HepCare Europe No-one gets left behind: addressing the hidden burden of HCV related - PowerPoint Presentation

HepCare Europe No-one gets left behind: addressing the hidden burden of HCV related advanced liver disease in PWID in the communityDr John Lambert, Professor of Medicine and Consultant in Infectious Diseases, Mater Hospital and UCD Dublin    

HEPCARE: A new Hepatitis C Care service model Primary Care Secondary care WP4: HepCheck (screening) WP5: HepLink (linkage to care) WP 7: HepFriend (peer advocacy support) WP 6: HepED (inter-professional education) WP8: HepCost WP 1 Coordination; WP 2 Dissemination; WP3 Evaluation  VISION:Create an innovative, integrated system for HCV treatment, based on the joint participation of primary and speciality care practitionersOBJECTIVE: Improve access to HCV testing and treatment among key risk groups, including drug users and homeless, through outreach to the community and integration of primary and secondary care services HEPCARE EUROPE is a €1.8M 3-year EU-supported project at 4 member state sites Consortium members: UCD (Ireland); SAS (Spain); SVB (Romania); University of Bristol (UK); University College London (UK)

Community Education Preparing the at risk population for testing, assessment and treatment) Education of Community Health Care Workers Improve understanding of new treatments, and prepare them to act as partners in treatment and support in a ‘shared care’ primary/secondary integrated partnership. Point of Care Testing Evaluation of point of care testing with HCV oral tests in diverse populations and different countries/settings and assessment of cost effectiveness Community Fibroscan testing strategy Implementation and evaluation of the strategy, and assessment for advanced disease patients the reasons for non-attendance. Linking Services across Diseases Address key conditions in vulnerable populations in a linked up fashion (drug and alcohol addiction, primary care, STD, blood borne virus testing, TB, Hepatitis B vaccination) Community nurse outreach and peer advocacy support Community focused assessment for HCV disease in HCV+ as vulnerable communities do not access secondary care services. Educational tools and pathways To help HCV negative people to minimise their risk of HCV infection and other blood borne viruses How to make HCV a ‘rare disease’ in the EU

Evolution of Hepatitis C care Old Model New Model Screening Blood test (invasive) Mouth Swabs (non invasive) Medication route administration Injection Oral Diagnosis of disease severity Liver biopsy (invasive) Fibroscan (non invasive) Cost (direct) +++ +++++ Cost effectiveness Moderate High Efficiency of treatment: Sustained viral response Moderate High Place of care Hospital Specialist Clinic Primary care and Specialist clinic

HCV elimination is on the global agendaGlobal Health Sector Strategy on Viral Hepatitis “Eliminating viral hepatitis as a major public health threat by 2030” Action plan for the prevention and control of Viral Hepatitis “ A WHO European Region that is free of new hepatitis infections” Glasgow Declaration “It is possible and essential to set as a goal the elimination of both hepatitis B and C as public health concerns” Elimination Manifesto"Our vision for a Hepatitis C-free Europe”Sept. 2015Feb. 2016 May 2016Sept. 2016

Increase in sterile needle and syringes provided per PWID/year from 20 in 2015 to: 200 by 2020 and 300 by 2030Harm reduction 90% of people aware of HCV infection by 2030 Testing targets 80% of people treated by 2030 Treatment targetsIncidence targets 30% reduction in new HCV infections by 202090% reduction in new HCV infections by 2030Mortality targets 10% reduction in mortality by 2020 65% reduction in mortality by 2030WHO strategy comes with targets, by 2030

HepCheck Homeless, Hep C & Competing Priorities Conclusions Community based screening intervention can enhance HCV diagnosis for at risk populations. Referrals to/attendance to secondary care remains a challenge for this cohort. Psychosocial factors at the core of why patients do not attend secondary care for HCV management. Addiction, mental health and homelessness were especially problematic Future research should examine interventions to improve attendance rates at secondary care . John S. Lambert 1 2 , Carol Murphy 1, Eileen F. O’Connor 2, Dee Menezes1 , Walter Cullen 2, Tina McHugh 1, Geoff McCombe 2, Gordana Avramovic 1 2, Austin O’Carroll³, 1. Mater Misericordiae University Hospital, Dublin, Ireland. 2. University College Dublin, Ireland. 3. Safetynet Primary Care Network, Dublin, Ireland. 619 OFFERED SCREENING 547 SCREENED 72 NOT SCREENEDPrevious HCV Ab test?Yes +ve: 12 Yes -ve: 11Yes, unsure of result: 3No/missing: 4638% Ab positive (206)Of which:112 "new positives"94 "known positives 57 % Ab negative (310) 31 no result/awaiting result (5%) 51 referrals 33 attendances 2 completed treatment HOMELESS HEPCHECK Screening results RESULTS A total of 619 individuals were offered screening. Their ages ranged from 17 to 86, with the average age being 36.7 years and were 74% male (455 male, 163 female, 1 missing). Of the 619 offered screening, just under a third reported having had a previous HCV test before (216) of which half recalled a positive result, 36% negative (79) & 13% unsure of the result (29). Screening 547 HCV Antibody tests were performed 38% (n=206) tested positive 57% (n=310) tested negative 5% (n=31) recorded as no result/awaiting result Of the 206 testing positive, 54% (112) were “new” positives while the remaining were” known positives” Following a positive test 51 patients were referred to specialist care and 33 attended 2 or more appointments. One individual completed treatment whilst another is still on treatment at the time of writing. Qualitative interviews The most common reasons for homelessness were alcohol and/or drugs, and for some, this was combined with family/relationship problems and mental health problems. Acknowledgements HEPCARE EUROPE : Bridging the gap in the treatment of Hepatitis C . Method The target population was homeless people accessing the Safetynet primary healthcare services in Dublin. Individuals were invited to undertake a short questionnaire and HCV antibody test. Qualitative interviews were also carried out with selected patients. (n=49) exploring a broader range of health and lifestyle issues.

Qualitative Interviews with selected patients49 participants were administered the questionnaire, of which most (78%) were currently living in a hostel. The remaining were sofa surfing, sleeping rough or staying with friends. The average time period of homelessness was 6.2 years, with a range of 2 months to 20 years. The most common reasons for homelessness were co-morbidities such as alcohol and/or drugs, and for some, this was combined with family/relationship problems and mental health problems. Most (42%) saw a GP once a week.

When asked about their HCV antibody result, 63% said they had previously received a specialist appointment. When asked about their HCV healthcare pathway, the most common theme was stable accommodation: participants reported this to be a barrier to attending specialist appointments and accessing treatment. The most common other reasons for non-attendance were active drug use, being in prison, fear of side effects of treatment and forgetfulness.

WP - HEPCHECK- OVERVIEW  DUBLINLONDON BUCHAREST SEVILLE TOTAL 1. No. of individuals offered/screened 712/569  -/310-/469657/4011,749   2. Proportion of individuals with positive HCV antibody on screening 137/56924%  123/31041.8%  166/46935%140/40134%559 3. No. of individuals screened (Ab only, bloods only, both Ab and bloods) Pending  PendingAb 365Ab + bloods 104 Ab: 264Bloods:116Ab + bloods: 21- 4. No. of HCV Ab+ individuals (either new or previously diagnosed) attending specialist appointment for HCV assessment.Pending60   65 51   222+  

Seek an Treat: community Fibroscan Rapid test allows POCT: Entire scan 5-7 minutes to completeAllows clinicians to arrange OGD or liver ultrasound urgently if evidence of cirrhosis Non invasive procedure/ No pain/No sedation required No risk of bleeding or infection which are potential complications of biopsy No requirement to admit as a day case Inexpensive scan 96% specificity when compared to liver biopsy staging.

Progression of untreated fibrosis in OAT patients Serial Transient Elastography Readings Indicate Progression of Untreated Fibrosis Among Patients Attending Opioid Substitution Treatment Clinic in South County Dublin J. Moloney 1,  G. Hawthorn 1 , P.A. McCormick2, E. Feeney3, D. Houlihan3, S. Keating 1, C. Murphy4, T. McHugh4, J.S. Lambert42008: 84 patients scanned77% were HCV Ab positive and 58% of this group were HCV viraemic.By 2016, all of the 2008 patients with TE scores > 13 Kilopascal (Kpa) had died (a total of 13 patients) and 11 of these patients died as a result of liver failure associated with hepatitis C viraemia and alcohol. 2016: 105 scans in surviving patientsCohort from 2008 who still attended the clinic and new patients attending the clinic. 16 patients (15%) of the 2016 population had TE scores > 13 Kpa, the previous threshold for death at eight years

The hidden burden of hepatitis C related advanced liver disease in the community Nadeem Iqbal 3 , John S Lambert 3,4 , Des Crowley 1,2, Hugh Gallagher2, Fidelma Savage2 , John Moloney2, Carol Murphy1,3, Tina McHugh3, Aileen Singleton2, Shay Keating2, Audrey Dillon2, Stephen Stewart3. The Hidden Burden: HCV-related advanced liver disease in the community Background for the Study Large number of HCV+ patients receiving methadone substitution therapy in drug treatment centre who do not attend specialist hepatology services Most of these patients have never had their liver disease staged, hence we postulated that many of these may have underlying advanced liver disease Fibroscan™ (FS) used to assess the liver stiffness. Cut-offs used for disease staging 8.5 kPa , which allowed access to direct acting antivirals (DAAs) in Ireland before Feb 2017.25kPa, which has a 90% positive predictive value for clinically significant portal hypertension. 35kPa, which is associated with a 10-20% risk of decompensation per year 1- Irish Prison Service 2- HSE Addiction Service 3- Mater Misericordiae University Hospital 4- University College Dublin

Hidden burden of HCV: Results (1) P = 0.001 P = 0.02

HepCare Europe: Reaching vulnerable patientsHigh incidence of HCV in the homeless communityMany have past/active IDU as risk factor; alcohol is additional riskHCV previously diagnosed in many, but not accessing care HCV common in all ‘marginalised populations’ in the EU (21-40+ %)Still a significant burden of HCV related liver disease undiagnosed in the community, a ‘time bomb’ for liver disease progressionTreatment of disease is priority is Ireland with limited resources/DAA availability, treatment of infection (treatment for prevention priority if unlimited DAA availability). €30 million is ‘ring-fenced’ annually for treatment. Treatment of disease/treatment for prevention concepts are not mutually exclusive30,000 in Ireland with HCV, we have treated the ‘easy’ first 2000, so how do we reach the remaining 28,000

Energy, Commitment and Resources A public health approach (simplification, integration, decentralization, equitable access) Innovations: HBV cure, HCV vaccine, pan-genotypic oral treatments Partnerships (governments, civil society, private sector involvement)Concrete and tailored action in countries, guided by national plansThe Irish Experience to date: vulnerable patients don’t go to hospital clinics for care; we must go to them; there is still a large burden of HCV related liver disease out there, and they are not accessing care and treatment: we must ‘Seek and Treat’. HCV Elimination agenda : what will it take..?

AcknowledgementsCo-funded by the European Commission through its EU Third Health Programme and Ireland’s Health Services Executive Participating GPs, Addiction Services, and patientsOur partners: UCL, Bucharest, U Bristol, SAS Seville

Primary Care Secondary care WP4: HepCheck (screening) WP5: HepLink (linkage to care) WP 7: HepFriend (peer advocacy support) WP 6: HepED (inter-professional education) WP8: HepCost WP 1 Coordination; WP 2 Dissemination; WP3 Evaluation   HEPCARE EUROPE 2017 NO ONE LEFT BEHIND Hepcare Team: Dublin: PI’s Drs Lambert and Cullen (Co Investigators Drs Stewart, Feeney, Houlihan)London: Drs Alistair Story and Julian SureyBucharest: Dr Cristiana OpreaSpain: Dr Juan Macias SanchezBristol: Drs Peter Vickerman and Matthew Hartman