prevention, treatment and care of hepatitis c among people who inject drugs jason grebely, phd...

Prevention, Treatment and Care of Hepatitis C among People Who Inject Drugs

Jason Grebely, PhDSenior LecturerViral Hepatitis Clinical Research ProgramThe Kirby InstituteUniversity of New South Wales

• The burden of HCV in many countries is driven by PWID and continues to grow

• Transmission of HCV continues among PWID

• Although HCV treatment uptake is low due to a number of barriers, treatment willingness is high among PWID

• HCV treatment is effective among PWID

• Strategies to enhance HCV assessment and treatment among PWID are required

Prevention, Treatment and Care of HCV among PWID

Issues

PWID are the core of the HCV epidemic and “ageing cohorts” of PWID will lead to considerable advanced liver disease burden

PWID are at the core of the HCV epidemic

1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.

PEOPLE LIVING WITH HCV INFECTION

PWID are at the core of the HCV epidemic

1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.

80% OF NEW INFECTIONS OCCUR AMONG CURRENT PWID IN MANY COUNTRIES

PEOPLE LIVING WITH HCV INFECTION

PWID are at the core of the HCV epidemic

1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.

60% OF EXISTING INFECTIONS ARE AMONG CURRENT & FORMER PWID IN MANY COUNTRIES

PEOPLE LIVING WITH HCV INFECTION

HCV is a major public health problem among PWID

Nelson PK, et al. Lancet 2011

• Global estimation: 10.0 million PWIDs (range 6.0–15.2) in 2010 were HCV antibody positive

• Global prevalence: 67.0%

Eastern Europe 2.3m

East and Southeast Asia 2.6m

North America 1.7m

Latin America 1.7m

Sub-saharan Africa0.8m

Disease burden due to HCV is substantial

Kwong et al PLoS One 2012

Human papilloma virus

E. ColiHIV/AIDS

Staphylococcus aureus

C. DificileRhinovirus

Group B Strep

Group A Strep

Haemophilus influenza

LegionellaChlamydia

Adenovirus

Gonorrhea

Health Adjusted Life Years (HALYs)

0 2000 4000 6000 8000 1000

Tuberculosis

Influenza

Hepatitis B virus

Hepatitis C virus

Respiratory syncytial virusParainfluenza virus

Years of Life Lost

Year-equivalents of reduced functioning

Streptococcal pneumonia

Liver-related mortality increases with age

Deans G, et al CMAJ Open. 2013

HCV transmission continues to occur among PWID

• Higher prevalence of HCV infection (67% vs. 20%)• Higher risk of infection (3-5% for HCV vs 1-2% for HIV)

Harm reduction interventions have been less effective for HCV

Mehta SH, Journal of Infectious Diseases 2011.

Interventions to prevent HCV among IDUs

• Opioid substitution therapy1-2

• High NSP coverage2

• Multiple combined interventions most effective2-3

1) Nolan S, et al. Addiction 2014 (In Press); 2) Turner KM, et al. Addiction 2011; 3) Hagan H, et al. Journal of Infectious Diseases 2011.

HCV treatment uptake among people who inject drugs is low, due to a number of barriers at the levels of the system, provider and patient

PWID have a high willingness to receive HCV treatment

PWID LIVING WITH HCV INFECTION

PWID have a high willingness to receive HCV treatment

80% OF PWID ARE WILLING TO RECEIVE HCV TREATMENT

PWID LIVING WITH HCV INFECTION

Stein MD, Drug and Alcohol Dependence 2001. Walley AY, J Substance Abuse Treatment 2005. Doab A, Clinical Infectious Diseases 2005. Fischer B, et al. Presse Med 2005. Strathdee S, et al Clinical Infectious Diseases 2005. Grebely J, et al. Drug and Alcohol Dependence 2008. Alavi M, et al. Clinical Infectious Diseases 2013.

Treatment uptake among PWID is still low….

80% OF PWID ARE WILLING TO RECEIVE HCV TREATMENT

PWID LIVING WITH HCV INFECTION

1-2%are treatedeach year

1) Grebely J. J Viral Hepatitis 2009. 2) Mehta S. J Community Health 2008. 3) Iversen J, J Viral Hepatitis. 2013. 4) Alavi M. Liver International. 2014.

Barriers to HCV assessment and treatment

Barriers to HCV assessment and treatment

PATIENT

Barriers to HCV assessment and treatment

PROVIDER

Barriers to HCV assessment and treatment

SYSTEM

HCV treatment can be highly successful among PWID

HCV treatment is effective in PWID - PEG-IFN/RBV

Dimova R, et al Clinical Infectious Diseases 2013

HCV treatment is effective in PWID - PEG-IFN/RBV

Dimova R, et al Clinical Infectious Diseases 2013

Strategies to enhance HCV assessment and treatment among PWID

The HCV Care Cascade – PWID in Australia

HCV TESTING

ASSESS &MONITOR

ENGAGE INTREATMENT

ENHANCE RESPONSE

80%40% 10% 5%

The HCV Care Cascade – Future requirements

HCV TESTING• guidelines

• systematic programs for HCV screening and diagnosis

• point-of-care HCV testing

The HCV Care Cascade – Future requirements

HCV TESTING

ASSESS &MONITOR

• guidelines

• systematic programs for HCV screening and diagnosis

• point-of-care HCV testing

• education

• guidelines

• infrastructure for HCV services

• non-invasive fibrosis assessment

First global recommendations for HCV among PWID

Robaeys* and Grebely*, et al. Clinical Infectious Diseases 2013

The HCV Care Cascade – Future requirements

HCV TESTING

ASSESS &MONITOR

ENGAGE INTREATMENT

• guidelines

• systematic programs for HCV screening and diagnosis

• point-of-care HCV testing

• education

• guidelines

• infrastructure for HCV services

• non-invasive fibrosis assessment

• linkage to care

• multidisciplinary care models

• effective, tolerable, simple, short-duration HCV therapy

The HCV Care Cascade – Future requirements

HCV TESTING

ASSESS &MONITOR

ENGAGE INTREATMENT

ENHANCE RESPONSE

• guidelines

• systematic programs for HCV screening and diagnosis

• point-of-care HCV testing

• education

• guidelines

• infrastructure for HCV services

• non-invasive fibrosis assessment

• linkage to care

• multidisciplinary care models

• effective, tolerable, simple, short-duration HCV therapy

• strategies to enhance adherence

• risk reduction to prevent reinfection

40%1998

55%2002

70%2012

90%2018

(projected)

95%of infected people were not receiving treatment in 2012

Efficacious treatments do not work if not given…..Effi

cacy

of t

reat

men

t (%

)

Amount of infected people treated (%)

Thomas DL Nature Medicine 2013. Grebely J and Dore GJ Antiviral Research 2014.

Acknowledgements

University of New South WalesThe Kirby Institute Prof. Gregory Dore

Arud Zentren für SuchtmedizinDr. Philip Bruggmann

INHSU executive boardMarkus Backmund, GermanyJulie Bruneau, CanadaOlav Dalgard, NorwayGreg Dore, AustraliaJason Grebely, AustraliaMatt Hickman, UKAlain Litwin, USGeert Robaeys, BelgiumTracy Swan, US