1. Treatment and access to treatment in low and middle income countries Adeeba Kamarulzaman University of Malaya Kuala Lumpur, Malaysia ANRS-NIDA Joint Satellite Drug Use and HIV and HCV Infection: The Challenge and The Potential Solutions

2. Global Estimates of HIV-Viral Hepatitis Coinfection

3. HCV Prevalence in Asia, Africa and Eastern Europe 1 Madhava V. Lancet 2002. 2 Nelson P, Lancet 2011. 3 Ba I, ICASA 2012 7 Dakar area – UDSEN study 3 -est.size IVDUs: 1324 - P(HIV): 5,2% - P (HCV): 23,3%

4. HCV Ab prevalence among people who inject drugs is high Source: Nelson PK et al. Global epidemiology of hepatitis B and hepatitis C and people who inject drugs. Lancet 2011: 278:571

5. Estimating HIV Prevalence in Malaysia Method Multi-parameter evidence synthesis methods were applied to combine all available relevant data sources Results An estimated 454,000 (95% [CrI]: 392,000 to 535,000) HCV Ab positive individuals were living in Malaysia in 2009 2.5% of the adult population Route of probable transmission - active or a previous history of IDU Females represented 1% (95% CrI: 0.6 to 1.4%) of all HCV infections, 92% (95% CrI: 88 to 95%) were attributable to non-drug injecting routes of transmission SA McDonald, A Kamarulzaman et al. Submitted for publication

6. Liver-related death: Leading cause of death in HIV-HCV patients 43 % 12 % 8 % 5 % 4 % 2 % 6 % 7 % Decompensated cirrhosis HCC Post-transplantation Cirrhotic Patients: > 50% deaths related to HCV Non cirrhotic patients : 60% deaths non related to HCV nor HIV Cirrhotic Patients: > 50% deaths related to HCV Non cirrhotic patients : 60% deaths non related to HCV nor HIV 1 HSogni P. Conference on French HIV-HCV Consensus Guidelines, 2012 13

7. % of patients with sustained virological response (SVR) IFN 24 W 70 50 30 20 10 60 40 IFN 48 W IFN +RBV 24 W IFN +RBV 48 W PEG-IFN +RBV 48 W 0 80 90 IFN = Interferon-α PEG-INF = Peg-Interferon-α RBV = Ribavirin PEG = PEG-IFN-α 2002 2011 1999 2014 PEG-IFN +RBV +new PI Telaprevir Or Boceprevir INF-free regimens 12 weeks ? 95-100% SVR

8. New Anti HCV Therapy PHOTON 1 & 2 – Sofosbuvir + RBV ERADICATE Study - Sofosbuvir + Ledipasvir C-WORTHY Trial - PI MK-5172 + NS5A inhibitor MK-8742, with or without ribavirin TURQUOISE 1 – ABT- 450/r/Ombitasvir,Dasabuvir + RBV

9. Estimated proportion of persons with chronic HCV receiving treatment in selected European countries in 2010 Source: Razavi et al J Hepatol. 2013;58(Suppl 1):S22–3 Treatment coverage remains very low, even in high-income countries

10. Total population (2012) Estimated number PLHIV (all ages, 2012) Reported number of adults receiving ART (2012) Coverage (range of uncertainty A ) Cambodia14,864,6476,00044,31882% [60%->95%] China1,350,695,000780,000151,519Not available India1,236,686,7322,100,000 570,62051% [44%-57%] Indonesia246,864,191610,000 29,96018% [12-25%] Malaysia29,239,92782,00014,594 41% [32%-52%] Myanmar52,797,319200,000 49,67646% [41%-51%] Nepal27,474,37749,000 7,16833% [28%-40%] PNG7,167,01025,00011,04284% [73%->95%] Thailand66,785,001440,000232,816 76% [71%-80%] Vietnam88,772,900260,00068,88358% [19%->95%] Estimated number of PLHIV and of people on ART in 10 countries in Asia-Pacific, 2012 A The range of uncertainty reflects the degree of uncertainty associated with estimates and defines the boundaries within which the actual numbers lie (see http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/ 2013/gr2013/20131118_Methodology.pdf, accessed 1 June 2014). Source: UNAIDS 2013, World Bank 2012) PLHIV=People living with HIV

11. Number of people who inject drugs (PWID) on ART per 100 HIV+ PWID Source: Beyrer, Baral Less than 25% of HIV+ PWID are on ART in Asia and Pacific < 25 25-75 > 75 PWID present but ART program data not available No PWID reported PWID=people who inject drugs

12. Multiple Barriers at Multiple Steps of the Continuum of Care Adapted from G. Matthews

13. Barriers to HCV Treatment in Low/Middle Income Countries Lack of Awareness Late Diagnosis Poor Treatment Literacy Multiple Comorbidities – TB Lack of Access to OST Limited Range of ARVs

14. Treating HCV in Resource-Poor Settings CID 2012:54 (15 May) d 1465

15. Lessons from HIV Reducing Cost of Treatment Simplifying Model of Care Service Integration Task Shifting Surveillance, Evaluation and Research Patient & Community Engagement Political and Financial Commitment

16. Overcoming Provider Barriers Easier assessment of the infection and the liver disease 2 -Dry-blood spots (HCV viral load quantification/genotyping) - Portable Fibroscan (Echosens) - Portable sonography Rapid Testing 1 - Point-of-care tests - Salivary rapid testing 1 Yaari A, J Viral Methods 2006. 2 Tuaillon E, Hepatology 2010 47  Mostly unavailable in RLS

17. Overcoming the Cost Barrier http://www.medicinespatentpool. org 48  History of HIV

18. Viral Hepatitis

19. Acknowledgements Karine Lacombe, Inserm Ying-Ru Lo, WPRO WHO Joe Sasadeusz, Alfred Hospital, Melbourne