ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Testing and Treatment

A/Prof Ben Cowie's plenary talk at AVHEC17 on the Australian Progress and challenges in Hep B was highly engaging and it is certainly true that the migration laws in Australia have been discriminatory with regards to hep B patients who may be rejected for a permanent residency.

 

He also highlighted the importance of testing people from high risk countries and Indigenous background, and stressed the role of primary care practitioners who are at the forefront and are in the best position to identify who needs monitoring and who needs treatment.   

 

Another issue he mentioned with regards to GPs who have patients with chronic hep b but are untreated or maybe under monitored is the possibility of litigation down the track if these patients develop cirrhosis or cancer. It is an important issue that might just be one of the things that can drive uninterested GPs to increase their awareness and treatment of this chronic disease. 

 

Link to Ben Cowie's speaker presentation here

 

 

The Australian Viral Hepatitis Elimination Conference 2017 is aimed at equipping medical practitioners with strategies to achieve this goal by the next decade.The conference has used key note speakers from around the world to deliver these strategies.

In one of the sessions titled Poster walk: DAA treatment therapies, we reviewed several recent research articles with results that, when fully implemented, will enhance the elimination of viral hepatitis in Australia.

One of the research articles we reviewed was titled: High SVR rates with eight and twelve weeks of pangenotypic Glecaprevir/Pibrentasvir: integrated efficacy and safety analysis of genotype 1-6 patients without cirrhosis.

In this presentation, we learnt that a new medication for the treatment of hepatitis C is being registered in Australia very soon. It is highly effective against all genotypes, so no genotype testing is necessary; a cost saving measure. It is also highly effective in 8 weeks, again a cost saving measure and a boost for compliance.

It can be used in renal impairment and has very few drug interactions. I am fascinated with this new medication because it would be suitable for many of my patients with compliance problems, renal problems and who are on many medications with possibilities of drug interactions with anti retroviral medications.

I have no bias or interest with any drug company. My interest is with what will enhance the elimination of viral hepatitis in Australia.

Access various Posters for DAA Treatment Therapies from AVHEC17 here

The presentation by Professor Dore was a rapid but detailed overview of the situation of the current situation with Hepatitis C and how things have progressed over the past two years with the introduction of the Direct Acting Antiviral drugs since 2015, and more particularly, the subsidisation of these medications on the Australian Pharmaceutical Benefits Scheme in March 2016.

Professor Dore is the head of the Viral Hepatitis Research Program at the Kirby Institute at the University of New South Wales, and an Infectious Diseases Physician at St Vincent’s Hospital in Sydney.

The Real world efficacy of antiviral therapy in chronic hepatitis C (REACH-C) in Australia research report is published by his team.

He emphasised the impact of these medications as safe, effective and well tolerated drugs, in contrast to those previously available. The availability of these drugs almost without restriction to eligible patients has made a major impact on both and individual and population level. With almost a quarter of a million patients in Australia living with Hep C, knowingly or otherwise, the possibility of eliminating Hep C as a major public health issue in Australia is an achievable aim by 2026 to 2030.

Over 32,000 people were treated between March and December in 2016, representing 14% of those effected. However, figures for 2017 show declining numbers being treated compared to last year. The figures are still encouraging for people in “at risk” groups including this with Cirrhosis and those who inject drugs, and post treatment follow-up requires enhanced efforts.

Professor Dore went on to compared the “real world efficacy” of the DAAs in various situations and spoke of the REACH-C trial observational cohort, and compared the different efficacies of the different DAA regimes, and genotypes of Hep C. Various diverse models of care delivery in different situations were then discussed. Modelling of Hep C elimination in different scenarios (Pessimistic, intermediate, and optimistic) were given.

In summary, it was concluded that: Australia is leading the world in treating Hep C with DAAs, key populations for the elimination of Hep C are being reached, outcomes are favourable despite some failures in followup, and to reach the goals set by WHO, bradened models of treatment delivery are required over the next two to three years.

Professor Dore is Head, Viral Hepatitis Clinical Research Program, Kirby Institute, UNSW, Sydney Australia, and Infectious Diseases Physician, St Vincent’s Hospital, Sydney, Australia. He has been involved in viral hepatitis and HIV epidemiological and clinical research, clinical care and public health policy for 20 years.

Access Prof Greg Dore's speaker presentation here

 

 

This session was focused on the "whole system approach" and working together to deliver care to people living with HCV.

HCV affects more than 250,000 Australians resulting in up to 630 deaths from liver cancer and liver failure each year. Globally, more than 500,000 people die from HCV related causes. How can we work together with research organisation, policy makers, primary care providers, community and affected populations to change the course of HCV infection and its impact as a public health threats?

The speaker, Dr Jacqui Richmond, gave us a fantastic introduction to motivate me as a primary care provider to manage HCV in my general practice setting. In the past, there were not many primary care practitioners who wanted to be involved in HCV care in the community due to multi-factorial barriers and lack of clinical infrastructure.

With the advent of well-tolerated, short duration, interferon free DAA therapy, there is an opportunity to increase accessibility to treatment by providing care in the community setting.

Jacqui gave us very informative talk about how to deliver health services to people living with hepatitis C. Hepatitis C elimination will not occur without a whole of system approach. Elimination will not occur without GPs, nurses,community-based workers, peer workers, pharmacists, aboriginal health workers and CALD workers. Our implementation plan is to utilise a health system framework to increase demand through health promotion, increase clinical capacity through training and education, streamline clinical pathways to increase access to hepatitis C testing & treatment in the community & prison settings, establish integrated HCV prevalence and incidence over time, pilot and evaluate new interventions to increase uptake of HCV testing & treatment.

Many hands make light work. A partnership approach is the only solution. We are at the beginning of a long journey, hepatitis C is not going to be prioritised by every health professional po. We are competing for the attention of health professionals against well-resourced diseases and organisations. TOGETHER we are stronger.

Link through to Jacqui's presentation here.

Fantastic final lecture of the day at the 2017 Australasian Viral Elimination Conference! Dr Jacqui Richmond really nailed it when she said that we will not eliminate hepatitis C without a whole of system approach. A very insightful lecture into the challenges in educating the workforce and the reasons why there has been such a slow uptake of new knowledge into practice. To move DAA prescribing into the community is the essential next phase towards elimination, but this will require a change in practice on the part of GPs. Jacqui used the diffusion of innovation theory to explain how this change might happen. A very thought provoking lecture.

Jacqui Richmond has worked in viral hepatitis for the last 20 years in nursing, education, research, and policy development. Jacqui currently works at the Burnet Institute, Melbourne Health and La Trobe University, where the broad focus of her work is on building the capacity of the health professional workforce to test, treat and manage the health care needs of people living with viral hepatitis.

Link to Jacqui Richmond's speaker presentation here

 

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