1. #LJWG2015 HEPATITIS C IN PEOPLE WHO USE DRUGS Improving Care for Hepatitis C: A Framework Approach LONDON 2015

2. #LJWG2015 What are the ODNs doing to reach PWIDs in London? Professor Graham Foster Professor of Hepatology Queen Marys, University of London Consultant, Barts Health, London

3. Conflicts of Interest Speaker and consultancy fees received from AbbVie, BI, BMS, Gilead, Janssen, Roche, Merck, Novartis, Springbank, Achillion, Idenix

4. HCV – What are we doing? The drugs The patients What we are doing

5. HCV – What are we doing? The drugs The patients What we are doing

6. LDV/SOF 8 weeks12 weeks LDV/SOFLDV/SOF + RBV 201/216202/215206/216 SVR12 (%) SVR12 G1 treatment naive Genotype 1 8 -12 weeks cures >90% SVR12 (%) nNnN 455 473 307 322 148 151 Sofosbuvir + ledipasvir AbbVie Cocktail

7. Genotype 3 PegIFN + Ribavirin Data are from an audit of 639 patients tretated with PegIFN/RBV; Shoeb D, et al. Eur J Gastroenterol Hepatol 2011;23:747–753 Patient subgroup (n=639) S Asian n=317 Non-Asian n=322 >40 years n=437 <40 years n=201 Cirrhosis n=161 No cirrhosis n=436

8. Valence NEJM 2014 Noncirrhotic 212/250 12/13 94 86/92 Naïve, Noncirrhotic 87 87/100 Experienced, Noncirrhotic 92 Naïve, Cirrhotic 60 27/45 Experienced, Cirrhotic SVR12 (%) 0 20 40 60 80 100 85 Overall 212/250 Overall Cirrhotic Sofosbuvir for G3 24 weeks therapy (AKA £70,000)

9. Genotype 3 The best way to cure Genotype 3 is with Interferon

10. HCV – What are we doing? The drugs The patients What we are doing

11. HCV –The Patients Three populations:- Cirrhosis Transmitters – ‘difficult to access’ Stable mild/moderate

12. HCV – The Patients Three populations:- Cirrhosis – all oral regimes NOW (funded) Transmitters – difficult to access Stable mild/moderate

13. HCV –The Patients Three populations:- Cirrhosis Transmitters – ‘difficult to access’ Stable mild/moderate – in the clinic, noisy, will demand therapy

14. HCV – The Patients? Three populations:- Cirrhosis Transmitters – difficult to access Stable mild/moderate

15. HCV – who needs therapy now? Logically we should treat transmitters next BUT Transmitters have no political clout Transmitters are expensive to treat

16. HCV – Accessing Transmitters Community based services BBV nurses treat in the community Out-reach nurse treats in the community

17. HCV – Accessing Transmitters Community based services BBV nurses treat in the community ‘Hepatitis C is your problem’ Out-reach nurse treats in the community

18. HCV – Accessing Transmitters Community based services BBV nurses treat in the community ‘Hepatitis C is your problem’ Out-reach nurse treats in the community ‘How many patients does your community nurse actually see?’

19. HCV – Accessing Transmitters It will not be easy It will require financial incentives

20. HCV – What are we doing? The drugs The patients What we are doing

21. We are lobbying for a higher tariff for treating people in the community We have set up a scoring system for prioritisation (transmitters get bonus points) We are working with PHE to monitor the epidemic

22. Phylogenetic clustering of hepatitis C virus among people who inject drugs in Vancouver, Canada Hepatology Volume 60, Issue 5, pages 1571-1580, 29 SEP 2014 DOI: 10.1002/hep.27310 http://onlinelibrary.wiley.com/doi/10.1002/hep.27310/full#hep27310-fig-0004 Volume 60, Issue 5, http://onlinelibrary.wiley.com/doi/10.1002/hep.27310/full#hep27310-fig-0004 We can MAP the epidemic We can trace transmitters We can focus on cohorts

23. HCV – What we need We need to join up PHE and NHSE We need an incentive to treat in the community If we do this sensibly, cohesively we can fix this (and we can do it cheaply)

24. #LJWG2015