Hepatitis C among people who inject psychoactive drugs … C among people who inject psychoactive...
Transcript of Hepatitis C among people who inject psychoactive drugs … C among people who inject psychoactive...
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Hepatitis C among people who inject psychoactive drugs in the UK: insights from national survey data and the way forward
Ellen HeinsbroekIDU team, National Infection Service, Public Health England
[email protected] IMS Users Annual Meeting, 18th July 2017
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Outline• Hepatitis C in people who inject drugs
• Insights from the unlinked anonymous monitoring (UAM) survey• Anti-HCV testing results• Self-reported HCV VCT• Access to care
• Way forward• Global health sector strategy• New Direct-Acting Antivirals• Treatment as prevention• Enhancing the UAM survey
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Hepatitis C• Bloodborne virus: 6 genotypes
• Often asymptomatic until severe liver damage• End-stage liver disease (ESLD)• Hepatocellular carcinoma (HCC)
• Curable
• No vaccine
• UK: estimated 214,000 chronic cases
• At risk: people who inject drugs (PWID)
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*PHE, Hepatitis C in the UK, 2016 report
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Insights from the unlinked anonymous monitoring (UAM) survey
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The Unlinked Anonymous Survey of People Who Inject drugs• Recruits people who inject psychoactive drugs across England,
Wales & Northern Ireland
• Sentinel surveillance by voluntary recruitment at collaborating drug agencies.
• First established in late 1980s as part of HIV monitoring
• Participants• Complete a short behavioural questionnaire • Provide a Dried Blood Spot sample: HIV, HBV, HCV
• An unlinked and anonymous methodology
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UAM Survey Aims:
1. Measure the prevalence of blood borne viral infections among PWID (HIV, HBV, HCV).
2. Monitor changes in both risk and protective behaviours related to drug taking.
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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Prop
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ith a
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atiti
s C
and
test
ing
upta
ke (%
)
Survey year
Hepatitis C testing uptake
Proportion with hepatitis C
Trends in Hepatitis C prevalence and voluntary and confidential HCV testing uptake* among PWID in EW&NI:1998/2000 - 2015
Source: Survey data tables PHE, 2015 *Self reports
0%
20%
40%
60%
80%
100%
NorthEast
NorthWest
London East ofEngland
SouthEast
SouthWest
WestMidlands
Yorkshire& Humber
EastMidlands
Proportion with antibodies to HCV in 2015 by region
NW (2015): Anti-HCV prevalence 68%HCV VCT uptake 90%
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HCV testing / access to care
Unpublished results removed for public access: please contact [email protected] for information
8 Hepatitis C testing and access to care among people who inject psychoactive drugs in the United Kingdom (UK): insights from national survey data.
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Way forward: national picture
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Direct-acting antiviral (DAA) therapy • Sofosbuvir / Ledipasvir
• Oral
• Shorter treatment duration
• Improved side effects
• High sustained viral response (~cure) rates• >90% genotype 1
• Cost: 12/24 week course of Sofosbuvir: £35,000/£70,000
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NICE technology appraisal guidance 330: Sofosbuvir for treating chronic hepatitis C. 2015.
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Global Health Sector Strategy • WHO Global Health Sector Strategy (GHSS) on viral hepatitis for
the period 2016-2021
• First-ever global targets for viral hepatitis control
• “Eliminate viral hepatitis as a major public health threat by 2030”
Impact• Reducing HCV-related morbidity and mortality
• 10% reduction in HCV mortality by 2020, 65% by 2030
• Reducing the number of new (incident) chronic infections• 30% reduction in HCV incidence by 2020, 80% by 2030
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Global Health Sector Strategy Key interventions PWID• Harm reduction
• 200 needles and syringes per PWID per year in 2020, and 300 in 2030
• Increased proportion diagnosed• 30% in 2020, 90% in 2030
• Increasing proportion and number treated• 80% of eligible persons in 2030
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Increased number treated
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PHE, Hepatitis C in the UK, 2016 report
Provisional UK-wide estimates of numbers initiating HCV treatment
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Increased proportion diagnosed
14 Adapted from: PHE, Hepatitis C in the UK, 2016 report
2011 2013 2015 2020* 2030Year
Estimated UK-wide proportion of PWID aware of their HCV infection, 2011-2015, and targets for 2020-2030
100
90
80
70
*2020 target met in 2011-2015
Pro
porti
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war
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thei
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V s
tatu
s (%
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Reducing HCV mortality
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Deaths from ESLD or HCC in those with hepatitis C mentioned on the death certificate in the UK, 2005-2015
Adapted from: PHE, Hepatitis C in the UK, 2016 report
x: 2020 target
x: 2030 target
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Reducing the number of new chronic infections
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Preliminary estimates of incidence of HCV-related ESLD/HCC: 2010-2015, and 2020 and 2030 targets
x: 2020 target
x: 2030 target
Adapted from: PHE, Hepatitis C in the UK, 2016 report
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Reducing the number of new infections
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Adapted from: PHE, Hepatitis C in the UK, 2016 report
Estimated UK-wide incidence of HCV among PWID 2011-2015, and goals for 2020-2030
2011 2013 2015 2020 2030Year
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Directly acting antivirals and Treatment as Prevention
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InfectionEarly entry to care
Early diagnosis
Early DAA treatment CURE
HCV morbidity
Transmission
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Treatment as prevention
Modelling study: impact treatment severe / moderate / mild disease
• Severe (3500/yr): • ESLD/HCC incidence from 1240 cases in 2015 to 630 (95%CI 530-770) in 2020 • Negligible preventative impact
• Mild (2500/yr):• Negligible impact on ESLD/HCC incidence within 15 years• Annual prevalence/incidence from 34%/5% in 2015 to 11%/1.4% in 2030
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Harris et al, J Viral Hep, 2016 23, 631–643
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Modelling studies
20 Harris et al, J Viral Hep, 2016 23, 631–643
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Measuring hepatitis C incidence
All UAM samples from 2017 onwards will be routinely tested for HCV RNA.
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Uninfected
RNARNA positive,
antibody negative
(51-75 days)
AvidityHCV antibodies with weak avidity
(2-6 months)
Established infection
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Discussion• Fluctuations in incidence
• Incidence unstable in cross-sectional surveys• Transient state of incident infections/outbreaks
• Trends in incidence need longer-term monitoring and mathematical modelling
• Importance of avidity/RNA for monitoring incidence, chronic prevalence, reinfection
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Conclusion• +/- 50% PWID infected with HCV
• Little change in key indicators 2011-2015
New opportunities
• Direct-acting antivirals
• Global Health Sector Strategy (GHSS)
• Change required to reach GHSS targets 2020 & 2030
• Treatment as prevention expected to reduce incidence
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Thank you for your attention
We are grateful to the survey participants and collaborating sites across the UK for their support of the UAM Survey of PWID
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Acknowledgements PHE: Vivian Hope, Monica Desai, Rachel Glass, Claire Tanner, Jackie Njoroge, Ross Harris, Samreen Ijaz, John Parry, Katelyn Cullen, Fortune Ncube, Jason Shute, Sema Mandal, Helen Harris
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Adequate harm reduction
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PHE, Hepatitis C in the UK, 2016 report
Estimated UK-wide proportion of PWID reporting adequate needle and syringe provision, 2011-2015
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Trends in equipment sharing among current* PWID in EW&NI: 1991 - 2015
* Those who had last injected in the four weeks preceding participation in the survey.Source: Survey data tables PHE, 2016
0%
20%
40%
60%
80%
100%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Prop
ortio
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port
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shar
ing
(%)
Survey Year
Sharing of needles and syringes
Sharing of needles and syringes as well as other injecting paraphernalia
NW (2015):Needles and syringes 15%Other injecting equipment too 34%