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

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

Scotland’s Hepatitis C Action Plan Phase I The Business Case Phase II Investment to improve services Phase III Continuing investment Phase IV ???

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

Phase I: Key evidence Projected number of PWID (ever injected) in Scotland developing liver failure each year with different Rx rates 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

Scotland’s Hepatitis C Action Plan Phase I The Business Case Phase II Investment to improve services Phase III Continuing investment Phase IV ???

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 )

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

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/ /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

Diagnosis: Overall Progress Number of new HCV diagnoses per year in Scotland N ,000 1,500 2,000 2, Phase II onwards Phase I Pre % Year Scotland: Estimated: Projected: 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 (McLeod et al. JECH 2014) Tested Tested Positive International Context Czech Repub Portugal England Austria Switzerland Spain Belgium Scotland Germany Denmark France Sweden Estimated % infected popln diagnosed Razavi et al. J Viral Hepat. 2014

Scotland’s Hepatitis C Action Plan Phase I The Business Case Phase II Investment to improve services Phase III Continuing investment Phase IV ???

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

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) IFN-free therapy Incident cases Status-Quo Target Active PWID (13%  33%) Target Advanced Fibrosis (40%  60%) IFN-free therapy Incident cases (i) Severe Liver Morbidity (ii) New infection

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