Prevention, Treatment and Care of Hepatitis C among People Who Inject Drugs Jason Grebely, PhD Senior Lecturer Viral Hepatitis Clinical Research Program The Kirby Institute University of New South Wales

Prevention, Treatment and Care of HCV among PWID Issues The burden of HCV in many countries is driven by PWID and continues to grow Transmission of HCV continues among PWID Although HCV treatment uptake is low due to a number of barriers, treatment willingness is high among PWID HCV treatment is effective among PWID Strategies to enhance HCV assessment and treatment among PWID are required

PWID are the core of the HCV epidemic and “ageing cohorts” of PWID will lead to considerable advanced liver disease burden

PWID are at the core of the HCV epidemic PEOPLE LIVING WITH HCV INFECTION 1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.

PWID are at the core of the HCV epidemic 80% OF NEW INFECTIONS OCCUR AMONG CURRENT PWID IN MANY COUNTRIES PEOPLE LIVING WITH HCV INFECTION 1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.

PWID are at the core of the HCV epidemic 60% OF EXISTING INFECTIONS ARE AMONG CURRENT & FORMER PWID IN MANY COUNTRIES PEOPLE LIVING WITH HCV INFECTION 1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.

HCV is a major public health problem among PWID Eastern Europe 2.3m North America 1.7m East and Southeast Asia 2.6m Sub-saharan Africa 0.8m Latin America 1.7m Global estimation: 10.0 million PWIDs (range 6.0–15.2) in 2010 were HCV antibody positive Global prevalence: 67.0% Nelson PK, et al. Lancet 2011

Disease burden due to HCV is substantial Hepatitis C virus Streptococcal pneumonia Human papilloma virus Hepatitis B virus E. Coli HIV/AIDS Staphylococcus aureus Influenza C. Dificile Rhinovirus Respiratory syncytial virus Parainfluenza virus Group B Strep Years of Life Lost Group A Strep Year-equivalents of reduced functioning Haemophilus influenza Tuberculosis Legionella Chlamydia Adenovirus Gonorrhea 2000 4000 6000 8000 1000 Health Adjusted Life Years (HALYs) Kwong et al PLoS One 2012

Liver-related mortality increases with age Deans G, et al CMAJ Open. 2013

HCV transmission continues to occur among PWID

Harm reduction interventions have been less effective for HCV Higher prevalence of HCV infection (67% vs. 20%) Higher risk of infection (3-5% for HCV vs 1-2% for HIV) Mehta SH, Journal of Infectious Diseases 2011.

Interventions to prevent HCV among IDUs Opioid substitution therapy1-2 High NSP coverage2 Multiple combined interventions most effective2-3 1) Nolan S, et al. Addiction 2014 (In Press); 2) Turner KM, et al. Addiction 2011; 3) Hagan H, et al. Journal of Infectious Diseases 2011.

HCV treatment uptake among people who inject drugs is low, due to a number of barriers at the levels of the system, provider and patient

PWID have a high willingness to receive HCV treatment PWID LIVING WITH HCV INFECTION

PWID have a high willingness to receive HCV treatment 80% OF PWID ARE WILLING TO RECEIVE HCV TREATMENT PWID LIVING WITH HCV INFECTION Stein MD, Drug and Alcohol Dependence 2001. Walley AY, J Substance Abuse Treatment 2005. Doab A, Clinical Infectious Diseases 2005. Fischer B, et al. Presse Med 2005. Strathdee S, et al Clinical Infectious Diseases 2005. Grebely J, et al. Drug and Alcohol Dependence 2008. Alavi M, et al. Clinical Infectious Diseases 2013.

Treatment uptake among PWID is still low…. 80% OF PWID ARE WILLING TO RECEIVE HCV TREATMENT 1-2% are treated each year PWID LIVING WITH HCV INFECTION 1) Grebely J. J Viral Hepatitis 2009. 2) Mehta S. J Community Health 2008. 3) Iversen J, J Viral Hepatitis. 2013. 4) Alavi M. Liver International. 2014.

Barriers to HCV assessment and treatment

Barriers to HCV assessment and treatment PATIENT

Barriers to HCV assessment and treatment PROVIDER

Barriers to HCV assessment and treatment SYSTEM

HCV treatment can be highly successful among PWID

HCV treatment is effective in PWID - PEG-IFN/RBV Dimova R, et al Clinical Infectious Diseases 2013

HCV treatment is effective in PWID - PEG-IFN/RBV Dimova R, et al Clinical Infectious Diseases 2013

Strategies to enhance HCV assessment and treatment among PWID

The HCV Care Cascade – PWID in Australia TESTING ASSESS & MONITOR ENGAGE IN TREATMENT ENHANCE RESPONSE 80% 40% 10% 5%

The HCV Care Cascade – Future requirements TESTING guidelines systematic programs for HCV screening and diagnosis point-of-care HCV testing

The HCV Care Cascade – Future requirements TESTING ASSESS & MONITOR guidelines systematic programs for HCV screening and diagnosis point-of-care HCV testing education guidelines infrastructure for HCV services non-invasive fibrosis assessment

First global recommendations for HCV among PWID Robaeys* and Grebely*, et al. Clinical Infectious Diseases 2013

The HCV Care Cascade – Future requirements TESTING ASSESS & MONITOR ENGAGE IN TREATMENT guidelines systematic programs for HCV screening and diagnosis point-of-care HCV testing education guidelines infrastructure for HCV services non-invasive fibrosis assessment linkage to care multidisciplinary care models effective, tolerable, simple, short-duration HCV therapy

The HCV Care Cascade – Future requirements TESTING ASSESS & MONITOR ENGAGE IN TREATMENT ENHANCE RESPONSE guidelines systematic programs for HCV screening and diagnosis point-of-care HCV testing education guidelines infrastructure for HCV services non-invasive fibrosis assessment linkage to care multidisciplinary care models effective, tolerable, simple, short-duration HCV therapy strategies to enhance adherence risk reduction to prevent reinfection

Efficacious treatments do not work if not given….. 40% 1998 90% 2018 (projected) 95% of infected people were not receiving treatment in 2012 55% 2002 70% 2012 Efficacy of treatment (%) Amount of infected people treated (%) Thomas DL Nature Medicine 2013. Grebely J and Dore GJ Antiviral Research 2014.

Acknowledgements INHSU executive board Arud Zentren für Suchtmedizin Dr. Philip Bruggmann University of New South Wales The Kirby Institute Prof. Gregory Dore INHSU executive board Markus Backmund, Germany Julie Bruneau, Canada Olav Dalgard, Norway Greg Dore, Australia Jason Grebely, Australia Matt Hickman, UK Alain Litwin, US Geert Robaeys, Belgium Tracy Swan, US