1. How aspirations can be built and levels of performance can be assured: Learning from the Scottish Action Plan Professor Sharon Hutchinson LJWG LDAPF Conference Hepatitis C in London – practical steps to elimination London, 17 th November 2014

2. Scotland’s Hepatitis C Action Plan  To prevent the spread of Hepatitis C, particularly among people who inject drugs (PWID)  To diagnose Hepatitis C infected persons, particularly those who would most benefit from treatment  To ensure that those infected receive optimal treatment, care and support Aims

3. Scotland’s Hepatitis C Action Plan Phase I2006-08The Business Case Phase II2008-11Investment to improve services Phase III2011-15Continuing investment Phase IV2015-20???

4. Hepatitis C Landscape in Scotland, 2006 Phase I: Key evidence 0 20,00040,000 Living with Chronic Infection Diagnosed (ever) Attended clinic (in 2006) Started Treatment (in 2006) 38,000 14,500 (38% of chronics) 3,500 (9% of chronics) 450 (1% of chronics) Ever injected drugs 34,000 Estimates

5. Phase I: Key evidence Projected number of PWID (ever injected) in Scotland developing liver failure each year with different Rx rates 201020202030 0 50 100 150 Uptake of HCV Rx: 225 PWID per year 1,000 PWID per year 2,000 PWID per year N Increasing uptake of antiviral therapy to 2,000 per year could prevent in excess of 5,000 cirrhosis cases (incl. 2,700 liver failures) during 2008-30

6. Scotland’s Hepatitis C Action Plan Phase I2006-08The Business Case Phase II2008-11Investment to improve services Phase III2011-15Continuing investment Phase IV2015-20 ???

7. Phase II: Principles & Characteristics  Based on extensive evidence base & consultation process  Involved high level actions  Adopted multidisciplinary approach  Strong governance / clear accountability  Leadership (e.g. national coordination lead by HPS)  Agreed outcomes / performance monitored (e.g. targets on treatment)  Good coordination/communication (e.g. national / local networks)  Supported by serious investment (£100million during 2008-15)

8. Phase II: Key Actions Prevention: Improvements in Injection Equipment Provision Diagnosis: Awareness raising initiatives : Finger prick sampling in non-clinical settings Treatment: Increase in clinical capacity : Funding for treatment and national procurement of antiviral therapy

9. Prevention of Infection in Scotland: Progress * * Incidence of HCV infection among PWID in Scotland (derived from PCR data) 0% 5% 10% 15% 20% 25% 2008/0920102013 2011/12 Palmateer et al; PloS One, 2014 (plus updated data for 2013) Provision of Key Interventions to PWID Year2008/092011/12 Needles/syringes (N/S) distributed 4.4 million 4.7 million Paraphernalia* distributed 0.4 million 2.5 million On methadone50%64% Initiated on HCV therapy among PWID <30 yrs ~50~100 * Cookers/Filters

10. Diagnosis: Overall Progress Number of new HCV diagnoses per year in Scotland N 0 500 1,000 1,500 2,000 2,500 200620082012 Phase II onwards Phase I 2010 2004 Pre 20052010201520202025 0 20 40 60 80 100 % Year Scotland: Estimated: 2006-13 Projected: 2014-25 Progress In Drug Services % Infected Popln diagnosed Number of people tested for HCV in drug services (Scotland’s 4 largest NHS Boards) Dried Blood Spot Testing (introduced into drug services during 2009) Drug services referred 16% of new HCV diagnoses in Scotland during 2009-13 (McLeod et al. JECH 2014) Tested Tested Positive 500 1500 400 800 0 0 1000 2000 1000 600 200 1999 2001 2003 2005 2007 20092011 International Context 0102030405060708090100 Czech Repub Portugal England Austria Switzerland Spain Belgium Scotland Germany Denmark France Sweden Estimated % infected popln diagnosed Razavi et al. J Viral Hepat. 2014

12. Scotland’s Hepatitis C Action Plan Phase I2006-08The Business Case Phase II2008-11Investment to improve services Phase III2011-15Continuing investment Phase IV2015-20???

13. Phase IV  Government is supportive  Principles for HCV diagnosis and treatment in Scotland, in the context of the new highly effective therapies, to be published in 2015

14. Modelled incidence of HCV-related (i) Severe Liver Morbidity and (ii) chronic infection in Scotland, according to different treatment strategies and 2,000 treated per year (Innes et al. Gut 2014) 40 80 120 160 200 IFN-free therapy Incident cases Status-Quo Target Active PWID (13%  33%) Target Advanced Fibrosis (40%  60%) 20102015202020252030 20102015202020252030 0 100 200 300 400 500 600 IFN-free therapy Incident cases (i) Severe Liver Morbidity (ii) New infection

15. Aim going forward in Scotland To rapidly control the number of people who develop HCV related liver failure and/or hepatocellular carcinoma and the number of people who die from HCV related disease