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
North America
1.7m
Latin America
1.7m
Eastern Europe 2.3m
Sub-saharan
Africa
0.8m
East and
Southeast
Asia 2.6m
• 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
Group A Strep
Haemophilus influenza
Tuberculosis
Legionella
Chlamydia
Adenovirus
Gonorrhea
Years of Life Lost
Year-equivalents of reduced functioning
0
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
HCV
TESTING
80%
ASSESS &
MONITOR
40%
ENGAGE IN
TREATMENT
10%
ENHANCE
RESPONSE
5%
The HCV Care Cascade – Future requirements
HCV
TESTING
• guidelines
• systematic
programs for HCV
screening and
diagnosis
• point-of-care HCV
testing
The HCV Care Cascade – Future requirements
HCV
TESTING
ASSESS &
MONITOR
• guidelines
• education
• systematic
programs for HCV
screening and
diagnosis
• guidelines
• point-of-care HCV
testing
• non-invasive
fibrosis assessment
• infrastructure for
HCV services
First global recommendations for HCV among PWID
Robaeys* and Grebely*, et al. Clinical Infectious Diseases 2013
The HCV Care Cascade – Future requirements
HCV
TESTING
ASSESS &
MONITOR
ENGAGE IN
TREATMENT
• guidelines
• education
• linkage to care
• systematic
programs for HCV
screening and
diagnosis
• guidelines
• multidisciplinary
care models
• point-of-care HCV
testing
• non-invasive
fibrosis assessment
• infrastructure for
HCV services
•effective, tolerable,
simple, shortduration HCV
therapy
The HCV Care Cascade – Future requirements
HCV
TESTING
ASSESS &
MONITOR
ENGAGE IN
TREATMENT
ENHANCE
RESPONSE
• guidelines
• education
• linkage to care
• systematic
programs for HCV
screening and
diagnosis
• guidelines
• multidisciplinary
care models
• strategies to
enhance adherence
• point-of-care HCV
testing
• non-invasive
fibrosis assessment
• infrastructure for
HCV services
• effective,
tolerable, simple,
short-duration HCV
therapy
• risk reduction to
prevent reinfection
Efficacy of treatment (%)
Efficacious treatments do not work if not given…..
40%
55%
70%
90%
95%
1998
2002
2012
2018
of infected people
were not receiving
treatment in 2012
(projected)
Amount of infected people treated (%)
Thomas DL Nature Medicine 2013. Grebely J and Dore GJ Antiviral Research 2014.
Acknowledgements
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