Prof Nicola Gardini teaches Italian at Oxford University and is a researcher of renaissance texts, a translator, author and poet. He gave an erudite and thoughtful paper on "illness" in literature, his interest in this started when he translated Virginia Woolf's essay "on Being Ill " and developed further when exploring the writings of AIDS Sufferers. In his opinion whether we are living or dying is a linguistic construct. He pointed out that as doctors we are engaged in narratives as we diagnose and that in this we are similar to an author developing the plot of a novel.

He describes AIDS literature as initially being all about dying and loss, but now about infection and disease. He used the seminal work by Edward White "A Farewell Symphony" 1997 as an example. In his opinion literature can be an antidote to bias and stigma. It gives a voice and expression to gay men and AIDS sufferers. He made an interesting observation that literature is kind to TB compared AIDS with its attendant decline in body and lack of "spiritual lifting up."

His recent novel: "La vita non vissuta" (The Unlived Life) describes the story of a man leaving his wife for a male lover, only to be infected by him with HIV. It describes his coming to terms with his infection and "being ill" he ended his lecture with the point that it is possible to be "I'll" but still healthy in mind and body.

After a morning spent walking off jet lag and discovering Milan, the conference opened after lunch.  After a fascinating round table on PrEP which Rebecca and Emma have blogged about it was time for the first plenary lectures.

Dr Robert Alexander specialises in medical IT at IBM in Italy and gave a fascinating and slightly scary overview of the magnitude and importance of data currently and into the future. He pointed out that as humans we are pattern recognition machines and use this in diagnostics. He showed the mind boggling facts about how much data is transferred in 1 internet minute in 2017: 

He pointed out that each of us will produce about 1tB of health related data in our lifetime. Also we will have more and more sensors either worn or implanted generating real-time health data, (think smart watches and pacemakers!)

Data is going digital with pathology and genomics/proteomics following radiology and demographics.

Health data only comprises about 10% of available human data and this comprises 10% of data that would impact on an individual’s health outcomes, so we are only scratching the surface. How do we access the "dark data" below? Well, Robert described the Data Scientist as the "sexiest job of the 21st Century!

Diagnosis and management of Non-Alcoholic Steatohepatitis (NASH) & Non-Alcoholic Fatty Liver Disease (NAFLD)

Sanjay Bhagany (Consultant physician/honorary senior lecturer in infectious diseases/HIV medicine, Royal Free Hospital, London)

Emmanuel Tsochatzis (senior clinical lecturer and consultant hepatologist at the UCL Institute for Liver and Digestive Health, Royal Free Hospital, London)

Abnormal liver function (LFT) tests and fatty liver are common and often frustrating conditions seen in general practice. I see a significant number of refugees who have abnormal LFTs as well as managing patients with HIV with abnormal LFTs so I was keen to get up early and get to this 7:30am lecture!

Emmanuel made the important point that you can’t always trust the LFTs. Patients can have severe disease with normal LFTs and grossly abnormal LFTs with just fatty liver.  It is important to remember that 25% of general population have fatty liver and of those 10% develop cirrhosis. 

Fibroscan is important for assessing liver disease although for rural towns like mine, access can be an issue. 

Steatosis can cause over-estimation of stiffness in fibroscan.  A fibroscan result of >7 is worrying in fatty liver.

Important strategies for everyone with abnormal LFTs associated with fatty liver include addressing CVD risk factors, there is some evidence this will improve fatty liver.  We should be considering fatty liver as part of metabolic syndrome, commonly managed in general practice.  Extending this to people living with HIV is important as HIV infection itself is fibrogenic.

NASH/NAFLD prevalence in people living HIV is up to 50%. Causes are multifactorial and include HAART therapy plus virus protein inflammation plus lifestyle. Nadir CD4 count and a history of use of older HIV drugs are risk factors for liver disease.

Emmanuel talked about some of the difficulties in making an accurate diagnosis of fatty liver including ultrasound and biological markers as well as non-invasive assessments, all of which have their limitations. 

Treatment essentially is about reducing weight including bariatric surgery if appropriate.  Emmanuel talked about the experimental use of maroviroc.

In summary, it is important to think of NASH/NAFLD in people living with HIV and reducing cardiovascular risk and monitoring of progression are the mainstay of management. 

The Future of HIV Therapy

Dr Roy Gulick (Professor of Medicine and Chief of the Division of Infectious Diseases at Weill Medical College of Cornell University) from New York provided a great summary of current treatment guidelines and new developments underway with ART.

In summary:

ART is now recommended to commence at any CD4 count when a patient is also ready to start. If resources are a priority then treatment should be offered first to those with a CD4 <350.

There are currently 29 approved HIV medications and up to 10 starting regimes.

5 broad mechanistic classes (NRTI, NNRTI, PI, INSTI,EI)

Recommended standard strategy is 2NRTI +(NNRTI,PI,or INSTI)

If there is multiclass failure to the 29 drugs two new entry inhibitor class drugs are showing promise.

1 Fostemsavir (oral HIV attachment inhibitor with Phase 2 results soon to be released)

2 Ibalizumab (monoclonal antibody given parenteral, binds to CD4 receptor/works as HIV entry inhibitor)

2 New classes of HIV Rx being developed:

1 HIV Maturation Inhibitors

2 HIV Capsid Inhibitors

Newer approaches to safety and tolerability in the future ART include:

Using lower doses of drug eg (EFV 400mg vs 600mg). Other studies in progress are ATV 300mg, DRV 400mg

Newer drugs eg tenofovir alafenamide(TAF). Switching TDF to TAF improved renal/bone markers

2 Drug regimes: PI/r+3TC (or FTC), PI/r+ integrase inhibitor, NNRTI +integrase inhibitor , DTG+3TC/Paddle Study(results showed VL all suppressed by 8 wks)

Less frequent dosing eg RAL daily formulation

New co formulations eg ATV/c and DRV/c

New injectable drugs RPV LA, Cabotegravir

Latte 2 study is looking at IM CAB +IM RPV with conclusions showing IM is comparable to PO and well tolerated. Phase 3 studies are evaluating IM q4wks.

Dr Gulick concluded by saying that future ART Rx will involve greater use of sub dermal implants and injections with potentials for dosing going from weekly up to every 1-3 months. Costs will radically decline and affordability improve. Convenience will also continue to improve. We have already seen the dosing levels of 20 tablets a day reduce to one a day in the last 10 years. Interestingly life expectancy in ART uses from recent studies in US, Canada and UK were showing higher figures than for the average population!  Presumably regular medical intervention can be a good thing for our species!

The welcome to the conference was at 2pm…and I had already eaten so much “information” gelato I was decidedly full…however as with all good food (for thought).. there is always room for more…so I decided to sample the “Round Table: Modles of HIV testing and delivery of PrEP”

This session was opened by Prof Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot ) who highlighted some of the issues limiting or preventing the implementation of PrEP in Europe.  He discussed the cost benefit of people on PrEP versus the lifetime cost of treating those living with HIV and the distinct need to highlight PrEP's feasibility. He discussed the need for close partnerships with the community and political support to facilitate PrEP implementation.

Dr Emma Devitt from Dean St Clinic (also see Emma Clements post) highlighted their exemplary model of testing using cutting edge technologies to facilitate patient’s access, testing availability, results turn around and treatment options.  Amongst routine STI services, Dean St service provision includes on site laboratories, HIV and Hepatitis specialist clinics, HIV oncology clinic, Urology and dermatology services, Dietetics, Contraceptive/LARC services, Anoscopy, ED/Psychology/Psychosexual and a Pharmacy service. Most impressively to facilitate their ‘self-testing’ model they have guided self-sampling videos embedded in the mirrors in their bathrooms to guide clients through the process self-collected swabs.   Of course there was mention of the GeneXpert technology which provides extremely quick results turn around but what struck me here was the added option of a web link to the next available treatment appointment should your result be positive - its the total package of care!  Statistical modelling showed that since the introduction of the Express model at Dean St, STI’s are treated 8 days faster than previously and for every 2 people diagnosed with a bacterial STI’s one partner was spared exposure suggesting public health implications and cost savings.  This rapid STI diagnosis and treatment is thought to be one of the causative agents in the recent dramatic reduction in HIV diagnosis seen at Dean St.

Gus Cairns editor of AIDMAP and co-ordinator of PrEP in Europe talked through his personal experiences of HIV diagnosis in 1985 and why he is such an advocate for PrEP in the modern era.  He talked about 20 years of fear inducing messages when condoms were advertised as the only responsible way to have sex. PrEP had brought with it a reduction in the crippling anxiety that many MSM experienced during sex, in PrEP the protective behaviour is separate in time from the risky action itself and described it as ‘enhancing’ sex by reducing the fear. He went on to highlight that PrEP is not enough and in a powerful slide simply put the U=U message (undetectable=untransmissible) reminding me that we need to be confident and unanimous in this message.

Finally and to finish the session was a round table of questions in summary.  These addressed the following questions… How do we approach and include the young? How can we promote PrEP to wider audiences? Is there a future for over the counter PrEP?  Much like describing all the culinary experiences of Gelato tasting in Milan it is impossible to capture the sheer depth and flavour of the responses but needless to say I will find room for more taste sensations tomorrow!

The next session I attended was an industry sponsored session on Maturing Patients, Maturing therapy: Multidisciplinary management in HIV.  The session on management of Cancer in HIV by Christine Katlama (Professor of Infectious Diseases and Head of the HIV Clinical Research Unit
Department of Infectious Diseases France) & Jean-Philippe Spano (Professor in Medical Oncology, in the Department of Medical Oncology of Pr. David Khayat at the Pitié-Salpétrière Hospital in Paris, France) highlighted the increasing medical issue of people living with HIV and cancer diagnoses.  Amongst some interesting case studies, the main points discussed were that viral-induced cancers are more prevalent in HIV positive patients compared with HIV negative patients, the impact of smoking is excessive and needs addressing and multidisciplinary team approaches are extremely important to maximise the therapeutic management of HIV patients with cancers.

They demonstrated a great example of this collaboration in the form of a 6 weekly web-conference that they have set up in Paris between Oncologists, HIV specialists, pharmacists and immunologists where they discuss cases and ensure any possible treatment interactions between ART and chemotherapy are evaluated by experts as well as consideration of the possible benefits of new immune therapies. Whilst perhaps not the direct purpose of the session I found the take home message for me was thinking about the importance of cancer screening and prevention in the comorbidity assessments of stable HIV positive clients that nurses are increasingly involved with.  Smoking cessation should be continually encouraged and revisited at every possible occasion in a supportive way as unsurprisingly tobacco smoking is attributable to many of the cancers diagnosed.

Day 1 @ #EACS2017 did not disappoint!  Much like colourful displays of gelato in Milan’s exquisite restaurants the conference proved to be a veritable feast of tasty information and similar to the difficulty in picking your ice cream flavour so was the conundrum of choosing what session to attend!

To begin the day I started at the WAVE (Women Against Viruses in Europe) Workshop.  I listened to a very empowering speech given by Justyna Kopeć a Polish lady diagnosed with HIV 20 years ago who’s talk was entitled “The longest relationship I ever had”.  She highlighted at least 3 occasions when her diagnosis was missed between 1993 and 1997 which included participating in an anonymous HIV testing at university in which she did not collect her result, vising the gynaecologist with several recurrent vaginal infections and a GP visit for continued weight loss without dieting.  She talked about her journey of hope as new drugs came on the market at the time of her diagnoses, fear of dying, fear of treatment, fear of a daily routine, and trust in her doctors, trust in her family and friends and trust in science and in patient centred care.  She also talked about the changes over time for young women newly diagnosed in today's era in terms of pregnancy and living long enough to watch those children grow.  This session was a great reminder that HIV can affect anyone.  As a nurse I often see clients for HPV wart treatments and other symptoms such as vaginal candida and it reminded me of the importance of thinking of underlying reasons for persisting infections, accurate history taking (as people are transient between services and indeed countries) and not to overlook HIV as a possibility for someone who is not in the forefront of my mind as “high risk”.  Justyna closed with the statement “HIV testing should be a standard procedure among ALL sexually active people”.

Please also see the post from Emma Clements

Sophie Flavell and John White spoke about STI testing and screening.

Important take home messages for me in this session were:

- don’t forget that for MSM with high risk behaviour Hep C is sexually transmitted ie make sure you include it in STI screen in high risk populations

- consider using doxycycline 200mg as a stat dose as PEP for chlamydia and syphilis (70% reduction in infections)

- pooled testing (3 samples in one pot)for chlamydia/gonorrhoea NAAT is currently not funded but saves money and will form part of the future in STI testing

Day 1, post number two.

This afternoon I attended a round table discussion on PrEP, after the opening ceremony. It seemed everyone in the conference was there as the room was packed! 

Rebecca Houghton will be blogging about this in more detail but I wanted to touch on the excellent presentation by Dr Emma Devitt from Dean Street Clinic in London as this was another analysis of a model of care, but of a single service. It is well known that the Dean Street model of care is progressive and hearing her discuss the way the service has actively adapted to the needs of the community in it's location, design, and flexible staffing is a lesson we should absorb. The clinic's redesign in 2014 to include an express service running 6 days a week is of note as it takes full advantage of many technologies that are available to us; videos explaining self-specimen collection that play within the mirror in the bathroom; and their GeneXpert has been calibrated to bypass a middle man and text clients their results directly. Inspiring stuff! She highlighted that express models still require medical staff on site to support nurses and health care assistants, and also discussed how the delivery of PrEP is evolving in their clinic with nurse prescribing. 

Hello from the 16th European AIDS conference in Milan. 

This morning I attended a very interesting workshop organised by WAVE, Women against Viruses in Europe, where numerous aspects of caring for women with HIV were presented and discussed.

The session started with a very powerful and insightful presentation by Justyna Kopec who has just celebrated her 20th anniversary of living with HIV. She discussed her journey to diagnosis and disclosed a number of lost opportunities to an earlier diagnosis (eg testing and then never returning for results) and highlighted that staff at her 'clinic' were integral to her feeling supported throughout her life living with HIV. This was a really excellent presentation to kick off with to remind us all to keep patients are at the centre of their care.  (see Catherine Orr’s notes from this session here)

Following was an analysis of the models of care for HIV positive Women in Europe split into West, Central and Eastern areas by Dr Annette Haberl from Germany, Dr Cristiana Oprea from Romania and Dr Inga Iatysheva from Russia, respectively. There is a huge amount of detail surrounding the variations in HIV care in each country and all face similar challenges in varying degrees i.e. coordination of allied specialist services such as gynaecology, psychology and social supports, or lack of integrated services, particularly in less economically enabled countries; barriers to accessing care surrounding child care responsibilities; lack of gender autonomy; fear of stigma. 

I noted that nurse led models of care for women living with HIV did not come up in discussion from any of the 3 speakers; the analysis may have not drilled down to this level but nurse led models of care could be useful in resource poor environments particularly. Additionally, further research as a high priority area was raised, and 2 speakers suggested that WAVE could be the right platform to assist coordinate research, exchange experience and create expert advisory groups. 

At the first day of the European AIDS Conference 2017, Sharon Walmsley (Senior Scientist at Toronto General Hospital Research Institute) spoke at the Women Against Viruses in Europe (WAVE) forum.  

When considering ART in women it is important to remember the following

• drug trials rarely include significant numbers of women
• Consider whether woman is planning pregnancy (remember safety of ART in pregnancy is generally based on expert opinion not on evidence)
• Consider drug interactions with contraception
• Stribild and Genvoya not recommended in pregnancy as elvitegravir and cobicistat do not cross placenta so baby is not getting adequate levels
• Consider co-morbidity in the older woman especially around menopause and cardiovascular risk
• HIV and/or ARTs seem to cause higher rates of early menopause
• Women living with HIV have higher rates of CVD AND women living with HIV have higher rates of osteoporotic fractures
• Therefore consider change of ART at menopause
• Women represent >50% of people living with HIV however studies of drugs for HIV rarely include significant numbers of women. 

 More to come...

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:

• The Rural Experience by Annie Balcomb (General Practitioner, Prince St Medical Practice Orange NSW)
• Bridging the Prescriber Divide – Treatment Made Easy by Alex Thompson(Director, St Vincent's Hospital And The University Of Melbourne)
• Eliminating Hepatitis C - The Cairns Experience by Darren Russell(Director, Cairns Sexual Health)

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:

• Global burden of hepatitis & use of pooled procurement to expand access by Homie Razavi (Managing Director, Center For Disease Analysis)
• Where is New Zealand in the race to eliminate Hepatitis C? by Ed Gane (Hepatologist, Auckland City Hospital)

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:

• Global burden of hepatitis & use of pooled procurement to expand access by Homie Razavi (Managing Director, Center For Disease Analysis)
• Where is New Zealand in the race to eliminate Hepatitis C? by Ed Gane (Hepatologist, Auckland City Hospital)

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.

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.