Highlights
- •Alcohol use disorder is a major contributor to HCV-related liver disease burden.
- •Alcohol use could reduce individual and population level benefits of HCV treatment.
- •Impact of alcohol use on liver disease should be monitored in the DAA era.
- •World Health Organization has set a 65% HCV mortality reduction target by 2030.
- •To achieve this target, strategies are needed to manage the use and impact of alcohol.
Background & Aims
The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis
C virus (HCV) elimination. However, in the context of alcohol use disorder the ability
of DAAs to achieve these targets may be compromised. The aim of this study was to
evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis
in three settings.
Methods
HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland
(1995–2011/2012/2013, respectively) were linked to hospital admissions (2001–2012/2013/2014,
respectively). Alcohol use disorder was defined as non-liver-related hospitalisation
due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were
plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated
population attributable fractions (PAFs) were computed.
Results
Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales,
and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis
diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol
use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates
were considerably higher in people with alcohol use disorder in New South Wales and
Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder
in British Columbia (aHR 1.92; 95% CI 1.76–2.10), New South Wales (aHR 3.68; 95% CI
3.38–4.00) and Scotland (aHR 3.88; 95% CI 3.42–4.40). The PAFs of decompensated cirrhosis-related
to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales
and Scotland, respectively.
Conclusions
Alcohol use disorder was a major contributor to HCV liver disease burden in all settings,
more distinctly in Scotland. The extent to which alcohol use would compromise the
individual and population-level benefits of DAA therapy needs to be closely monitored.
Countries, where appropriate, must develop strategies combining promotion of DAA treatment
uptake with management of alcohol use disorders, if World Health Organization 2030
HCV mortality reduction targets are going to be achieved.
Lay summary
The burden of liver disease has been rising among people with hepatitis C globally.
The recent introduction of highly effective medicines against hepatitis C (called
direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA
scale-up could eliminate hepatitis C as a public health threat in the coming decades.
However, our findings show heavy alcohol use is a major risk factor for liver disease
among people with hepatitis C. If continued, heavy alcohol use could compromise the
benefits of new antiviral treatments at the individual- and population-level. To tackle
hepatitis C as a public health threat, where needed, DAA therapy should be combined
with management of heavy alcohol use.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: October 26, 2017
Accepted:
October 7,
2017
Received in revised form:
August 21,
2017
Received:
May 9,
2017
Identification
Copyright
© 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
