Establishing a hepatitis C continuum of care among HIV/hepatitis C virus-coinfected individuals in EuroSIDA.

OBJECTIVES: The aim of the study was to establish a methodology for evaluating the hepatitis C continuum of care in HIV/hepatitis C virus (HCV)-coinfected individuals and to characterize the continuum in Europe on 1 January 2015, prior to widespread access to direct-acting antiviral (DAA) therapy. METHODS: Stages included in the continuum were as follows: anti-HCV antibody positive, HCV RNA tested, currently HCV RNA positive, ever HCV RNA positive, ever received HCV treatment, completed HCV treatment, follow-up HCV RNA test, and cure. Sustained virological response (SVR) could only be assessed for those with a follow-up HCV RNA test and was defined as a negative HCV RNA result measured > 12 or 24 weeks after stopping treatment. RESULTS: Numbers and percentages for the stages of the HCV continuum of care were as follows: anti-HCV positive (n = 5173), HCV RNA tested (4207 of 5173; 81.3%), currently HCV RNA positive (3179 of 5173; 61.5%), ever HCV RNA positive (n = 3876), initiated HCV treatment (1693 of 3876; 43.7%), completed HCV treatment (1598 of 3876; 41.2%), follow-up HCV RNA test to allow SVR assessment (1195 of 3876; 30.8%), and cure (629 of 3876; 16.2%). The proportion that achieved SVR was 52.6% (629 of 1195). There were significant differences between regions at each stage of the continuum (P < 0.0001). CONCLUSIONS: In the proposed HCV continuum of care for HIV/HCV-coinfected individuals, we found major gaps at all stages, with almost 20% of anti-HCV-positive individuals having no documented HCV RNA test and a low proportion achieving SVR, in the pre-DAA era.

Historical epidemiology of hepatitis C virus (HCV) in selected countries.

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

Strategies to manage hepatitis C virus (HCV) disease burden.

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm.

The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.

Pesticide environmental indicators and environmental policy.

A current concern in many European countries is the environmental impact of agricultural pesticide usage and appropriate policy development to reduce impact. Currently, relatively hazardous pesticides that might be targeted for replacement by other products or management practices are not positively identified, with consequently few incentives for farmers to choose the least environmentally-risky chemicals. There is a lacuna in terms of widely-agreed operational environmental indicators, and an urgent need for comparative environmental assessment tools for pesticides, for use by both agriculturists and policy-makers. Such a system could, for example, provide a basis on which to differentiate an eco-tax according to the environmental threats posed by each product, and thus improve policy effectiveness. The heterogeneity of pesticide chemicals should be taken into account more explicitly in policy design. Through a comparison of different approaches covered in the literature on pesticide environmental classifications, this paper assesses the feasibility of developing environmental banding to improve the effectiveness of pesticide policy. A more pragmatic approach lies in the development of pesticide groupings rather than a continuous scale of environmental burden, i.e. focusing on broad similarities and differences rather than precise individual ordering. In particular, hazard indicators should be considered further, as a first stage in progress towards comprehensive environmental impact measures.

Women, family, and work in Indonesian transmigration.

PIP: The gender contribution to employment may be a critical factor in determining household economic viability. The significance for the resettlement program of the poor and landless from Indonesia's Inner Islands to the Outer Islands is clear. The aim of this paper is to examine the nature and extent of the role of women in off-farm employment (OFE) in a sample of South Sumatra, Indonesia transmigrants during the summer of 1989 at 9 different sites with different agricultural environments, settlement histories, and access to markets. A summary is provided of the literature on women's work and peasant household economies in Indonesia. Spatial and structural characteristics of employment among transmigrant women are described as well as life course influences on men's and women's OFE. A descriptive and explanatory model is presented that characterizes women's work and includes the influences of changing family structure on time allocation. Women's work appears fundamentally different from men's; household domestic work has a degree of flexibility in timing and tasks can be accomplished simultaneously. The hypothesis is that women will try to maximize their levels of flexibility and simultaneity in their income generating efforts. Discussion focuses on several theories of peasant household economies: 1) the Chayanov peasant model which posits that labor allocation for farm production in order to satisfy consumption needs is dependent on household demographic structure and the consumer labor balance; and 2) the New Home Economics theory which emphasizes the single utility function of the household. The villages represent 3 irrigated rice-growing and double cropping areas with established infrastructures and access to markets; 3 area with tidal swamp rice production and few resources; and area with rainfed rice production and limited resources and an area with ample resources; and 2 areas with smallholder rubber production. There were 560 ethnically Javanese households included in the sample, with an average proportion of 10% in each settlement. OFE is either on scheme, which means within the transmigration scheme and involves short distances to work, or off scheme, which entails longer work trips. 61% of the sample were involved in on scheme and 42% were involved in off scheme OFE, of which 10% were heads of households and 4% were spouses.^ieng