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在刚刚闭幕的肝病学领域国际年度压轴盛会——美国肝病研究学会年会（AASLD2023）上，美国加利福尼亚大学旧金山分校Rena K. Fox教授应邀在“Overcoming Challenges in the Hepatitis C Care Cascade”专题中，介绍了美国利用电子病历改善丙型肝炎病毒（HCV）筛查、转诊和治疗的卫生系统解决方案，并于会后接受《国际肝病》专访时进一步分享丙型肝炎临床管理和消除威胁目标的经验和观点，访谈视频和中英文对照访谈原稿分享如下。

 

一、建议所有成年人接受HCV筛查

 

《国际肝病》

在哪些人群中应该加强HCV的筛查工作，以及如何提高筛查率以确保早期发现和治疗？

 

Rena K. Fox教授

 

在美国，目前的普遍的筛查建议是所有成年人都应该接受丙型肝炎的筛查。这个新的建议是2020年开始实施的，与之前针对有限群体的筛查建议相比，这是一个很大的进步。目前提议进行普遍筛查的原因是丙型肝炎的风险因素包括注射、药物使用和输血等，但是患者并不总是报告（自己经历过的）相关风险事件。研究发现，进行普遍筛查更有可能检测到丙型肝炎。

 

英文原文：

 

: Which populations should priority be given for HCV screening, and how can we improve screening rates to ensure early detection and treatment?

 

Dr. Rena Fox: Great question. In the United States, the recommendation currently is that all adults should be screened for hepatitis C. So that is a universal screening recommendation. That has been in place since 2020 now and was a real improvement over prior screening recommendations, which were for more limited groups.The reason for a universal screening is because the risk factors for hepatitis C are things like prior injection, drug use, blood transfusions and so patients don't always self-report what those risk factors are and it's found that having a universal screening is more likely to be able to pick up a detected hepatitis C.

 

二、“两手抓”，新确诊和既往确诊但未治疗者均需重视治疗连接

 

《国际肝病》

在HCV筛查阳性后，如何有效地将患者与治疗服务关联起来，并克服可能存在的障碍？

 

Rena K. Fox教授

 

如何将检测结果呈阳性的患者与治疗联系起来，这个问题的答案很大程度上取决于你工作的环境。首先需要做的事情是将筛查检测与诊断检测联系起来，以确认患者是否为慢性感染。接下来，医疗工作者得到检查结果后，会立即将结果呈阳性的患者转交给可提供治疗的医生。

 

我认为，面临的一个问题是如何找到以往被诊断为丙型肝炎但并没有接受治疗的患者。对于新确诊患者，我们希望他们能够立即接受相关治疗。因此，我认为患者可以分为两类，一类是新感染或新诊断的患者，另一类是已经诊断出丙型肝炎但没有接受治疗的患者，这两类患者的治疗连接均需重视。

 

英文原文：

 

: After a positive HCV screen, how can we effectively link patients to treatment services and overcome potential barriers?

 

Dr. Rena Fox:  This is a really good question about linking patients with a positive test to treatment. The answer depends on the setting in which you are working. So ideally your screening test, which is an antibody test, would be reflexed to a diagnostic test which is a hepatitis C RNA.   So, the first item is that the screening test be linked to a diagnostic test to confirm the infection is chronic.  And then again, if you are in a system where patients would be tested and have treatment available, the ideal would be that when the ordering physician or provider gets the result that they would then immediately refer them to a treater.

 

I think some of the problems that we are facing are how to locate patients who have been diagnosed in the past but have not been treated. And, you know, going forward, if the position was a new diagnostic test, you would want them to be referred for treating immediately. So, I think there is kind of two halves here, new infections being or new diagnosis versus finding people who have existing diagnosed hepatitis C but have not been treated.

 

三、治愈率高达95%，注意HBV筛查和用药禁忌

 

《国际肝病》

目前有哪些最新的治疗方法和药物可用于HCV感染，它们的疗效和副作用如何？

 

=Rena K. Fox教授

 

自2014年以来，直接作用抗病毒（DAAS）类药物的问世可谓医学奇迹，独树一帜。对于大多数既往未接受治疗的丙型肝炎患者，目前的一线治疗主流选择有索磷布韦/维帕他韦（丙通沙?）和格卡瑞韦/哌仑他韦（艾诺全?）。

 

这两种药物的药效很一致，但是两者之间仍有一些区别。后者需要每天服用，一次3片，通常持续8周。前者则是每天服用，一次1片，通常持续12周。这两种药物的持续病毒学应答率均超过了95%，达到了非常高的治愈率。

 

在不良反应方面，二者均非常轻微。部分患者可能会感到疲惫或恶心。但除此之外的其他DAA，需要注意其禁忌证。此外，在选择这两种药物时，需要确保患者已经接受了HBV检测，如果患者罹患乙型肝炎，则在患者接受DAA治疗期间需要进行特殊监测。

 

英文原文：

 

: What are the current state-of-the-art treatment methods and medications available for HCV infection, and what is their efficacy and side effect profile?

 

Dr. Rena Fox:  So since 2014 we have had a class of medications called direct acting antivirals called DAAS and these medications are really basically a medical miracle. They really, really are in a class of their own. The current first line treatments for most patients with Hepatitis C who have never been treated before are one of two choices. The trade names are Epclusa? and Maviret?.

 

Those two drugs are very equivalent to each other. There are some differences between them. Mavyret is 3 pills taken once a day, typically for eight weeks and Epclusa is 1 pill taken once a day, typically for 12 weeks. The efficacy rates are over 95% for a permanent cure. So, it is hard to beat, hard to beat with any medication for any condition to create that kind of a cure rate.

 

In terms of side effects, they are very mild and few. So, some patients might have fatigue or nausea. There are a couple of medications that you have to watch out for in terms of contraindications. The other issue is that for both of them, you need to be sure that the patient is already tested for hepatitis B because of the patient has hepatitis B then they need specific monitoring while they're on hepatitis C drug.

 

四、授权非专科医师、协助基层社区进行丙型肝炎诊治

 

《国际肝病》

如何解决HCV治疗中的可及性、成本和复发等挑战，以确保更多感染者能够获得治愈？

 

Rena K. Fox教授

 

就改善治疗可及性而言，我认为治疗手段越容易获得越好。扩大非专业人员提供治疗的能力是一个很好的计划。治疗的应用、处方和监控并不困难。我认为，非专业人士应该越来越多地获得授权，并学会如何开处方和监控治疗过程。让每一位患者都去看专科医生，这件事不太现实，也不太可能，这是未来我们需要做的一项重要工作。

 

此外，出台帮助卫生保健系统和社区改善治疗服务的政策。例如在美国，我们有一项叫做HEDIS的医疗保健有效性数据和信息集，但是并没有针对丙型肝炎的HEDIS。如果我们能够推动针对丙型肝炎的HEDIS的实施，那我们就能够帮助激励医疗系统为丙型肝炎患者提供治疗，这将大有助益。

 

实际上，美国加州于2022年通过了一项名为AB789的新法律，该法律要求初级保健医生进行HBV和HCV检测，如果患者的检测结果为阳性，就进行治疗或者提供转诊。所以我们要做的是激励、政策、让非专业人士获得提供治疗的权限，用媒体进行宣传让患者对丙型肝炎有更多的了解并减少相关的羞耻感。

 

在一些国家和地区，这方面确实取得了惊人的成功。例如埃及最近刚刚实现了丙型肝炎的完全消除，考虑到达成这一目标的困难程度，这无疑是令人难以置信的成功。但是如果我们有药物，这件事情是可以做到的，我们知道如何诊断和如何治疗。目前，主要需要解决的是与组织、人员、优先事项和资金相关的问题。我现在在做的就是将这些信息传达给更多的人。

 

英文原文：

 

: How can we address challenges such as accessibility, cost, and relapse in HCV treatment, to ensure that more infected individuals can achieve a cure?

 

Dr. Rena Fox: Well, in terms of improving access, I think that the more available the treatment is, the better. Really expanding the ability for non-specialists to provide treatment is an excellent plan. The use of the treatment, the prescription and monitoring not difficult and I think non specialists should be more and more empowered and taught how to do the prescribing and do the monitoring. Because if you make every patient have to see a specialist, it is not nearly as realistic or possible. So that is one item.

 

I think another item is policy. Policies that help healthcare systems and communities have incentives to improve their treatment. For example, in the US, we have things called a HEDIS measure. We do not have a HEDIS measure for hepatitis C, which would help a lot if we could help incentivize systems to get for hepatitis C patients treated.

 

Laws, actually, in California, there is a new law that was passed in 2022 called AB789, which requires primary care doctors to test for hepatitis B and C, and to treat or refer to treatment if a patient is positive. So, incentives, policies, having non specialists empowered for treatment and then, you know, media campaigns so that patients know more about it, and also to reduce any stigma.

 

There are really, there have been amazing success in this in some communities and also in some countries. Egypt has recently just accomplished an incredible campaign and really worked to eliminate Hepatitis C in Egypt, where was extremely trouble. So, this can be done if we have the drugs. You know, we know how to make the diagnosis, we know how to cure this. It is really a matter of kind of organization, people, priorities, funding. And I am getting the word out.

 

 

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