide clues to the early events in the C protein - RNA interactions leading to C protein oligomerization, RNA encapsidation and virion assembly.

Support for patients with hepatitis C : An exploratory qualitative study of medical specialists’ perceptions

Objective: To explore the range of meanings about the role of support for patients with hepatitis C by examining medical specialists' perceptions. Method: The study employed a qualitative, open-ended interview design and was conducted in four major teaching hospitals in Adelaide, South Australia. Eight participants (three infectious disease physicians, four gastroenterologists, one hepatologist), selected through purposive sampling, were interviewed about general patient support, their role in support provision, the role of non-medical support and their reasons for not using support services. Results: Main themes included a focus on support as information provision and that patient education is best carried out by a medical specialist. The use of support services was defined as the patient's decision. Participants identified four key periods when patients would benefit from support; during diagnosis, failure to meet treatment criteria, during interferon treatment and following treatment failure. Conclusions: It was concluded that while barriers exist to the establishment of partnerships between specialists and other support services, this study has identified clear points at which future partnerships could be established. Implications: A partnership approach to developing support for patients with hepatitis C offers a systematic framework to facilitate the participation of health professionals and the community in an important area of public health.

Hepatitis C in the workplace : a survey of women’s occupational health and safety in the beauty therapy industry

Objective: To examine current knowledge and practice of occupational health and safety (OH&S) regarding hepatitis C in beauty therapy practice. Methods: A questionnaire was sent to all beauty therapy practices identified through the Telstra Yellow Pages and distributed via beauty therapy product agencies. Results: 119 questionnaires were completed by employers and employees in 99 beauty therapy practices in metropolitan Adelaide. Beauty therapists reported carrying out many practices that had exposed them to blood in the past. More than 80% of the procedures carried out by beauty therapists in the previous week were reported to have led to exposure to blood. 39.5% of respondents had not received information about OH&S practices related to blood spills and 77.5% of respondents had received no OH&S information about hepatitis C. Knowledge of hepatitis C and its transmission was poor, with 62% of respondents incorrectly identifying the prevalence of hepatitis C and respondents incorrectly identifying sneezing (28%), kissing (46%) and sharing coffee cups (42%) as a modes of transmission. 80% of beauty therapy practices had no OH&S representative. Conclusion: Beauty therapy practice can expose both operator and client to blood and is therefore a potential site for the transmission of blood-borne diseases including hepatitis C. OH&S information is inadequate in this industry and knowledge of hepatitis C is poor.

Hepatitis C : a socio-cultural perspective on the effects of a new virus on a community’s health

Since the emergence of diagnostic medical tests in Australia in 1990, hepatitis C (HCV) has been shown to account for over 90 percent of all non-A non-B hepatitis, revealing it to be a widespread and major public health problem. The diagnosis of HCV involves a diverse range of issues for affected persons, introducing identity and lifestyle changes, which are commonly articulated through psychological concepts. In this article we argue that it is important to examine the broader social and cultural contexts that contribute to the experiences of persons affected by HCV. The thematic analysis of qualitative data from six individuals diagnosed with HCV is included to exemplify some of the processes that are involved in the changing identity of a person following a positive diagnosis. The theoretical framework for the interpretation of these processes is interpretive interactionism. In this research, we are attempting to extend the understanding of the effects of HCV diagnoses beyond internal, psychological processes by examining how these diagnoses transform some of the processes of self-formation and expression. The participants’ experiences indicate that there are at least four dimensions of self that were significant to their changing sense of self: relationship of self to others; the emotional self; self-stories and identity; and self-scrutiny and relationships. We conclude that a socio-cultural perspective contributes to the explanation of the transition period following a HCV-positive diagnosis and the redefinition of self towards a HCV status.

Hepatitis C and policy implementation : ethics as a dialogic process for resource allocation

Hepatitis C, which was first identified in 1988, has become an important issue for public health as epidemiological and clinical evidence has emerged. These disciplines have highlighted the extent of infection and its medical consequences. Now, governments at both the state and federal levels are sifting through this evidence and are attempting to create structures to deal with the problem of hepatitis C. These structures have generally taken the form of expert committees and working parties organised from established medical, scientific and public health bodies...

Unravelling the maze : Hepatitis C, psychosocial factors and access to antiviral therapy

In this paper we present an examination of the literature on the psychosocial aspects of hepatitis C (HCV), and ask what are the implications for patients and clinicians regarding access to treatment? Hepatitis C (HCV) is a blood-borne communicable disease that was identified in 1988. In Australia, an estimated 217,000 people live with HCV. The virus causes serious liver inflammation, can lead to liver cirrhosis and a small percentage of sufferers will develop hepatocellular carcinoma. Reports about the psychosocial aspects of HCV appeared from around 1994 indicating a similar set of societal responses to people with HIV; stigmatisation and discrimination. A number of calls were made for the establishment of counselling and support services to address the specific mental health needs of people with HCV. We conducted a systematic review of the literature between 2002-2012 about the psychosocial aspects of HCV and its relationship to access to treatment and identified a number of key issues that suggest the anticipated progress in this area has not been made. The majority of people with HCV already experience marginalisation, and the diagnosis of HCV further compounds their marginalisation through stigma and discrimination and complicates clinical decision-making around treatment. We conclude that the need for mental health services that are capable of addressing the complexities of the psychosocial aspects of HCV remains. Concomitantly, primary care clinicians require greater clarity and consistency about the clinical guidelines for HCV to meet the increasing expectations on them to deliver comprehensive patient management within primary care. (248 words)

The concept of congruent patient-centred care for hepatitis C management

Patient-centred care has been touted as the cornerstone of an effective and efficient primary health care system. However, primary care by its nature is a fragmented system. The system co-evolves in response to needs rather than being planned. In recent years, Medicare Locals were formed in Australia with the intention to tap into this pragmatic nature of primary care and foster health services delivery which is responsive to community and individual patient needs i.e. ‘patient-centred care’. However, it remains to be seen what and how theoretical framework/s can inform this work. For this presentation we aim to illustrate with a case study how hepatitis C is currently managed in primary care and hypothesise what a congruent model of patient-centred care for hepatitis C management could look like.

Interferon-free therapy for hepatitis C, how prepared is Australia for biosimilars?

The Hepatitis C virus (HCV) affects some 150 million people worldwide. However, unlike hepatitis A and B there is no vaccination for HCV and approximately 75% of people exposed to HCV develop chronic hepatitis. In Australia, around 226,700 people live with chronic HCV infection costing the government approximately $252 million per year. Historically, the standard approved/licenced treatment for HCV is pegylated interferon with ribavirin. There are major drawbacks with interferon-based therapy including side effects, long duration of therapy, limited access and affordability. Our previous survey of an at-risk population reported HCV treatment coverage of only 5%. Since April 2013, a new class of interferon-free treatments for chronic HCV is subsidised under the Pharmaceutical Benefits Scheme: boceprevir and telaprevir - estimated to cost the Australian Government in excess of $220 million over five years. Other biologic interferon-free therapeutic agents are scheduled to enter the Australian market. Use of small molecule generic pharmaceuticals has been advocated as a means of public cost savings. However, with the new biologic agents, generics (biosimilars) may not be feasible or straightforward, due to long patent life; marketing exclusivity; and regulatory complexity for these newer products.

Hepatitis C, mental health and equity of access to antiviral therapy : a systematic narrative review

Introduction Access to hepatitis C (hereafter HCV) antiviral therapy has commonly excluded populations with mental health and substance use disorders because they were considered as having contraindications to treatment, particularly due to the neuropsychiatric effects of interferon that can occur in some patients. In this review we examined access to HCV interferon antiviral therapy by populations with mental health and substance use problems to identify the evidence and reasons for exclusion. Methods We searched the following major electronic databases for relevant articles: PsycINFO, Medline, CINAHL, Scopus, Google Scholar. The inclusion criteria comprised studies of adults aged 18 years and older, peer-reviewed articles, date range of (2002--2012) to include articles since the introduction of pegylated interferon with ribarvirin, and English language. The exclusion criteria included articles about HCV populations with medical co-morbidities, such as hepatitis B (hereafter HBV) and human immunodeficiency virus (hereafter HIV), because the clinical treatment, pathways and psychosocial morbidity differ from populations with only HCV. We identified 182 articles, and of these 13 met the eligibility criteria. Using an approach of systematic narrative review we identified major themes in the literature. Results Three main themes were identified including: (1) pre-treatment and preparation for antiviral therapy, (2) adherence and treatment completion, and (3) clinical outcomes. Each of these themes was critically discussed in terms of access by patients with mental health and substance use co-morbidities demonstrating that current research evidence clearly demonstrates that people with HCV, mental health and substance use co-morbidities have similar clinical outcomes to those without these co-morbidities. Conclusions While research evidence is largely supportive of increased access to interferon by people with HCV, mental health and substance use co-morbidities, there is substantial further work required to translate evidence into clinical practice. Further to this, we conclude that a reconsideration of the appropriateness of the tertiary health service model of care for interferon management is required and exploration of the potential for increased HCV care in primary health care settings.

A smoking cessation intervention for people with chronic Hepatitis C : a randomised controlled trial

Purpose The purpose of this study was to examine the validity of current practice in smoking cessation for the general population i.e., a telephone counselling and nicotine replacement therapy (NRT) intervention and its applicability to people with chronic hepatitis-C. Methods A randomised controlled trial was conducted over twelve weeks. Following consent, ninety-two smokers (outpatients) with chronic hepatitis-C were recruited by the Nurse Practitioner hepatology, randomly assigned and stratified by number of cigarettes smoked (i.e., 15 and greater; <15) into the intervention group (telephone counselling and NRT) and control group (telephone counselling). Outcomes measured included socio-demographics, nicotine dependence, depression, anxiety and stress and quality of life (QOL). All statistical data were analysed using SPSS. Results After 12 weeks, the intervention group showed a sustained reduction of smoking i.e., 5.8(CI: 2.4,9.3) cigarettes less per day, whereas the control group showed 1.6(CI:-1.9,5.2) cigarette reduction. Although not statistically significantly different (F=2.9, p=0.090) the intervention group on average smoked 4.2 fewer cigarettes compared to the control group. After twelve weeks, seven patients in the intervention group and three patients in the control group reported quitting. Whilst not statistically significant (Fisher’s Exact, p=0.311) this was a clinically significant result. No differences were found for nicotine dependence or depression, anxiety and stress. The intervention group experienced no change in QOL (-0.1,CI:-0.9, 0.6), however, the environmental score for the control group decreased by 1.8(CI:1.0, 2.6,p= 0.001). This was statistically significant. Conclusion A telephone counselling and nicotine replacement therapy intervention from the nurse practitioner, hepatology reduced smoking in patients with chronic hepatitis-C. The intervention group showed a sustained reduction over the 12 weeks. A total of 10 patients quit smoking at the end of the study. QOL deteriorated in the environmental subscale for the control group. These results informed a nurse practitioner model of care for approaches to smoking cessation.

Hepatitis C and initiates into injecting drug use among young people: Part I: The first shot

Explores how young people in Australia first come to inject drugs and how they learn about hepatitis C and sterile injecting drug use. Background on hepatitis C; Reasons for injecting drugs; Selection criteria for young people's participation in the i2i Project.

Managing mental health co-morbidities in hepatitis C: A systematic review of clinical guidelines

BACKGROUND Mental health co-morbidities are prevalent in hepatitis C (HCV), and in practice often considered a contraindication for initiation of treatment. A systematic review was conducted to explore whether and how current HCV clinical practice guidelines address pre-existing mental health co-morbidities. METHODS A review of the literature was undertaken to identify guidelines for the management of HCV, published in English, between 2002 and January 2015. Characteristics of the guidelines were recorded and key themes on mental health were summarized across predefined stages in the patient journey (diagnosis, pre-HCV drug therapy, on HCV drug therapy, post-HCV drug therapy, advanced disease or palliative care). RESULTS Twenty-five HCV clinical guidelines were included. Referral to psychiatrist is generally recommended as pre- and in-treatment assessment of mental health co-morbidities but HCV guidelines do not offer explicit instructions on how to manage mental health co-morbidities. Post-treatment assessment of mental health co-morbidities were lacking. Conclusions Current chronic HCV clinical guidelines are limited in their advice to clinicians regarding the management of mental health co-morbidities.

A systematic review of hepatitis C clinical practice guidelines: Benefits, limitations and harms

Background Hepatitis C (HCV) was described as a “viral time bomb” due to its prevalence and potential for causing serious, life-threatening complications. The Australian’s National Hepatitis C Strategy calls for a coordinated, evidence-based approach to testing, management, care and support of HCV. This review aimed to systematically and comparatively appraise existing international HCV clinical guidelines. Methods A systematic search of bibliographic databases and reference lists from selected papers were the source of data. Inclusion criteria were latest clinical guidelines as defined by Institute of Medicine, published in English, between January 2002 and November 2014. Quality of the guidelines was independently assessed using the iCAHE instrument. Results Twenty-eight international clinical practice guidelines were included. The majority of the international guidelines were based on the same primary studies however clinical recommendations on pre- and in-treatment assessments, choice of pharmaceuticals, and dosages and duration of the same pharmaceutical agents varied considerably. This diversity was beyond what would be considered reasonable practice context variations. Furthermore, there is limited guidance on post-treatment surveillance and care. Conclusions/implications There is a need for a harmonised international consensus on the clinical management of HCV. Key message A lack of consistency among international HCV clinical guidelines may impede effective and efficient patient care.

Communication ethics in public health

As new diseases and medical conditions emerge, new community groups appear in the public health arena as consumer advocates or lobby groups seeking to affect policy or to represent ‘communities’ formed around these new diseases and conditions. The role of these groups in public health, their political status, and the extent to which they are actually representative are highly problematic for public health. These new constellations of social groups and activities challenge traditional ideas about public health decision-making and demand a rethinking of the constituency and limits of public health. Using discourse theory, symbolic interactionism, and ethological theory, the authors examine one case, exploring the perspectives of various communities on hepatitis C, and explore some issues that this raises for public health.