2025 – Six years to Hep C Elimination

1. 2025 –Six years toHep C Elimination Mark Gillyon-Powell JP NHS England Health & Justice Jan/Feb 2019

2. WHO and how and why International ambition England ambition Improved treatment National procurement Doing what we do – but better and more of it Testing (both) > Diagnosis > Referral > Treatment / Cure The opportunity…

3. Hepatitis CThe Basics Graham R Foster Barts Liver Centre QMUL

4. What is hepatitis C? • Hepatitis C is a virus • It can survive for a long time outside the body • Hepatitis C is passed on through blood • Current or former injecting drug users at huge risk • People in prison are more likely to have hepatitis C

5. HCV – a global epidemic Negro F and Alberti A. Liver Int 2011;31(Suppl 2):1–3

6. HCV causes slowly progressive liver fibrosis 100 90 80 70 60 50 40 30 20 10 0 Cirrhosis leads to HCC in 5% per year Percent of patients with cirrhosis 0–10 11–20 21–30 31–40 41–50 51–60 61–70 >70 Age of patients (years) Adapted from D’Souza. ClinGastroenterolHepatol 2005;3:910–17

7. Say hello to your liver • The biggest organ in the body • Very strong – it takes 30 years to kill it

8. HCV – What does it do?

9. HCV – What does it do?

10. Hep C and the liver • If you have Hep C for 20-30 years…… • You are in trouble!

11. Hepatitis C is an infectious virus Age distribution of newly reported confirmed cases of hepatitis C virus infection --- Massachusetts, 2002 and 2009

12. Hepatitis C What can we do about ? • We need drugs to kill the virus • Enter the Germans….

13. The Hepatitis C Virus Receptor bindingand endocytosis Transportand release Fusion and uncoating Virionassembly ER lumen (+) RNA Translation andpolyprotein processing LD LD LD Membranousweb RNA replication ER lumen 3680/3826 DAA: direct-acting antiviral agent; ER: endoplasmic reticulum; GT: genotype; IFN: interferon; LD: luminal domain; NA: nucleos(t)ide analogue; NS: non-structural protein; SVR: sustained virological response Lindenbach BD, Rice CM. Nature 2005;436(Suppl):933–8; Liang J, Ghany MG. N Engl J Med 2014;370:2043–7.

14. NS5A inhibitors We now have really good drugs that target different stages in the HCV lifecycle Receptor bindingand endocytosis Receptor bindingand endocytosis Transportand release Transportand release Fusion and uncoating Fusion and uncoating Virionassembly Virionassembly ER lumen ER lumen (+) RNA (+) RNA Translation andpolyprotein processing Translation andpolyprotein processing LD LD LD LD LD LD Membranousweb Membranousweb RNA replication RNA replication ER lumen ER lumen 3680/3826 Non-NA NS5B inhibitors NA NS5B inhibitors NS3 protease inhibitors Lindenbach BD, Rice CM. Nature 2005;436(Suppl):933–8; Liang J, Ghany MG. N Engl J Med 2014;370:2043–7. DAA: direct-acting antiviral agent; ER: endoplasmic reticulum; GT: genotype; IFN: interferon; LD: luminal domain; NA: nucleos(t)ide analogue; NS: non-structural protein; SVR: sustained virological response

15. Phase 3 evaluation of SOF/VEL FDC for 12 weeks in Tx-naive and -experienced G1, 2, 4, 5, and 6 patients with and without cirrhosis: ASTRAL-1 study SVR12* (%) 618/624 206/210 117/118 104/104 116/116 34/35 41/41 *HCV RNA <15 IU/mL A once a day tablet for 12 weeks kills the hepatitis C virus

16. A cure for hepatitis C • If you take a tablet for Hep C the virus will go away • The drugs have no side effects (yes, really)

17. What happens when we cure Hep C? • When we cure Hep C:- People feel better People don’t get cirrhosis People don’t infect their friends

18. What happens when we cure Hep C? • When we cure Hep C:- People feel better People don’t get cirrhosis People don’t infect their friends BUT If you have cirrhosis you can still get cancer

19. Hep C in England • The NHS wants to treat everyone • Drugs are free, tests are free, support is free • We will do whatever we need to do to get people treated

20. NHSE Tactics • Set up regional networks • Allocate treatment numbers per network (‘run-rate’) with local prioritisation • Enforce ‘out-reach’ treatments with incentives and penalties • Insist on use of ‘lowest acquisition cost’ medication

21. What happened when England starting treating Hepatitis C Deaths from HCV or HCC in patients with HCV (PHE report on HCV 2016) Transplants for HCV

22. Hepatitis C What next? • If we can eliminate HCV we can save hundreds of millions a year • We can save thousands of lives • Lets do this!

23. So what is different about custodial settings? Resistance and stigma Misunderstanding and myths Opt-out vs opt-in When to test? Which test(s)? Time at establishment Which drug?

24. Health & Justice; Where are we now? • All prisons say that they are doing opt-out testing • We measure rates of test offer / uptake at or near reception • We measure positives referred to specialist treatment within two weeks of diagnosis • Generally, good relationships exist between commissioners and ODNs • We don’t measure non-reception testing • Different prisons / commissioners / specialists choose different testing methods, so no consistency and impacts process / pathway

25. The reported performance – with caveats… Context: Sevenfold increase in testing since opt-out Threshold: Amber = 50%, Green = 75% Test uptake: National = 29.6% North = 30.2%, Mids & East = 23.6% South = 31.3%, London = 38.9% Range: 100% (Buckley Hall, Peterborough Female) to 0% (East Sutton Park), 0.5% (Maidstone) Uptake amongst eligible population Testing outside of reception not currently measured

26. What can improve and how can we do it? • ‘Reception’ Testing • Workforce • Guidance and methodology • Pathway examination • Recording • Population Testing • Partnership • Guidance and methodology • Incentives? • Peers • Active Case Management

27. What can improve and how can we do it? • Close working • Prison, Prison Health, Commissioner, ODN, Peers • New partners through national procurement • National Health & Justice Team • Process • Simplify! Less steps, shorter processes E.g. pan genotypic drug, Point of Care Testing, diagnostic ‘Hit Squad’ • Actively consider steps on the pathway as potential points of attrition, and change them