Professor Kate Dolan from the National Drug and Alcohol Research Centre, UNSW, presented data from their global systematic review of the HIV situation in prisons, which looked at imprisonment rates, HIV prevalence, HIV incidence, AIDS-related mortality, and services provided in prison, in the time period under observation from 2008 to 2013.

The review identified that 30 million individuals enter and leave prison per year, leading to the conclusion that good prisoner health is good public health, as any diseases contracted in prison, or made worse by poor conditions in custodial settings, returns to the community.

Drug dependence is a key factor in imprisonment in Australia, with 84% of people who inject drugs in Australia re-incarcerated within two years of release and the mean number of prison sentences sitting at 5. Whilst HIV prevalence is very low amongst Australian prisoners, transmission remains a risk and the prevalence of hepatitis B and hepatitis C has remained high.

Dr Fabienne Hariga, from the United Nations Office on Drugs and Crime then outlined a comprehensive package of 15 interventions for HIV prevention, treatment, and care in prisons, in particular looking at the introduction of needle and syringe program (NSP) into prisons, which she stated should be the number one priority.  

Dr Hariga outlined evidence from the evidence for action technical paper entitled Interventions to Address HIV in prisons: Needle and syringe programmes and decontamination strategies, which spoke to the feasibility and effectiveness of NSP in prison settings.

However, Dr Hariga conceded that current coverage of NSP in prisons is very low and many programs have not been sustainable to due strict controls implemented and a lack of confidentiality and anonymity, resulting in low uptake of the program by prisoners.

She concluded that a mixed model incorporating peer-based distribution, dispensing machines, and a health service, seems the best measure as part of a comprehensive package of interventions.

Away from the excitement created by Bill Clinton giving his Put Patient’s Health First to Improve Outcomes and Programme efficiency presentation today, a small group gathered for a Civil Society meeting on viral hepatitis called by the World Health Organisation (WHO). This informal meeting aimed to strengthen the engagement of civil society in WHO processes, enhance the dialogue on hepatitis-related work and build on the experiences of communities and groups living with, or affected b,y viral hepatitis undertaking advocacy work and providing services.  

Worldwide, between 130 and 170 million people are living with chronic hepatitis C and another 250 to 350 million are living with chronic hepatitis B—resulting in approximately 1.4 million deaths per year. Recognising the tremendous burden caused by viral hepatitis, this small event is one of a number of initiatives WHO is implementing, in order to build capacity and mobilise resources to respond to viral hepatitis. 

WHO established the Global Hepatitis Programme in 2010, following the adoption of resolution WHA63.18 (page 34) by the World Health Assembly, calling for a comprehensive approach to the prevention and control of viral hepatitis. Since then they have released:

• Prevention and Control of Viral Hepatitis Infection: Framework for Global Action (2012);
• Global policy report on the prevention and control of viral hepatitis in WHO Member States (2013); 
• Guidelines for the screening, care and treatment of persons with hepatitis C infection (2014);

and convened a Global Partners’ Meeting on Hepatitis to discuss the current status of the epidemic, levels of response in countries and future actions for enhanced hepatitis control worldwide. This meeting resulted in a "Call to action to scale up global hepatitis response" which puts pressure on the global community to increase access to prevention, diagnosis and treatment of viral hepatitis.

Furthermore, a new global resolution to promote a comprehensive response to viral hepatitis was adopted by the World Health Assembly in June 2014. WHA67.6 calls for enhanced action to improve equitable access to hepatitis prevention, diagnosis, and treatment and asks countries to develop comprehensive national hepatitis strategies.

At the event today the development of guidelines for hepatitis B and the development of a global strategy and plan for viral hepatitis which would include targets for the elimination of hepatitis B and C, were two of a number of initiatives currently being worked on by WHO demonstrating that momentum at global level is beginning to gather pace, but as we have learnt from HIV, there is a long road ahead, with much more collective action needed as we begin the journey.

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In the Hepatitis Co-infection session today, Sanjay Bhagani from the Royal Free Hospital, London described co-infection with hepatitis C for a person living with HIV as “double trouble” for the liver.

He began by looking at the D:A:D study which examined the causes of death in 49,734 HIV-infected patients followed in the period from 1999 to 2011. In this study liver-related diseases were found to be a frequent cause of non-AIDS related death, responsible for 13% of deaths.

A second study showed that persons co-infected with HIV and HCV have liver fibrosis stages similar to those without HIV who are nearly a decade older, with progression shown to be faster even when controlling for alcohol and other co-morbidities. Bhagani also demonstrated that hepatotoxicity was more common in co-infected patients even with modern HAART.

It was not all bad news, however, with the era of Direct Acting Antiviral (DAA) based therapy now a reality. Bhagani outlined results from a number of trials looking at interferon-sparing and interferon-free therapies, which revealed similar SVR rates in co-infected patients as in mono-infected patients.

Such results have meant the EASL recommendations on the treatment of hepatitis C released in April 2014 state that the same treatment regimens can be used in HIV/HCV patients as in patients without HIV infection, as the virological results of therapy are identical. Bhagani advocated for the need for an improved cascade of care and access to treatment for people living with HIV and HCV, due to the aggressive, multi-system impact of co-infection.

Dr Josh Davis stated in his presentation today that a funded HCC surveillance program is urgently needed for the Northern Territory. HCC incidence is much higher in the Northern Territory than the Nationally and there are significantly higher rates amongst the Aboriginal and Torres Strait Islander population (six-fold).

His study findings showed that the majority of Aboriginal and Torres Strait Islander people present when symptomatic and because of this late presentation palliation was the only form of treatment for 53% of these patients. 

I was inspired by Jacqueline Clegg's report on the nurse-led outreach program for assessment and treatment of chronic hepatitis C via telemedicine in the prison setting. She told of the success of the program in which assessment for treatment was done using Clinical Nurse Consultants as the key providers providing decentralised care with specialist back up via telemedicine.

The pilot program was a success and the model was shown to be both effective and safe. It would be good to see application of this model in rural and remote settings for hepatitis B. Jacqueline said that this may be in the pipeline for a future pilot, I look forward to hearing more.

Professor Henry Chan gave a comprehensive overview of the of HBV in the Asia Pacific in the opening plenary this morning. Professor Chan began by by making the point that hepatitis B virus (HBV) has been around for over 40 years and still presents a significant health burden for the Asia-Pacific region. HBV is the most common cause of liver cancer in Asia. In some countries, over 80% of hepatocellular carcinoma (HCC) is caused by HBV.

He outlined that vaccination for HBV has made a difference, using Taiwan as an excellent example where prevalence of HBV in children has dropped dramatically to as low as 0.19 per 100,0000 in 2007, since the introduction of universal vaccination in 1984. However, achieving adequate coverage is still a challenge for many countries in the region.

There are also challenges regarding the treatment of hepatitis B. There are effective treatments available, however cost and access to the best first line therapies often presents a problem, particularly in resource- poor settings. This can lead to further challenges regarding resistance (following the use of older drugs such as  lamivudine).   Professor Chan presented evidence for the need for continuous long term therapy for  hepatitis B and how this presents challenges in all settings.

Following 40 years of hepatitis B, there is still much work to be done and challenges to be overcome to ensure the health burden of hepatitis B is reduced in the Asia Pacific region.