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

Global Estimates of HIV-Viral Hepatitis Coinfection

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

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

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 % 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

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,

% of patients with sustained virological response (SVR) IFN 24 W IFN 48 W IFN +RBV 24 W IFN +RBV 48 W PEG-IFN +RBV 48 W IFN = Interferon-α PEG-INF = Peg-Interferon-α RBV = Ribavirin PEG = PEG-IFN-α PEG-IFN +RBV +new PI Telaprevir Or Boceprevir INF-free regimens 12 weeks ? % SVR

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

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

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, ,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 /gr2013/ _Methodology.pdf, accessed 1 June 2014). Source: UNAIDS 2013, World Bank 2012) PLHIV=People living with HIV

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 < > 75 PWID present but ART program data not available No PWID reported PWID=people who inject drugs

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

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

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

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

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 Tuaillon E, Hepatology  Mostly unavailable in RLS

Overcoming the Cost Barrier org 48  History of HIV

Viral Hepatitis

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