1. 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

2. 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

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

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

5. 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 ) Grebely J and Dore GJ Antiviral Research In Press.

6. 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 ) Grebely J and Dore GJ Antiviral Research In Press.

7. 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

8. 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

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

10. HCV transmission continues to occur among PWID

11. 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.

12. 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.

13. 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

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

15. 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 Walley AY, J Substance Abuse Treatment Doab A, Clinical Infectious Diseases Fischer B, et al. Presse Med Strathdee S, et al Clinical Infectious Diseases Grebely J, et al. Drug and Alcohol Dependence Alavi M, et al. Clinical Infectious Diseases 2013.

16. 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 ) Mehta S. J Community Health ) Iversen J, J Viral Hepatitis ) Alavi M. Liver International

17. Barriers to HCV assessment and treatment

18. Barriers to HCV assessment and treatment
PATIENT

19. Barriers to HCV assessment and treatment
PROVIDER

20. Barriers to HCV assessment and treatment
SYSTEM

21. HCV treatment can be highly successful among PWID

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

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

24. Strategies to enhance HCV assessment and treatment among PWID

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

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

27. 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

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

29. 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

30. 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

31. 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 Grebely J and Dore GJ Antiviral Research 2014.

32. 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