1. HepCare Europe
No-one gets left behind: addressing the hidden burden of HCV related advanced liver disease in PWID in the community
Dr John Lambert, Professor of Medicine and Consultant in Infectious Diseases, Mater Hospital and UCD Dublin 1

2. HEPCARE: A new Hepatitis C Care service model
VISION:
Create an innovative, integrated system for HCV treatment, based on the joint participation of primary and speciality care practitioners
OBJECTIVE:
Improve access to HCV testing and treatment among key risk groups, including drug users and homeless, through outreach to the community and integration of primary and secondary care services
Primary Care
Secondary care
WP4: HepCheck (screening)
WP5: HepLink (linkage to care)
WP 7: HepFriend
(peer advocacy support)
WP 6: HepED
(inter-professional education)
WP8: HepCost WP 1 Coordination; WP 2 Dissemination; WP3 Evaluation
HEPCARE EUROPE is a €1.8M 3-year EU-supported project at 4 member state sites
Consortium members: UCD (Ireland); SAS (Spain); SVB (Romania); University of Bristol (UK); University College London (UK)

3. How to make HCV a ‘rare disease’ in the EU
Community Education
Preparing the at risk population for testing, assessment and treatment)
Community Fibroscan testing strategy
Implementation and evaluation of the strategy, and assessment for advanced disease patients the reasons for non-attendance.
Point of Care Testing
Evaluation of point of care testing with HCV oral tests in diverse populations and different countries/settings and assessment of cost effectiveness
Linking Services across Diseases
Address key conditions in vulnerable populations in a linked up fashion (drug and alcohol addiction, primary care, STD, blood borne virus testing, TB, Hepatitis B vaccination)
Educational tools and pathways
To help HCV negative people to minimise their risk of HCV infection and other blood borne viruses
Community nurse outreach and peer advocacy support
Community focused assessment for HCV disease in HCV+ as vulnerable communities do not access secondary care services.
Education of Community Health Care Workers
Improve understanding of new treatments, and prepare them to act as partners in treatment and support in a ‘shared care’ primary/secondary integrated partnership.

4. Evolution of Hepatitis C care
Old Model
New Model
Screening
Blood test (invasive)
Mouth Swabs (non invasive)
Medication route administration
Injection
Oral
Diagnosis of disease severity
Liver biopsy (invasive)
Fibroscan (non invasive)
Cost (direct)
+++
+++++
Cost effectiveness
Moderate
High
Efficiency of treatment: Sustained viral response
Place of care
Hospital Specialist Clinic
Primary care and Specialist clinic

5. HCV elimination is on the global agenda
Glasgow Declaration
Sept.
2015
“It is possible and essential to set as a goal the elimination of both hepatitis B and C as public health concerns”
Elimination Manifesto
Feb.
2016
"Our vision for a Hepatitis C-free Europe”
Global Health Sector Strategy on Viral Hepatitis
May
2016
“Eliminating viral hepatitis as a major public health threat by 2030”
Action plan for the prevention and control of Viral Hepatitis
Sept.
2016
“A WHO European Region that is free of new hepatitis infections”

6. WHO strategy comes with targets, by 2030
Incidence targets
30% reduction in new HCV infections by 2020
90% reduction in new HCV infections by 2030
Mortality targets
10% reduction in mortality by 2020
65% reduction in mortality by 2030
Harm reduction
Increase in sterile needle and syringes provided per PWID/year from 20 in 2015 to: 200 by 2020 and 300 by 2030
Testing targets
90% of people aware of HCV infection by 2030
Treatment targets
80% of people treated by 2030

7. HOMELESS HEPCHECK Screening results
HepCheck Homeless, Hep C & Competing Priorities
John S. Lambert 1 2, Carol Murphy 1, Eileen F. O’Connor 2, Dee Menezes1, Walter Cullen 2, Tina McHugh 1, Geoff McCombe 2, Gordana Avramovic 1 2, Austin O’Carroll³, 1. Mater Misericordiae University Hospital, Dublin, Ireland. 2. University College Dublin, Ireland. 3. Safetynet Primary Care Network, Dublin, Ireland.
HOMELESS HEPCHECK Screening results
RESULTS
A total of 619 individuals were offered screening. Their ages ranged from 17 to 86, with the average age being 36.7 years and were 74% male (455 male, 163 female, 1 missing).
Of the 619 offered screening, just under a third reported having had a previous HCV test before (216) of which half recalled a positive result, 36% negative (79) & 13% unsure of the result (29).
Screening
547 HCV Antibody tests were performed
38% (n=206) tested positive
57% (n=310) tested negative
5% (n=31) recorded as no result/awaiting result
Of the 206 testing positive, 54% (112) were “new” positives while the remaining were” known positives”
Following a positive test 51 patients were referred to specialist care and 33 attended 2 or more appointments.
One individual completed treatment whilst another is still on treatment at the time of writing.
Qualitative interviews
The most common reasons for homelessness were alcohol and/or drugs, and for some, this was combined with family/relationship problems and mental health problems.
Acknowledgements
HEPCARE EUROPE : Bridging the gap in the treatment of Hepatitis C .
619 OFFERED SCREENING
547 SCREENED
72 NOT SCREENED
Previous HCV Ab test?
Yes +ve: 12
Yes -ve: 11
Yes, unsure of result: 3
No/missing: 46
38% Ab positive (206)
Of which:
112 "new positives"
94 "known positives
57% Ab negative (310)
31 no result/awaiting result (5%)
51 referrals
33 attendances
2 completed treatment
Method
The target population was homeless people accessing the Safetynet primary healthcare services in Dublin. Individuals were invited to undertake a short questionnaire and HCV antibody test.
Qualitative interviews were also carried out with selected patients. (n=49) exploring a broader range of health and lifestyle issues.
Conclusions
Community based screening intervention can enhance HCV diagnosis for at risk populations.
Referrals to/attendance to secondary care remains a challenge for this cohort.
Psychosocial factors at the core of why patients do not attend secondary care for HCV management.
Addiction, mental health and homelessness were especially problematic
Future research should examine interventions to improve attendance rates at secondary care.

8. Qualitative Interviews with selected patients
49 participants were administered the questionnaire, of which most (78%) were currently living in a hostel. The remaining were sofa surfing, sleeping rough or staying with friends. The average time period of homelessness was 6.2 years, with a range of 2 months to 20 years.
The most common reasons for homelessness were co-morbidities such as alcohol and/or drugs, and for some, this was combined with family/relationship problems and mental health problems. Most (42%) saw a GP once a week.

9. When asked about their HCV antibody result, 63% said they had previously received a specialist appointment. When asked about their HCV healthcare pathway, the most common theme was stable accommodation: participants reported this to be a barrier to attending specialist appointments and accessing treatment.
The most common other reasons for non-attendance were active drug use, being in prison, fear of side effects of treatment and forgetfulness.

10. WP - HEPCHECK- OVERVIEW
DUBLIN
LONDON
BUCHAREST
SEVILLE
TOTAL
1. No. of individuals offered/screened
712/569
-/310
-/469
657/401
1,749
2. Proportion of individuals with positive HCV antibody on screening
137/569
24%
 123/310
41.8%
 166/469
35%
140/401
34%
559
3. No. of individuals screened (Ab only, bloods only, both Ab and bloods)
Pending
Ab 365
Ab + bloods 104
Ab: 264
Bloods:116
Ab + bloods: 21 -
4. No. of HCV Ab+ individuals (either new or previously diagnosed) attending specialist appointment for HCV assessment. 60 65 51
222+

11. WORLD HEPATITIS DAY/WEEK: COMMUN ITY RESPONSE
50 people were Fibro scanned in the three outreach sites over the week.

12. Seek an Treat: community Fibroscan
Rapid test allows POCT: Entire scan 5-7 minutes to complete
Allows clinicians to arrange OGD or liver ultrasound urgently if evidence of cirrhosis
Non invasive procedure/ No pain/No sedation required
Inexpensive scan
96% specificity when compared to liver biopsy staging.
No requirement to admit as a day case
No risk of bleeding or infection which are potential complications of biopsy

13. Progression of untreated fibrosis in OAT patients
Serial Transient Elastography Readings Indicate Progression of Untreated Fibrosis Among Patients Attending Opioid Substitution Treatment Clinic in South County Dublin J. Moloney1, G. Hawthorn1, P.A. McCormick2, E. Feeney3, D. Houlihan3, S. Keating1, C. Murphy4, T. McHugh4, J.S. Lambert4
2008: 84 patients scanned
77% were HCV Ab positive and 58% of this group were HCV viraemic.
By 2016, all of the 2008 patients with TE scores > 13 Kilopascal (Kpa) had died (a total of 13 patients) and 11 of these patients died as a result of liver failure associated with hepatitis C viraemia and alcohol.
2016: 105 scans in surviving patients
Cohort from 2008 who still attended the clinic and new patients attending the clinic.
16 patients (15%) of the 2016 population had TE scores > 13 Kpa, the previous threshold for death at eight years

14. The Hidden Burden: HCV-related advanced liver disease in the community
The hidden burden of hepatitis C related advanced liver disease in the community
Nadeem Iqbal3, John S Lambert3,4, Des Crowley1,2, Hugh Gallagher2, Fidelma Savage2, John Moloney2, Carol Murphy1,3, Tina McHugh3, Aileen Singleton2, Shay Keating2, Audrey Dillon2, Stephen Stewart3.
Background for the Study
Large number of HCV+ patients receiving methadone substitution therapy in drug treatment centre who do not attend specialist hepatology services
Most of these patients have never had their liver disease staged, hence we postulated that many of these may have underlying advanced liver disease
Fibroscan™ (FS) used to assess the liver stiffness.
Cut-offs used for disease staging
8.5 kPa, which allowed access to direct acting antivirals (DAAs) in Ireland before Feb 2017.
25kPa, which has a 90% positive predictive value for clinically significant portal hypertension.
35kPa, which is associated with a 10-20% risk of decompensation per year
1- Irish Prison Service 2- HSE Addiction Service 3- Mater Misericordiae University Hospital 4- University College Dublin

15. Hidden burden of HCV: Results (1)
Total assessed (618)
75% male, mean age 38 ±7.2
HCV status known
(561)
HCV positive
(391)
Mean FS 11
Alcohol consumption
(136)
Mean FS 13.2
Abstinent
(255)
Mean FS 9.7
HCV negative
(170)
Mean FS 5.6
HCV status unknown
(57)
P = 0.001
P = 0.02

16. HepCare Europe: Reaching vulnerable patients
High incidence of HCV in the homeless community
Many have past/active IDU as risk factor; alcohol is additional risk
HCV previously diagnosed in many, but not accessing care
HCV common in all ‘marginalised populations’ in the EU ( %)
Still a significant burden of HCV related liver disease undiagnosed in the community, a ‘time bomb’ for liver disease progression
Treatment of disease is priority is Ireland with limited resources/DAA availability, treatment of infection (treatment for prevention priority if unlimited DAA availability). €30 million is ‘ring-fenced’ annually for treatment. Treatment of disease/treatment for prevention concepts are not mutually exclusive
30,000 in Ireland with HCV, we have treated the ‘easy’ first 2000, so how do we reach the remaining 28,000

17. HCV Elimination agenda : what will it take..?
Energy, Commitment and Resources
A public health approach (simplification, integration, decentralization, equitable access)
Innovations: HBV cure, HCV vaccine, pan-genotypic oral treatments
Partnerships (governments, civil society, private sector involvement)
Concrete and tailored action in countries, guided by national plans
The Irish Experience to date: vulnerable patients don’t go to hospital clinics for care; we must go to them; there is still a large burden of HCV related liver disease out there, and they are not accessing care and treatment: we must ‘Seek and Treat’.

18. Acknowledgements
Co-funded by the European Commission through its EU Third Health Programme and Ireland’s Health Services Executive
Participating GPs, Addiction Services, and patients
Our partners: UCL, Bucharest, U Bristol, SAS Seville

19. NO ONE LEFT BEHIND Primary Care Secondary care HEPCARE EUROPE 2017
Hepcare Team:
Dublin: PI’s Drs Lambert and Cullen (Co Investigators Drs Stewart, Feeney, Houlihan)
London: Drs Alistair Story and Julian Surey
Bucharest: Dr Cristiana Oprea
Spain: Dr Juan Macias Sanchez
Bristol: Drs Peter Vickerman and Matthew Hartman
Primary Care
Secondary care
WP4: HepCheck (screening)
WP5: HepLink (linkage to care)
WP 7: HepFriend
(peer advocacy support)
WP 6: HepED
(inter-professional education)
WP8: HepCost WP 1 Coordination; WP 2 Dissemination; WP3 Evaluation