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.

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In day one of AVHEC17, we had been hearing presentations on how important the role of primary care workers would be in achieving the goal of elimination of viral hepatitis. Day two sessions gave us the opportunity to hear the stories of those who were leading the way.

 

 

The Rural Experience

First up was Dr Annie Balcomb, a rural GP based in Orange, NSW, who has been involved in Chronic hepatitis C treatment since 2008, and presented on The Rural Experience. Dr Balcomb described the structure around the Chronic hepatitis clinic she has run in recent years - a model working closely with gastroenterologists in a shared-case arrangement, that takes referrals from local GP's, nurses, health workers, drug and alcohol services, mental health services, forensics, hospital inpatients, gastroenterologists, and importantly patient self-referrals. The model has seen her successfully treat over 100 patients since the introduction of DAA's in March 2016. 

 

Over this time, Dr Balcomb has observed frequently the stigma and shame felt by many patients with chronic hepatitis C - some driving hundreds of kilometres to obtain their medications from a pharmacy where they could enjoy anonymity, others describing that some of the worst judgement and stigma they faced was within our own health-care systems. On the back of this, one of the central tenants to her ongoing work is the education and upskilling of GP's and other health professionals in her region, to optimise patient access to information and effective treatment. 

 

 

Dr Balcomb is also committed to being a voice that identifies and challenges some other barriers to access of care. She proposed a number of "ways forward" (see page 10 of Speaker Presentation PDF from her talk) to maintain patient safety while optimising access through primary care. Most exciting for me, were the use APRI<1 and FIB4 >2 as a fibroscan triage tool that has allowed some 60% of her cohort to proceed to treatment as non-cirrhotic without the need to obtain pre-treatment fibroscan; the hope of exploring options of shared GP care with gastroenterology input for some cirrhotic patients, using tools such as telehealth to improve rural access; and the excitement of pan-genotypic DAAs simplifying the treatment landscape for newcomers to the game. She instils the excitement of being involved in this area of medicine, and encourages us all to pass it along to our GP colleagues back home.

 

Challenges Ahead in Primary Care on the Path to Elimination

Next up, Dr Nicole Allard, a GP with special interest in hepatitis B and refugee health (who must be secretly cloning herself in order to continue her work as a medical epidemiologist at VIDRL, Melbourne health at the Doherty institute and PhD student at Melbourne University). She spoke on the Challenges ahead in primary care, and made a statement early in her talk that drew a few puzzled looks, and a lot of smiling nods - that "GP's are specialists - they specialise in primary care and in looking after people from marginalised populations". Recognising this, and both the challenges and advantages it presents, will go a long way towards engaging those Primary Care Specialists across Australia. When your speciality is primary care, the breadth of knowledge required is vast, so the message of who needs testing must be simplified - inclusion of screening messages in the RACGP Red Book will help this, as well as automatic cascade testing of HCV RNA and HBV DNA as indicated based on initial screening bloods, without the need for a specific request or re-bleed. She spoke of the power of creating a testing demand from patients, of reducing the stigma to allow these conversations to take place more readily in families, communities and consult rooms, and in providing support to GP's on the ground to best equip them to carry out testing and ongoing management effectively. She also raised the valuable tool of GP-to-GP referrals for those with colleagues with a special interest in viral hepatitis management. She addressed the tertiary specialists on the importance of good quality communication back to the GP, to enable effective ongoing monitoring in primary care and highlighting the role that a well written and relevant letter has in GP education (and as a heads up in case any non-GP specialists missed the memo: good communication including letters = more referrals + better overall care for your patients. Just thought that was worth repeating!)

 

 

Bridging the Prescriber Divide – Treatment Made Easy

Off the back of those two powerhouse primary care presentations, Professor Alex Thompson, the Director of Gastroenterology at St Vincent's Hospital, spoke on Bridging the Prescriber Divide: Treatment Made Easy, and the models being utilised in Victoria to achieve just this. He highlighted that Australia is among the first countries allowing and actively encouraging the treatment of hepatitis C by primary care doctors, and the responsibility we have to demonstrate that it is a safe and effective approach. He highlighted that the DAA treatments are generally well tolerated, but that practitioners need to recognise that symptoms such as fatigue, headache, insomnia and GI side effects can and do occur, and that despite these being far more acceptable compared to those suffered during previous treatment eras, we still need to counsel our patients in this regard. His "5 key questions" in the approach to treatment work-up, represent a straightforward approach that is easy to follow (See: Speaker Presentation PDF page 9: The KISS principle; Is Cirrhosis Present; Who needs to see a specialist on page 13).

 

Prof Thompson also spend some time discussing the approach undertaken by the Eliminate Hepatitis C (EC) Partnership, which aims to "support and enhance programs to increase HCV treatment update among people who inject drugs, using nurse-led models of care in community and prison settings" and to "assess the feasibility and impact of treating high enough proportions of PWID to reduce new infections and inform HCV elimination models in Australia and globally". It's great to see the diversity of approaches being undertaken in trying to engage at-risk communities. See their implementation plan via page 16 on the Speaker Presentation PDF.

 

Eliminating Hepatitis C - The Cairns Experience

The final speaker for the morning, Associate Professor Darren Russell, is a sexual health physician and the Director of the Cairns Sexual Health service who spoke passionately about Eliminating Hepatitis C - The Cairns Experience. He recalls a meeting held in their department, the morning after the initial DAA's were PBS-listed in March 2016. The strategy was to identify and work with priority groups, with the plan to "Hit 'em hard, hit 'em early", ramp up quickly and clear the warehouse. Local liver clinics triaged back to GP's, with waitlists then cleared in just a few months. The Sexual Health Service adopted a same-day assessment and treatment clinic, that utilised on-site pathology and fibroscan with links to local pharmacies to ensure medications were kept on the shelves and therefore available for supply without delay. By working with community groups including Cairns Hepatitis Action Team (CHAT), media interest was stoked, prompting a dialogue in the community and firing up demand for testing and treatment in at-risk groups. Health professionals in prisons, ATODS, Aboriginal Medical Services, Rural and remote, and General Practice settings were supported with onsite ASHM training to equip them to respond to this demand, with liver and sexual health clinic support via phone/email/fax, and "academic detailing" where GP clinics who were interested but not yet prescribing received outreach support and training. This multi-pronged approach has led to the enviable situation, where Cairns can say that "virtually all the people in Cairns and surrounds - and further North - who know they have hepatitis C and want treatment, have been treated" with the focus now on increasing testing, finding the undiagnosed cases especially in those clients connected with mental health services and young injectors, and watching for incident cases in particular in prisons and Indigenous communities. It was an exciting demonstration of how a concerted whole of system approach, utilising resources including primary care and community groups, can lead to impressive results.

 

 

 

 

The Panel Discussion

The follow-up panel discussion was engaging and energising - it left me with a number of messages, first and foremost that Peer-to-peer GP education is key to getting the message out there. So I'll start with this blog, my local practice and GP and nursing colleagues, the Australia and NZ-wide community of GP's DownUnder and my at-risk patients. I'd encourage you to start a conversation too - with friends, family, colleagues - stamp the stigma and get word out that treatment is available... or better yet, sign up for some ASHM training and get testing and prescribing. It's not often in GP you get to say "You're cured" - let's give as many people as possible the opportunity!

 

 

See selected speaker presentations from this session, including:

I attended the Australasian Viral Hepatitis Elimination Conference as a GP hepatitis B prescriber in an AMS (Aboriginal Medical Service), so my particular interest was to find out how we are doing in the rural and indigenous sectors and to get ideas as to how we might improve our services.

In this regard the Northern Territory is above the national average of treated Hep C patients at around 17%. My practice seems more inclined toward identification and adequate surveillance of hepatitis B (already a massive task). One factor in this is the medicare payment of only 3 hepatitis tests at any one time, leading to less than satisfactory levels of hepatitis C antibody checks. However, I suspect infection rates are low with respect to hepatitis B, due to lower use of IV drugs in the rural indigenous setting.

However, if the above holds, one wonders if rates of hepatitis C in indigenous communities may not be higher than the (rising) age standardised rates presented by Prof Rebecca Guy in her presentation.

If there is one thing I would hope to improve having attended this conference, is awareness and testing for hepatitis C in my AMS.

On a global front, it was disappointing to hear data from Homie Razavi (Managing Director of Center for Disease Analysis) that we [Australia] may be falling short of the 5 million hepatitis C treatments necessary annually to achieve elimination by 2030, even if total numbers of cases are declining.

Homie pointed out that shortcomings include restriction on treatment of young patients and (worldwide) lack of primary care involvement. However, a major factor is lack of political will, as evidenced by the failure – to date – of the pooled procurement initiative. While Homie pointed out that individual countries may negotiate their own prices on hepatitis treatments, it is unlikely that they could negotiate the prices achievable through large, multinational orders (with cash changing hands through secure banking transactions to ensure transparency).

Ed Gane (Heptatologist at Auckland City Hospital) presented a succinct account of the challenges NZ faces in eradicating hepatitis C and how it is going about it.

The challenges are:

  • the still rising rates of infection (probably similar to rural NT)
  • the numbers of still undiagnosed patients and treatment uptake already falling (pool of "accessible" patients running out).

Solutions proposed include increased GP prescribing (33% of scripts vs almost none in 2015), pangenotypic treatment régimes and targetted testing.

 

I suggest that GP prescribing for hepatitis (and other "shameful" diseases such as HIV) has benefits beyond than just "increasing coverage". Patients are more likely to come for, and accept testing. Treatment proposed by a trusted GP is more likely to be understood and followed, than if prescribed by a specialist that they meet on 1 or 2 occasions (Note: I don't wish to belittle highly-skilled and caring clinicians, who often understand very well the complexities of care in an indigenous setting). No doubt this applies in the general population – and maybe even in NZ.

 

See selected speaker presentations from this session, including:

 

The Australasian Viral Hepatitis Elimination Conference 2017 held in Cairns was a an eye opener for me. I was intrigued by the international efforts to try and meet the WHO target to eliminate Hepatitis B and C by 2030. The revolution of treatment of Hepatitis C with DAAs which have high cure rates with fewer side effects should make this possible. However, the message was clear, to meet this target globally, efforts should not be at the local national level only, the international scene needs to be the focus.

Professor Samuel So, director of the Asian Liver Centre presented a great example of one of the ways this could be done in the Keynote 3 session, JoinJade: A Culturally and Linguistically Tailored Campaign to Help End Hepatitis B. His centre is targeting the Asian community with higher prevalence of Hepatitis B both in the US and in Asia.
View his presentation
here.

 

In plenary 4, Dr Homie Razavi, managing director CDA, also demonstrated international efforts with provision of epidemiology data and the Global Procurement Fund. He highlighted the challenges faced in trying to make this possible globally with no country signing up to the procurement fund which should make the DAAs more affordable, especially for poorer countries with higher rates of Hepatitis C infection.
View his presentation here.

 

Locally, here in Australia, the gap between the indigenous community and the rest of the community in Australia is just as wide for hepatitis infection. The rates of Hepatitis B and C are significantly higher among the indigenous population. There was discussion of formulating policies and programs targeting the indigenous community, including formal and non-formal or "cowboy" methods to improve access and treatment for this community.

Working for the Aboriginal and Torres Straight Islander community health service in Brisbane, this is important for me as a take home message. I can't wait to get back to work and start implementing the knowledge I acquired! I also hope to take this information back to my country of origin Zambia, my bit of effort in trying to eliminate Hepatitis globally.

 

A/Prof Rebecca Guy, Head of Surveillance, Education and Research Program, Kirby Institute UNSW, Australia, discussed the importance of Epidemiology and measuring our response at an Australian national level as we strive towards the WHO Hepatitis B and Hepatitis C targets.

She highlighted parts of the tracking process using examples of data from various specific population groups. The HCV prevalence of participants from NSP is around 55%, the highest incident in any group, with only 50% reporting a HCV test in the previous 12 month period. Of particular concern is the number of <25 year olds with HCV notifications that had not declined but remained at 15%. A measure of risk behaviour showed the incidence of needle/syringe sharing in the past month amongst people who inject drugs is around 15%.

We were reminded of the importance of our task as the number of people suffering from severe complications of HCV infection (cirrhosis/ hematoma/ death) continues to increase gradually.

Australia has made a dramatic response to the availability of DAAs by treating over 30,000 HCV in 2016, though our response needs to be sustained at more moderate levels in order to achieve Elimination of HCV in our nation by 2030.

With regards to HBV the incidence of notifications in young people < 24 continues to decline, likely to be a result of our Hep B childhood vaccination program. However, the HBV Diagnosis and care cascade continues to lag behind that of HCV.

In the Epidemiology sense, WHO targets currently set are defined as "elimination as a public health problem" rather than eradication (reduction of the world wide incidence to zero) or elimination in its stricter sense (cessation of transmission of a disease in a single country).

There are a number of ways of tracking progress towards elimination of HCV as a PHP.

 

 

  1. Modelling showed that while the number of new patients initiated on DAA will decline after the warehouse effect has passed, the WHO targets can be achieved before 2030 by intermediate estimates.
  2. Data at a finer geographical level showed widely differing treatment levels of both Hep B and Hep C across geographic regions of Australia and the need for targeted action in geographic locations.
  3. Collection and feedback of health service delivery data to individual sites or groups of services provides valuable insight and highlight specific needs and facilitate tailored management.
  4. Identify and overcome various barriers to accessing prevention services
  5. Importance of measuring new cases of HCV infection using HCV RNA testing as well as HCV antibody testing.
  6. Improve the completeness of Indigenous data.

 

 

 

 

 

 

A key part of this is the use of "data linkage" where information from all sources of hepatitis C related data are fed back to a central HCV notification centre to facilitate research analysis.

 

It is vital that we collect and feedback this data to the various local, state and National organisations for future Hepatitis Elimination management in Australia.

 

See also selected speaker presentations from this session, including:

Plenary session #5 was an inspiring reminder not to forget the people who are at the centre of why we do what we do. 

Rhondda Lewis, viral hepatitis health practitioner with Cairns Sexual Health Service and Yvonne Drazic started the session, speaking about their involvement with the Cairns Hepatitis Action Team (CHAT).   CHAT was established in 2013 by peers to empower patients to be the lobbyists and agents of change in the area of viral hepatitis. 

Through Asset Based Community Development, focusing on peers’ strengths and abilities to explore the community’s needs and visions for the future, the group has been very successful in organising many large events and contributing to the goal of having Cairns “Hep C free by 2020”. 

They have tried to avoid using the word “problem” when referring to viral hepatitis to reduce further potential for stigma and discrimination.  Instead, they focus on resilience, peer support, learning from others and increasing confidence to empower and promote real engagement to improve health efficacy.   They are rightly proud of CHAT reflecting Ottawa Charter principles in a real world setting. (1)

See Rhondda and Yvonne's presentation here. 

A/Prof Phillip J Mills, Kulkulgal Tribal Elder of Zenadth Kes and Associate professor with the Australia Institute of Tropical Health and Medicine (JCU) followed with a talk rallying us to press for policy change when it comes to how we manage the Aboriginal and Torres Strait Islander population who are affected by viral hepatitis.  He made excellent points that we should ensure that our services are culturally appropriate and consider the whole journey for the patient and the impact of various social determinants of health, rather than managing the disease in isolation.  He challenged us to consider that the language we use can come across as demeaning and damage the therapeutic relationship, thus affecting engagement in care.

Lastly, Melanie Walker, the CEO of the Australian Injecting and Illicit Drug Users League (AIVL) presented 3 case studies demonstrating the impact Hepatitis C can have on families.   She also pointed out to us that while 29,160 people with hepatitis C were cured in 2016, 5,900 new infections occurred over the same time period. 

If we want to reach the target of elimination of Hepatitis C by 2030, prevention and harm reduction need to be our focus, as well as considering how to assist those who are less well connected to the health care system to access treatment.  

Melanie discussed some of the barriers being no Needle and Syringe programs (NSP) in prisons, no formal recognition or funding of peer workers, punitive measures targeting people who inject drugs (PWID), stigma and reduced access to health services in regional Australia.   

In addressing these issues, AIVL’s work over 2017-2018 will focus on enhancing NSP service outcomes, building capacity amongst peer educators and other health professionals, improving Hep C outcomes for people exiting custodial care to improve transition to primary care, developing resources directed at harm reduction in the ATSI and CALD communities, creating a new website and continuing to write national policy papers to improve health outcomes in PWID.

These impressive goals have the potential to make real improvements to the health and well-being of the lives of PWID, as well as contributing substantially towards Australia’s elimination target.

See Melanie's presentation here

 

1. Lewis, RM, Drazic Y, Engaging community: The Cairns Hepatitis Action Team – paths to patient involvement, Journal of Virus Eradication Vol3, sup 2, August 2017

 

 

A very inspiring presentation given by A/Professor Phillip Mills that cuts to the core of the problem of the sub-optimal success often seen in many indigenous health programs, being namely that of the lack of genuine community engagement in the development and implementation of these programs.

Mills described this as a sort of unconscious neglect that is a manifestation of the dominance of mainstream culture in policy and program development, and ultimately a form of institutional racism.

For any hope for this to be addressed, he gently described the urgent need for a reckoning with Australia’s colonial past and a shift in collective consciousness of the general population.

A very important message for those working with indigenous populations.

Access speaker presentations from this session via the AVHEC17 website

 

Phillip is a Kulkulgal Tribal Elder of Zenadth Kes and Associate Professor with the Australia Institute of Tropical Health and Medicine (JCU) and has authored and co-authored award winning research papers, chaired scientific and inter-departmental committees and sat on ministerial policy committees on Indigenous Health. Phillip led the reform in indigenising the Public Health System as Executive Manager of mainstream Hospitals and Primary Health Care whose core mainstream business was Aboriginal and Torres Strait Islander Health with the establishment of specifically tailored evidence based scientific Indigenous Health Models. The success of his work in community developed scientific health interventions, culturally acceptable health care systems and protocols, and innovative evidence based bi-cultural health practices and structures earned him an Order of Australian Award Medal. His expertise has flowed on into the Community Control Sector where the application of his work has assisted enhancing the development of more comprehensive primary health care.

 

 

Tagged in: AVHEC 2017

Professor Rebecca Guy (Program Head and Professor, the Kirby Institute UNSW) gave a very illuminating presentation on the epidemiological mechanics of elimination programs and the areas that will need to be focused on if Australia is to achieve elimination of hepatitis C as a public health problem.

These areas were outlined as Modelling, Obtaining data at a finer geographical level, Developing better health service delivery data, Understanding barriers to assessing services, Monitoring of new cases and Improving completeness of indigenous data.

Of particular interest was the need to understand where new cases are coming from as this will help identify where our prevention strategies are failing and where we need to focus our efforts.

Notification of RNA data was suggested as a way for better identification of new cases.

Read more about other speaker presentations in this AVHEC17 session

 

In this presentation, Dr Nicole Allard describes a research project to examine whether an intensive follow-up and recall system improved liver cancer surveillance programs in patients with chronic hepatitis B.  On the basis of current recommendations for 6-8 monthly liver ultrasounds and AFPs, optimal screening was defined as having achieved 2 scans every 14 months, sub-optimal screening as one scan every 14 months and poor screening as less than one scan every 14 months.

The intervention consisted of nurses conducting an audit to detect patients requiring HCC surveillance within the clinic patient base, upskilling the healthcare workers in hepatitis B management, and establishing a proactive recall system consisting of a variety of strategies such as calling of patients, sending out of path forms by mail or sending out pre-appointment confirmation texts.

A participation rate of 75% was obtained in this patient cohort yet optimal screening was only achieved in 25% of patients. It was not clear what the baseline of adherence to screening schedules were like prior to the intervention, and thus it is difficult to interpret this result.

An important observation made during this study was that patients often had little understanding of their individual risk of HCC, and that this perhaps impacted on their adherence to screening schedules.

Recommendations included developing a low English literacy tool to help to explain this better to patients, implementing a community awareness program, considering the role of a liver cancer registry, and supporting the development of a more feasible method of screening.

See Nicole's presentation here 

This session at the 2017 Australasian Viral Hepatitis Elimination Conference was a series of oral abstract presentations exploring a wide range of strategies in engaging marginalised populations, including persons incarcerated, people who inject drugs (PWID), Aboriginal and Torres Strait Islander populations/communities, and Culturally and Linguistically Diverse (CaLD) populations. Subsequently, various models-of-care adopted for each population in their respective studies and community settings.

Prof Andrew Lloyd provided an overview of the care for HCV affected people in prisons in Australia. Among the total of 230K living with chronic HCV in Australia, 65k of those are persons incarcerated, with many of this cohort being PWID and/or undertaking opioid substitution therapy (OST). Prof Lloyd spoke of the challenges of treatment adherence given the frequently movement of prisoners from one area of the prison to another (or movement to other facilities) and in some cases relatively short stays. The Surveillance and Treatment of Prisoners with Hepatitis C (STOP-C) study that he leads via the Kirby Institute throutout prisons in NSW is a nurse-led model of hepatitis care (NLMC) are appears to be very effective: a 95% of treated/assessed rate and currently 100 cases treated per month, despite barriers of pharmacy technology, challenges in drug procurement, etc. Future directions in this study include: establishing an Australian national prisons hepatitis network; to implement a practical strategies, such as, a one-stop shop for testing and treatment, and a 'treatment-as -prevention' approach aiming to eliminate hepatgitis C from the prison sector.

 

Dr Phillip Read of the Kirketon Road Centre (KRC) Sydney, presented a model-of-care for Alcohol and other Drugs (AoD) clients engaging with a huge diversity of care providers. There are numerous non-medical services ranging from government services to NGO and religious-organisations contributing to the complex care model for AOD clients, offering a range of services beyond clinical treatment, such as counselling. Currently, it is estimated that at least 25K PWID living with hepatitis C are still needed to be treated. The possible solution to engage PWID populations is to use an OST infrastructure. There is, however, a few challenge facing this strategy. For example: methamphetamine IV users have less medical contact, with only 10% of them are in care. Patients often had poor venous access, poor adherence and high risk for reinfections. Furthermore, many patient’s relationships with AoD services may not be always harmonious - with many experiencing stigma and discrimination in these settings. Nevertheless, many can be tackled in AoD-specialised setting. For example, HCV RNA testing using dried blood spot will be very practical for PWID with poor venous access. Overall, the HCV elimination campaign will be benefit from co-working with peers in the model of care for AOD. 

Ms Carla Gorton and Ms Kathy Clark from Cairns Sexual Health Service in Queensland shared a personal experience of approaching and engaging with HCV in a sexual health setting/context. Their key messages were very strong: Respect, dignity, individualised care were required in providing care according to the individual’s need. Ms Gorton shared strategies for providing care for the sensitive group of people, including sexual worker and transgendered persons. Ms Kathy Clark provided contact, encouragement and transport to care. Personal engagement also helps to address issues such as shame and guilt and life priority. To reach people’s heart and mind, the networking of Cairns community members has facilitated a friendly access for hepatitis C patient to reach treatment without restriction.

Dr Malcolm McDonald is a consultant physician serving in three Indigenous health services in Far North Queensland. He shared in his presentation his plentiful experiences and great insight in approaching indigenous people in rural and remote communities. Each community has a unique history and different setting. Health Service should be in the community. It is encouraging to see that readily in-community care is available, including testing and treatment, even the in-community Fibroscan.  

 

The end panel discussion of this session emphasised the need of continuing care and information should be transferred to primary carer, as well as, the barriers of providing continuing care for these populations.

Access speaker presentations mentioned via the AVHEC website

 

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 global impact of chronic HBV cannot be underestimated, with 257 million people affected. More people die from chronic HBV compared to HIV/AIDS or malaria.  

 

Dr. Samuel So has launched a world-wide campaign with JoinJade, which aims to educate and engage people in the community, to increase awareness in order to achieve elimination of hepatitis B and thereby decreasing mortality and morbidity. 

 

The goal is to eliminate hepatitis B and C by 2030, and although this sounds ambitious, it is not impossible.  He recommended engagement of the government to coordinate stakeholders including the criminal justice systems to treat correctional facility inmates, professional organizations to treat patients in primary care and the CDC and local health departments.   

 

In the US, Asians and Pacific Islanders make up 6% of the US population, and these groups make up more than 60% of chronic HBV in the US.  In Australia, we see an increasing number of migrants from endemic countries and in the NT, most cases of CHB are made up of Indigenous and the CALD community.   

 

He initiated the campaign in Qinghai, China and this led to the Chinese government adapting a national vaccination program for hep B, and his efforts should be lauded.

  

His Jade Ribbon campaign has reached Australian shores, and hopefully this will lead to a better community engagement with regards to awareness, as well as better primary care involvement in identifying and treating patients with CHB. 

His talk ended with a video of Jackie Chan encouraging people to get tested and treated.

 

Link through to Prof Samuel So's speaker presentation here

 

JoinJade: Access the campaign 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

I am reporting from oral abstracts being presented at AVHEC17 regarding understanding the epidemics (modelling and surveillence).

 

The first talk , presented by Dr B Hajarizadeh (Kirby Institute, UNSW Sydney) , outlined results of Surveillance and Treatment of Prisoners with Hepatitis C (SToP-C) in New South Wales. This study was conducted in 4 prisons and revealed high HCV incidence in residents. It was confirmed that in almost all cases HCV transmission was primarily associated with intravenous drugs use. Prisoners almost always share needles so reinfection levels are twice higher than for primary infection. This study concludes the importance of introduction of wide preventive strategies including treatment as the very important part of prevention. 

 

Jenny Iversen (Kirby Institute, UNSW Sydney) stressed the importance to monitor progress towards elimination of Hepatitis C infection in Australia. The Australian Needle Syringe Program Survey (ANSPS) examined treatment within PWID over the last 5 years to ensure quality of care . The study included self-completed questionnaire and dried blood spots serological testing.  Associated factors (like age, gender, geographic location, frequency of drugs injections etc.) were also included in the study. This study was demonstrated high involvement of PWID with Hepatitis C infection after introduction of DAA under PBS. Further plans include recommendations for the RNA testing to confirm spontaneous and treatment induced clearance. 

 

Amy Kwon (Kirby Institute, UNSW Sydney) presented Part of BBV & STI Research, Intervention and Strategic Evaluation Program hold in Australia to assess level of DAA required to eliminate Hepatitis C by 2030. Using mathematical model and three possible scenarios (optimistic, pessimistic and intermediate), it was concluded that Australia finally will meet the WHO HCV elimination targets in 10-13 years. Australia invests around 1 billion dollars (2016-2020) in elimination program without restrictions on stages of Liver disease. The treatment mostly includes DAA with no Interferons; re-treatment is also allowed. Some limitations – like internal migration or reinfections – were also taken into consideration, however would not have crucial influence on the process of elimination. 

 

Recommendations for HCV testing were presented in a talk by Dr Nick Scott from Burnet Institute. He focused on models of care, treatment scale-up and care cascade among people who injects drugs in Australia. The suggestion was given for the additional testing (PCR test) to the HCV RNA. Effectiveness of such combination was confirmed statistically along with annual frequency of the testing. Such improvements in the testing system will make possible to achieve the WHO elimination target and minimize the likelihood of future outbreaks. 

 

Kelly Hoskins (Continuous Quality Improvement Facilitator, Northern Territory Government) presented data about Hepatitis B infection in the Indigenous populations. The prevalence of HBV infection within Aboriginal community is much higher (up to 12%) than in general Australian population (1%).  The project targeted on identification of those who are chronically infected and who never undergone HBV testing. The process was piloted in 5 Aboriginal communities and involved data collection and testing. The part of the project was also created (pointed?) to increase educational opportunity for the GP and other primary care providers for the proper Hepatitis B care with big attention  to find all Chronic Hep B clients and engage them to the care.  

 

Ms Maryam Alavi (Research AssociateKirby Institute, UNSW Sydney) talked about the 

burden of liver disease and comorbidities within PWID. The study revealed the importance of continuing to increase access to screening, care and treatment for individuals affected .  

 

The final presentation by Karen McCulloch (Research FellowUniversity Of Melbourne) 

characterized populations with Hepatitis C to improve access to antiviral therapy programs. This study evaluated comorbidities and other characteristics of people who are current PWID and non-PWID in NSW. The higher rate of comorbidities was reported in people with HCV infection so longer hospitalization was usually needed in case of inpatient care.

 

Link through to oral abstracts and speaker presentations 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

 

Link 

I'm reporting from oral abstracts from the Australasian Viral Hepatitis Elimination Conference 2017 with speakers discussing Models of Care/What are the challenges ahead for hepatitis B and C elimination? 

A wonderful world-wind tour of current models of care for upscaling chronic hepatitis C treatment, mostly based around nurse-led models of care linked in with tertiary care settings. A very promising model that appears to have had great success in accessing marginalised populations who require intensive case management. Missing from the discussion however was how General Practitioners could be incorporated into this model, or indeed exploration of a GP led model of care for clients with a reduced need for support.

A particularly interesting speaker presentation was given by Dr Carla Treloar about the development of a tool to monitor the experience of stigmatisation for those engaged in the health care system - a much neglected area of research in understanding the barriers to patients seeking access to care. Clearly, all options need to be on the table if we are to reach the aspirational targets of elimination, as it is unlikely that one-model-fits-all will be sufficient to reach all of the populations concerned.

Link to the oral abstracts and speaker presentations here

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.

For more information on the abstracts and oral presentations visit the AVHEC17 website

On the first day of the 2017 Australasian Viral Hepatitis Elimination Conference, Benjamin Cowie from the WHO Collaborating Centre for Viral Hepatitis/Doherty Institute gave an inspiring summary of Australia's Progress in the management of Hepatitis B which challenges us to go further.

Figures from 2015 show 232,600 people in Australia expected to have Hepatitis B, 144,216 diagnosed, 36,534 in care and 14,636 being treated. More than 6,000 notifications for Hepatitis B were made in 2016. 

There is a marked variation within Australia of the percentage of people being managed for hepatitis B, with the Southwestern area of Sydney monitoring and treating where appropriate more than 30% of their patients with hepatitis B, but in some areas in Australia areas this figure is as low as <5%.

The challenge then is to work at screening. Asking where a person or their parents were born, or whether they identify as Aboriginal or Torres Strait Islander will help to pick up 2/3 of potential cases. Late diagnosis leads to a marked increase in decompensated cirrhosis and liver cancer.

If we fail to look for Hepatitis B in the appropriate places, we are doing our patients a great disservice, and a potential long term medicolegal disservice to ourselves.

Link through to A/Prof Ben Cowie's presentation here

Dr Maia Butsashvili discussed Hepatitis C elimination in Georgia. 

Of a total national population of 3.7 million inhabitants, the incidence of chronic Hepatitis C in Georgia is 5.4% (i.e. 150,000 people).

Hepatitis C is found in 3 population subgroups in Georgia - PWID, MSM and healthcare workers; with the peak incidence being men in the 30-49 age group.

Georgia underwent a period of political and economic upheaval in the 1990s with the collapse of the Soviet Union. Injecting drug use was at its peak and healthcare procedures were compromised. Blood transfusions, dental and obstetric procedures (especially terminations of pregnancy as a form of contraception) are thought to be the source of the health care related hepatitis C infections.

With the help of the CDC, Georgia is running a pilot program to eliminate Hepatitis C in  its population.The Georgian government has supported this initiative, and the pilot is aiming for 90% diagnosis, 95% treatment and 95% cure of its Hepatitis C population by 2020. Coupled with this aim are the strategies of harm reduction in PWID communities (needle syringe and OST programs) and preventing transmission of Hepatitis C in the healthcare setting.

The pilot was initially established at 4 sites in 2015, and telemedicine support for difficult cases was provided by Boston specialists. All results are reviewed by a committee before treatment was selected and commenced. Treatment was initially with a combination of Sofosbovir, Ribavirin, and Interferon and more recently Harvoni has been added to the treatment regime. There were initial concerns that the treatment provided would be sold as there are no treatment programs in surrounding countries; this has been limited by fortnightly dispensing.

To date, Georgia has treated 30,000 of its target group of 150,000 and has screened half a million people from 2015 to 2017.  SVR in 2015 was 85%, and has risen in 2016 to 95%- the difference being the introduction of Harvoni and the treatment of the sickest patients initially. SVR is missing in 25%. 

Georgia has extended the pilot to 28 centres, and is now targeting the PWID population to improve detection, prevention and treatment in this community.Georgia has established a treatment centre in a drug treatment clinic (OST) and is using peer workers help PWID clients access and attend healthcare providers.

Other plans to scale up screening include providing incentives to primary care providers and delivering a mass information campaign.  It doesn't sound like they are going to stop.

Link through to Dr Maia Butsashvili's Speaker Presentation here