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Hepatitis C and liver disease prevention

Hepatitis C and liver disease prevention. Dr. Natasha Martin, DPhil Matthew Hickman, Daniela De Angelis, Peter Vickerman, Katy Turner, Vivian Hope, Norah Palmateer, Michael Sweeting, Sharon Hutchinson, Noel Craine, Graham Foster, David Goldberg, Alec Miners. PUBLIC HEALTH IMPORTANCE. In UK

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Hepatitis C and liver disease prevention

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  1. Hepatitis C and liver disease prevention Dr. Natasha Martin, DPhil Matthew Hickman, Daniela De Angelis, Peter Vickerman, Katy Turner, Vivian Hope, Norah Palmateer, Michael Sweeting, Sharon Hutchinson, Noel Craine, Graham Foster, David Goldberg, Alec Miners

  2. PUBLIC HEALTH IMPORTANCE • In UK • Liver disease is 5th commonest cause of death • HCV/HBV 2nd most important cause liver disease • Worldwide • HCV infection causes ~1/4 liver disease (over 350,000 deaths per year)

  3. Estimated number of people infected with anti-HCV antibodies Sweeting et al. Biostatistics 2008; De Angelis et al, Statistics in MeicalResearch 2009; Ross et al EJPH in press

  4. Intervention Effectiveness • NSP is effective in reducing self-reported injecting risk behaviour • BUT on HCV transmission • Insufficient review level evidence that NSP is effective • Weak evidence that OST is effective • No review level evidence for other interventions Palmateer et al Addiction 2010 105: 844-59 (http://www.hepcscotland.co.uk/action-plan.html

  5. Pooling UK evidence on intervention impact Judd et al. BMJ 2005. Craine et al. J Epi & Inf 2009; Hope JVH 2010; Turner Addiction in press

  6. Intervention Effect

  7. But what about the effect on HCV prevalence? England and Wales data • HCV prevalence has decreased over time in some settings • But none have decreased HCV to low levels • Recent data from England/Wales suggests might be increasing Sweeting, M., et al., AJE 2009. 170: 352-60

  8. Bristol Surveys – 2006 : 2009 • HCV Prevalence • ~53% 2006 (n=299) • ~57% 2009 (n=336) • Recent infections/incidence • ~40% 2006 (15 Antibody-ve PCR+ve) • <10% 2009 (3 Antibody-ve PCR+ve) • > 80% reduction in incidence

  9. Can scaling up the coverage of existing interventions reduce HCV prevalence?

  10. Impact of changing coverage of OST and NSP from 50%: 0%, 60%, 70%, 80%

  11. Implications • NSP and OST can reduce HCV incidence. • And have averted infections • BUT unclear whether further scaling up feasible or could lead to substantial reductions in HCV prevalence • Other prevention options needed • Could HCV treatment have an impact?

  12. HCV antiviral treatment: Barriers among active IDUs • Antiviral treatment effective (~60%) for curing HCV infection and approved for active injecting drug users (IDUs) • BUT few currently being treated (<1%) • Perceived reluctance/concern over high rates of: • Non-completion/compliance • Re-infection following treatment

  13. MATHEMATICAL Model Outcome: Impact on HCV prevalence Non-responder infected IDUs Antiviral treatment Allow for reinfection New injectors Uninfected active IDUs HCV chronically infected IDUs Death or cessation from each state Infection Martin et al. J Hepatology 2011; J Theoretical Biology 2011

  14. projections

  15. Relative prevalence reductions at 10 years with varying treatment rates ‘Baseline’: untreated endemic chronic infection prevalence Martin et al. J Hepatology 2011

  16. Prevalence reductions at 10 years • Population of 3500 IDUs, 1400 chronic infections • 70 treated annually (20 per 1000 IDUs) • 30% reduction by 2021 (40%  28%) • 140 treated annually (40 per 1000 IDUs) • 58% reduction by 2021 (40%  17%) Martin et al. J Hepatology 2011

  17. projections through time (5, 10, 20 years) annually treating 20 per 1000 IDUs • Swift and substantial reductions at low prevalence • Significant reductions even at high prevalence • 3500 IDUs, 1400 infected (40% prevalence), 70 treated/yr • 15% reduction in 5 years (4034%) • 30% reduction in 10 years (4028%) • Halved in 20 years (40 20%) Martin et al. J Hepatology 2011

  18. Incremental cost per QALY vs. no treatment: Equal efficacy (SVR) for ex- and active IDU • Treating IDUs may be highly cost effective – and more cost effective (at prevalences <60%) than treating ex/nonIDU • Averts infections Martin et al in preparation

  19. Implications

  20. Scale-up – from modelling to reality – empirical data needed • Trouble with models • Theoretical: projections not observations • Need to introduce heterogeneity: injecting risk/ HCV treatment uptake/ SVR • Model combined effects of HCV Rx, OST & NSP • BUT models can raise hypotheses/ provide theoretical framework/ justification for future work • Now empirical evidence required

  21. Scaling up HCV treatment • What are the best models/ways of delivering HCV treatment to injectors in community? • Start with OST population • Peer projects/ support • Treatment advocacy • Who is not worth starting treatment with i.e. compliance/SVR too low

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