Treatment and access to treatment in low and middle income

countries

Adeeba KamarulzamanUniversity of Malaya

Kuala Lumpur, Malaysia

ANRS-NIDA Joint Satellite

Drug Use and HIV and HCV Infection: The Challenge and The Potential Solutions

Global Estimates of HIV-Viral Hepatitis Coinfection

HCV Prevalence in Asia, Africa and Eastern Europe

1Madhava V. Lancet 2002. 2Nelson P, Lancet 2011. 3Ba I, ICASA 20127

Dakar area – UDSEN study3

-est.size IVDUs: 1324- P(HIV): 5,2%- P (HCV): 23,3%

Bulgaria

Greece Ita

ly

Cyprus

Austria

Romania

0

20

40

60

80

20052010

ThailandNepal

PakistanMacau

MyanmarIndonesia

VietnamPhillipinesCambodia

ChinaMalaysia

JapanKorea (Republic of)

AustraliaBangladesh

SingaporeIndia

TaiwanAfghanistan

Maldives

0 10 20 30 40 50 60 70 80 90 100

HCV Ab prevalence among people who inject drugs is high

Source: Nelson PK et al. Global epidemiology of hepatitis B and hepatitis C and people who inject drugs. Lancet 2011: 278:571

Estimating HIV Prevalence in Malaysia

Method

Multi-parameter evidence synthesis methods were applied to combine all available relevant data sources

Results • An estimated 454,000 (95% [CrI]: 392,000 to 535,000) HCV Ab

positive individuals were living in Malaysia in 2009• 2.5% of the adult population• Route of probable transmission - active or a previous history of

IDU• Females represented 1% (95% CrI: 0.6 to 1.4%) of all HCV

infections, 92% (95% CrI: 88 to 95%) were attributable to non-drug injecting routes of transmission SA McDonald, A Kamarulzaman et al. Submitted for publication

Liver-related death: Leading cause of death in HIV-HCV patients

Unknown

Other

Suicide

Overdose

lung

non HIV infections

Cardiovscular

HIV

Cancer (non HIV non HCV)

Liver (including HCC)

0 5 10 15 20 25 30 35 40

43 %

12 %

8 %

5 %

4 %

4 %

4 %

2 %

6 %

7 %

Decompensated cirrhosisHCCPost-transplantation

Cirrhotic Patients: > 50% deaths related to HCVNon cirrhotic patients : 60% deaths non related to HCV nor HIV

1HSogni P. Conference on French HIV-HCV Consensus Guidelines, 2012

13

% o

f pati

ents

with

sus

tain

ed v

irolo

gica

l res

pons

e (S

VR)

IFN

24 W

70

50

30

20

10

60

40

IFN

48 W

IFN+RBV

24 W

IFN+RBV

48 W

PEG-IFN+RBV

48 W

0

80

90

IFN = Interferon-αPEG-INF = Peg-Interferon-αRBV = RibavirinPEG = PEG-IFN-α

2002

2011

1999

2014

PEG-IFN+RBV

+new PI Telaprevir

Or Boceprevir

INF-free regimens12 weeks

? 95-100% SVR

 New Anti HCV Therapy

• PHOTON 1 & 2 – Sofosbuvir + RBV• ERADICATE Study - Sofosbuvir +

Ledipasvir• C-WORTHY Trial - PI MK-5172 + NS5A

inhibitor MK-8742, with or without ribavirin• TURQUOISE 1 –

ABT-450/r/Ombitasvir,Dasabuvir + RBV

Estimated proportion of persons with chronic HCV receiving treatment in selected European countries in 2010

Source: Razavi et al J Hepatol. 2013;58(Suppl 1):S22–3

Treatment coverage remains very low, even in high-income

countries

Total population (2012)

Estimated number PLHIV (all ages, 2012)

Reported number of adults receiving ART

(2012)

Coverage (range of

uncertaintyA)

Cambodia 14,864,64 76,000 44,318 82% [60%->95%]

China 1,350,695,000 780,000 151,519 Not available

India 1,236,686,732 2,100,000

570,620 51% [44%-57%]

Indonesia 246,864,191 610,000

29,960 18% [12-25%]

Malaysia 29,239,927 82,000 14,594

41% [32%-52%]

Myanmar 52,797,319 200,000

49,676 46% [41%-51%]

Nepal 27,474,377 49,000

7,168 33% [28%-40%]

PNG 7,167,010 25,000 11,042 84% [73%->95%]

Thailand 66,785,001 440,000 232,816

76% [71%-80%]

Vietnam 88,772,900 260,000 68,883 58% [19%->95%]

Estimated number of PLHIV and of people on ART in 10 countries in Asia-Pacific, 2012

A The range of uncertainty reflects the degree of uncertainty associated with estimates and defines the boundaries within which the actual numbers lie (see http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/20131118_Methodology.pdf, accessed 1 June 2014). Source: UNAIDS 2013, World Bank 2012)PLHIV=People living with HIV

Number of people who inject drugs (PWID) on ART per 100 HIV+ PWID

Source: Beyrer, Baral

Less than 25% of HIV+ PWID are on ART in Asia and Pacific < 25

25-75

> 75

PWID present but ART program data not available

No PWID reportedPWID=people who inject drugs

Multiple Barriers at Multiple Steps of the Continuum of Care

Adapted from G. Matthews

Barriers to HCV Treatment in Low/Middle Income Countries

• Lack of Awareness• Late Diagnosis• Poor Treatment Literacy• Multiple Comorbidities – TB• Lack of Access to OST• Limited Range of ARVs

Treating HCV in Resource-Poor Settings CID 2012:54 (15 May) d 1465

Lessons from HIV

• Reducing Cost of Treatment• Simplifying Model of Care• Service Integration• Task Shifting• Surveillance, Evaluation and Research• Patient & Community Engagement• Political and Financial Commitment

Overcoming Provider Barriers

Easier assessment of the infection and the liver disease2

-Dry-blood spots (HCV viral load quantification/genotyping)- Portable Fibroscan (Echosens)- Portable sonography

Rapid Testing1

- Point-of-care tests- Salivary rapid testing

1Yaari A, J Viral Methods 2006. 2Tuaillon E, Hepatology 2010

47Mostly unavailable in RLS

Overcoming the Cost Barrier

http://www.medicinespatentpool.org

48

History of HIV

Viral Hepatitis

Acknowledgements

• Karine Lacombe, Inserm• Ying-Ru Lo, WPRO WHO• Joe Sasadeusz, Alfred Hospital, Melbourne