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Shruti H. Mehta, PhD MPH Professor, Johns Hopkins Bloomberg School of Public Health

Hepatitis C a mong p eople w ho i nject d rugs (PWID) in India: High burden but limited access to care. Shruti H. Mehta, PhD MPH Professor, Johns Hopkins Bloomberg School of Public Health Department of Epidemiology Baltimore, MD. July 21, 2014.

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Shruti H. Mehta, PhD MPH Professor, Johns Hopkins Bloomberg School of Public Health

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  1. Hepatitis C among people who inject drugs (PWID) in India: High burden but limited access to care Shruti H. Mehta, PhD MPH Professor, Johns Hopkins Bloomberg School of Public Health Department of Epidemiology Baltimore, MD July 21, 2014

  2. Hepatitis C and injection drug use in India • Limited surveillance data • Estimated prevalence of HCV In the general population: 1- 2% • Predominantly HCV genotype 3 infection • Estimated 1.1 million PWID in India Aceijas 2007; Sievert 2011; Chakravarti 2005

  3. Presentation outline & Data sources • Burden of HCV and liver disease among PWID in India • Access to care and treatment for HCV among PWID in India • Challenges / opportunities • The India IDU Initiative • Cross-sectional sample of 14,481 PWID from 15 sites (~1000 per site) from Dec 2012 – Dec 2013 • Recruited using respondent-driven sampling (RDS) • Diversity of HCV among PWID • 810 HIV-infected persons sampled across 15 sites from 2009 – Jan 2011 • Chennai HIV, HCV and Eeral (liver disease) study[CHHEERS] • ~800 PWID sampled in Chennai • Detailed characterization of liver fibrosis Chennai (CHE)

  4. High burden of hepatitis C infection and HIV/HCV coinfection in India (n=14,481) Hepatitis C antibody prevalence HCV/HIV co-infection prevalence Established epidemics Large cities Emerging epidemics (documented) Emerging epidemics (anecdotal) Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

  5. Predominance of genotype 3 HCV infection but variability by region New Delhi Punjab Uttar Pradesh Rajasthan Manipur Mizoram West Bengal Subtype 1a Subtype 1b Subtype 3a Tamil Nadu Subtype 3b Subtype 6n Solomon CROI 2013

  6. High burden of liver fibrosis / cirrhosis Chronic HCV HIV/ HCV co-infection Mehta EASL 2014; Solomon et al AIDS 2009

  7. Fibrosis, cirrhosis associated with traditional risk factors…

  8. …but also strong associations with metabolic cofactors

  9. Rapid HCV disease progression? • No/mild fibrosis at baseline: Fibroscan <8 kPa • 31% experienced progression to moderate fibrosis • 12% experienced progression to severe fibrosis/cirrhosis • Moderate fibrosis at baseline: Fibroscan 8-12.3 kPa • 47% experienced progression to severe fibrosis/cirrhosis

  10. The hepatitis C care continuum (aka CLIFF)n=5,777 Minimum Maximum Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

  11. Variability by stage of drug use epidemic… Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

  12. …but no variability by stage of liver disease

  13. Barriers to HCV+ diagnosis 14,450 persons 1,272 (9%) EVER tested for HCV 13,178 (91%) NEVER tested for HCV • 53% wanted to know their status • 25% were referred by a physician 6721 (51%) NEVER heard of HCV 6,457 (49%) Heard of HCV • 73% cited low risk perception • 14% did not know where to get tested • 44% tested in private/NGO testing centers / 41% in government centers • Testing more common in sites with established epidemics Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

  14. Facilitators of HCV+ diagnosis Note: also examined gender, years of drug use, lifetime frequency of injection, needle sharing, utilization of other services (SNEP, TB treatment, etc.) Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

  15. Challenges • Co-factors complicate disease progression & treatment response • Metabolic co-factors (e.g., steatosis, insulin resistance) • High burden of alcohol use • Subtype diversity • Access to HCV genotype testing important for management • Low levels of knowledge: start with HCV literacy • Limited access to care & testing locations • Cost

  16. Opportunity: Integrate HCV testing & treatment with HIV and harm reduction services ClinicalTrials.govIdentifier: NCT01686750

  17. Acknowledgements • YRGCARE • Suniti Solomon • AK Srikrishnan • M Suresh Kumar • AK Ganesh • S Anand • P Balakrishnan • CK Vasudevan • Accounts • Data Team • Lab Team • Site staff & participants • Funding sources • NIDA (DA12568, DA032059, DA026727) • OAR (I to I program) • ICMR • Johns Hopkins • Sunil Solomon • Gregory Lucas • David Celentano • Allison McFall • Mark Sulkowski • Dave Thomas • NACO, India

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