General Practice Registrar, NSW
Key Takeaway Messages: Moving Towards Elimination - Outcomes in Key Populations
I attended a collection of very interesting oral abstracts at the 2017 Australasian Viral Hepatitis Conference, each dedicated to addressing elimination of hepatitis outcomes in key population groups.
The first presentation by Timothy Papaluca involved a population group across 14 prisons in Victoria. It was a nurse-led HCV DAA program that evaluated the efficacy of the antiviral therapy delivered in the prison system using this model. After 17 months, 1180 prisoners had been assessed with 718 eligible for treatment and 633 prisoners having had treatment commenced. Per-protocol analysis achieved SVR12 of 95% but intention to treat analysis was only 68% with a percentage lost to freedom, highlighting the difficulties with follow up and adherence once they are out of the prison setting. With appropriate follow up and review through to SVR12 however, the prison setting provides an ideal scenario for implementing HCV DAA treatment based programs.
The second presentation by Marianne Martinello looked at HCV/HIV co-infection cohorts. An estimated 230,000 Australians live with chronic HCV and an estimated 2,700 of those have HCV/HIV co-infection. This cohort study evaluated HCV treatment uptake and outcomes of this cohort following DAA therapy. Annual HCV treatment uptake went from 7% in 2014 to 9% in 2015 before skyrocketing to 67% in 2016, while HCV RNA prevalence within the cohort fell from 79% to 74% and 28% in those respective years. Two key factors assisted in the dramatic uptake in treatment. Firstly, this cohort has a high proportion already linked in to HIV care and secondly, the introduction of broad based government subsidies for DAA therapy in 2016. SVR12 was 92% on an intention to treat basis and 96% among 159 individuals on a per-protocol basis, with one case of reinfection.
Phillip Read looked at ATSI patients at The Kirketon Road Centre, Sydney, an interesting look at their model of care for HCV. On a per-protocol basis where they were able to be followed up at 12 weeks, an SVR12 of 100% was achieved although a proportion were unable to be followed up at 12 weeks and modified intention to treat SVR12 was only 91%.
A remarkable achievement from a holistic program called “itha mari”, A Barkindji word roughly translated to “this way in the right direction”. With a patient-centred set agenda and activities such as lunches, workshops, art, storytelling, movies and food vouchers, KRC’s innovative program that is ATSI people led, showed quicker uptake than KRC’s non-indigenous patients and adherence. KRC’s commendable program with ATSI clients provides inspiration on improving follow up and outcomes not only for ATSI clients but the broader HCV demographic.
SIMPLIFY is an international open-label study that looked at DAA outcomes for specifically PWID group presented by Jason Grebely. It recruited participants who had recent (within six months) injecting drug use in 17 countries (19 sites) in 2016. Particiapnts received sofosbuvir/velpatasvir daily in a one-week electronic blister pack for 12 weeks. 96% completed treatment and SVR12 of 94% was achieved showing no difference between recent the PWID group and existing data for OST groups. Adherence to DAA was also highlighted in an informative pixel graph with green dots indicating compliance with daily medication while yellow dots showing missed doses, were surprisingly very low, with mean adherence of 89%. The simplified once daily regimens of DAA are more forgiving to patient adherence and the end points support the efficacy of DAA HCV treatment among recent PWID populations.
Darren Russell had incarcerated prisoners clamouring to be transferred to the Lotus Glen Correctional Centre (LTGC) near Mareeba in Far North Queensland once work spread within the prison community of their successful HCV treatment program for inmates. A total of 94 patients were treated with DAA therapy regimens and as of early 2017, no further existing patients at LTGC were known to have Hepatitis C in the prison.
Andrew Lee provided data in a prospective cohort study of patients treated by Cairns Hospital. Over a 13 month period, 481 received treatment for HCV. SVR12 results were available for only 77.8%. SVR12 results of those that followed protocol and not lost to follow up however, was 96%.
Greg Dore looked at HCV reinfection and injecting risk behaviour, following Elbasvir/Grazopevir treatment in patients on Opioid Agonist therapy (OAT). Of 296 patients in Co-STAR trial, 185 patients were enrolled in the follow up. Of the enrolled patients, 108 reported any drug use (injecting or non-injecting) while 47 reported injecting drug use in the past 6 months since follow up. Only 6 reinfections were found among this cohort suggesting HCV reinfection among patients on OAT following DAA therapy was uncommon despite ongoing drug use.