3rd International HIV/Viral Hepatitis Co-Infection Meeting HIV/Viral Hepatitis: Improving Diagnosis, Antiviral Therapy and Access Sunday, 17 July 2016 Durban, South Africa www.iasociety.org

Introduction Epidemiology of HIV, HBV & HCV infections Global Burden of Viral hepatitis WHO aims for eradication of viral hepatitis Lancet. 2012;380 (9859):2095; BMC Medicine 2014;12:159; WHO; 2014 [EB 134/36]; Lancet 6 July 2016 www.iasociety.org

Epidemiology: HIV, HBV & HCV infections 240 million persons are chronically infected with hepatitis B virus 130-150 million persons with hepatitis C 34 million persons with HIV 70% of global 34 million people with HIV live in sSA Corresponding to regions of high HBV and HCV endemicity HIV/HBV/HCV Mortality (annual death rate) (www.worldmapper.org in Nov 2012) Majority of persons with chronic hepatitis B and hepatitis C Unaware of their infection (95%) Do not benefit from clinical care and treatment or interventions designed to reduce onward transmission (1% access Rx) Liver-related mortality is twice as high for chronic hepatitis B co-infected as for chronic hepatitis C co-infected individuals. A CD4 count of <200 cells/mm3 is associated with a 16.2 fold increase in risk of liver-related death compared to a CD4 count of >350 cells/mm3 . Clinical Infectious Diseases 2012; 55(4):507; J Clin Virol 2014;61:20 www.iasociety.org

Global Burden of Disease Global Burden of Disease study: 1990-2013 Viral hepatitis is responsible for approximately 1.45 million deaths/yr HIV/AIDS: 1.3 million/yr Malaria: 0.9 million/yr Tuberculosis: 1.3 million/yr Viral hepatitis is now the 7th leading cause of mortality worldwide Mortality due to viral hepatitis has increased by 63% since 1990 Persistent lack of global awareness of the severity of the problem Lack of commitment to combat and ultimately eliminate the disease Lancet. 2012;380 (9859):2095; BMC Medicine 2014;12:159; WHO; 2014 [EB 134/36]; Lancet 6 July 2016 www.iasociety.org

Global Burden of Viral Hepatitis 1990-2013 Viral hepatitis is a leading cause of death and disability worldwide Globally, viral hepatitis deaths increased from 0·89 million (95% uncertainty interval [UI] 0·86–0·94) to 1·45 million (1·38–1·54) YLDs from 0·65 million (0·45–0·89) to 0·87 million (0·61–1·18) DALYs from 31·7 million (30·2–33·3) to 42·5 million (39·9–45·6) Mortality and morbidity mainly due to hepatitis B and C infections 96% [95% UI 94–97] of mortality and 91% [88–93] of DALYs in 2013 Unlike most communicable diseases, the absolute burden and relative rank of viral hepatitis increased between 1990 and 2013 Lancet 6 July 2016 www.iasociety.org

Global Burden of Viral Hepatitis 1990-2013 Burden of disease was not equally distributed worldwide Hepatitis-related mortality highest (≥33.50 deaths per 100 000 pop/year) Oceania, western sub-Saharan Africa and central Asia In absolute numbers, east Asia and south Asia Greatest number of hepatitis deaths (52% of the total number of deaths) Unlike HIV, which primarily occurs in low-income countries (mainly sSA) 58% hepatitis deaths occurred in upper-middle-income countries and high-income countries Lancet, 6 July 2016 www.iasociety.org

Burden of Liver Disease Liver disease due to chronic hepatitis B and C is a significant cause of morbidity and mortality in HIV infected individuals Liver-related mortality 2x higher in HBV/HIV than in HCV/HIV co-infection Without appropriate diagnosis and treatment A third of those chronically infected with viral hepatitis will die as a result of complications of chronic liver disease: Cirrhosis, liver failure and HCC Global antiretroviral therapy scale-up should limit HBV-related liver disease, through dual antiviral activity HBV mono-infected individuals: frequently undiagnosed with limited access to therapy New pangenotypic DAA regimens offer >90% cure to all HCV-infected individuals - short duration with minimal monitoring Requires easy access to affordable diagnostics and generics AIDS 2005;19(6):593; J Acquir Immune Defic Syndr 2000;24(3):211; J Inf Dis 2013;208(9):1454; South Afr Med J 2012; 102:157; World J Hepatol 2010; 2: 65 www.iasociety.org

WHO: Eradication of Viral Hepatitis WHO aims by 2030 90% reduction in new cases of chronic hepatitis B and C 65% reduction in hepatitis B and C deaths 80% of treatment eligible persons with chronic hepatitis B and C infections treated Globally, this will require Development and Implementation of National Guidelines for the Prevention and Treatment of Viral Hepatitis Development and Implementation of National Surveillance Strategies Access to sustainable and affordable diagnostics and therapeutics Enabling identification and linkage to care Effective utilisation of existing infrastructures for delivery of care www.iasociety.org

Eradication of Viral Hepatitis Ultimate elimination of HIV and viral hepatitis will require an effective partnership between: Affected communities Professional and community organisations Governments and National Departments of Health Researchers and health professionals Pharmaceutical companies www.iasociety.org

Meeting Objectives To review the latest therapeutic developments in viral hepatitis B and C To identify challenges and successes in scaling up diagnosis, screening, antiviral treatment and prevention of viral hepatitis in HIV co-infected persons To identify how to optimize outcomes and costs to achieve sustainable and equitable access to these therapies globally To learn from successful models, such as novel voluntary licensing agreements and map a path toward scaling up of viral hepatitis treatment programmes in low-, middle- and high-income settings To advance the agenda for viral hepatitis eradication by assembling key stakeholders for a face-to- face discussion of major barriers & solutions www.iasociety.org

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