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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Tracy Swan from the Treatment Action Group in New Your provided a brief yet comprehensive over view of where we are at in relation to hepatitis C treatment access. The webcast from this session is now available on  the HIV Drug Therapy Glasgow 2014 website

Or you can go to the specific talk. There is also an excellent talk at the end of this session which tries to explain the drug regulatory system, and role of generics, predominantly in Europe.  by Pauline Londeix


Tagged in: Glasgow2014 VH 2014

Helen Tyrrell, Hepatitis Australia, provided a progress report on the targets from the 2012 Auckland statement on viral hepatitis. Helen Tyrrell described the “national shame”, that 1,000 people will die from hepatitis related liver disease in Australia in 2014. These rates are higher than those at the height of the HIV/AIDS mortality in 1994 in Australia.  Viral hepatitis requires the same action and response which HIV/AIDS mortality rates elicited in order to reverse the “rising death toll from viral hepatitis”.

Target progress:

Target 1: by 2016, halve the incidence of hepatitis C infections by doubling the amount of new injecting equipment distributed in the general community and implementing NSPs in prisons. 

Limited progress has been made in achieving this target thus far. In 2012 the ACT announced a trial of the distribution of sterile injecting equipment in a prison, however the trial has not yet commenced.  Contrary to this target, the 4th National Hepatitis C
Strategy does not include a priority action area which encourages trial needle and syringe programs (NSPs) in prisons. This is a backwards step as this priority action area was included in the previous strategy. Veering off the path of prioritising the need for NSPs in prisons undermines the development of an enabling policy environment to assist with preventing HCV transmission in high HCV prevalence settings.    

Target 2: Apply consistent funding of Hepatitis B vaccines for all those at greatest risk

A national policy commitment to this target is reflected in the 2nd National Hepatitis B Strategy. Tyrrell highlighted that there has been inequitable access to funded vaccination programs for key populations.

Target 3: Ensure at least 80% of people living with Hepatitis B and C are diagnosed

April 2014 saw the announcement of $4.6 million in funding to increase the uptake of hepatitis B testing and treatment, however the planned distribution of this funding has not been publicised. This target largely related to hepatitis B as estimates suggest that 80% of people living with hepatitis C have been diagnosed.    

Target 4: Ensure 5% of people living with hepatitis C receive anti-viral medication each year

This target is reflected in the 4th 
National Hepatitis C Strategy. This target requires accelerated PBAC and Cabinet approval process for new HCV drugs and promotion of new treatment options.

Target 5: Guarantee that 10% of people living with hepatitis B receive antiviral treatment each year

This target is again reflected in the 2nd National Hepatitis B Strategy target, aiming for 15% of people living with hepatitis B to be on treatment.  

Whilst there has been some progress in the target areas, significant prioritisation of viral hepatitis will be required to meet the targets by 2016. The minimal progress is a call to action for state and federal governments to upscale the response required to both meet targets and reduce numbers of avoidable viral hepatitis related liver deaths. 



Tagged in: IAS2014 VH 2014

I’ve just had the privilege of attending the stream this morning on Community & Social Research – Preventing Viral Hepatitis.  All of the sessions were very valuable, however, I particularly enjoyed the session titled “Peer Link”, this was presented by Yvonne Samuels, Yvonne presented on behalf of Fiona Poeder who was unable to be present. 

Yvonne was a vibrant and passionate presenter who succinctly and clearly made the point that, while often overlooked, peer education is a powerfully effective tool for fighting viral hepatitis in injecting drug using communities. 

Peerlink, is a program run by NUAA (NSW Users and Aids Association).  It is a peer education project which has been developed and is delivered by people who use drugs.  It has recently been delivered in Nowra, Toronto and Mt Druitt.  The model is a holistic model that tackles Hepatitis C via education and prevention. It is based on the view that each individual community knows its own needs and own also contains the strategic information that that community needs for prevention.
Compellingly, Yvonne quoted, when you arrive in a community,  “What you do …. is shut up….You never arrive in a community with any ideas.”  Rather you need to arrive in the community ready to learn what the community needs.
The Peerlink program has three phases.
Phase 1
Making contact with the community, find a core group of people who use drugs and who are interested in being trainers in their own community (peer recruitment).  In this phase service partners are also identified and recruited.  In this phase there is initial training, the project outlined and planned.
Phase 2
In this phase Peerlink peer educator activities take place with individual contacts of the peer educator and also in groups.  If appropriate refresher training takes place. There are also health promotion activities and collaboration with service partners.  There is ongoing peer facilitator training.
Phase 3
Is working out how to withdraw the peer-link program while sustaining the gains that have been made.
The results have been impressive. In Mt Druitt there were 10 peer educators. In two years NUAA expected 800 peer education interactions. In actual fact, there were over 7,000  peer interventions.  In Toronto, there were seven peer educators.  It was expected that 800  interactions would occur in two years.  In actual fact over 9,000 conversations took place. In Nowra, there were nine Peer Educators. It was expected that in two years there would 400 interactions.  However, in two years there were more than 6,000 total peer interventions.
In summary, it was concluded that Peerlink demonstrates effectiveness in disseminating education to communities and reducing Hepatitis C.



Tagged in: VH 2014

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This insightful plenary session at the 9th Australasian Viral Hepatitis Conference began with Dr Dieter Glebe from Germany presenting on the origins of hepatitis B virus, a topic that rarely crops up in the clinic but is nonetheless fascinating.

Titled “Of bats and men: species specificity of hepadnaviral infection” Dr Glebe began by explaining the existing phylogenetic understanding of the virus in mammals which can be isolated in many species of non-human primates and also new world rodents such as woodchucks and ground squirrels. However, as the strains in the new world rodents cannot infect non-human primates and vice versa, Dr Glebe looked to bats, the mammalian viral mixing pot to investigate how the virus might have moved between rodents and non-human primates. He screened 3,080 bats from 54 species around the world, finding 10 animals PCR positive and a detection rate of 6-10% of hepadnaviral DNA in individual species. Most of the viruses were isolated from the liver.

The research then focused on assessing the zoonotic potential of these bat viruses. One strain isolated from a Panamanian tent making bat seemed to be the closest match to human virus and successfully replicated in human liver cells in vitro. Fortunately, the nucleoside analog entecavir was able to inhibit replication as with the human virus. However, and slightly worryingly, antisera from hepatitis B vaccinated humans was not protective against infection with the bat virus. Dr Glebe wrapped up the presentation with a charming picture of a non-human primate happily eating away at a bat, reminding us that nature often finds a way help species “mix”.

The second and final presentation of the session was titled “HBV Reactivation: Playing with fire” presented by Professor Maggie Bassendine from Newcastle, UK. Professor Bassendine began by reminding the audience that “resolved infection” is not immune clearance but immune control (as HBV cccDNA can still be found in some hepatocytes) and hence that control can be lost under certain circumstances. This reactivation can occur after receiving immunosuppressive therapy, such as chemotherapy or drugs associated with transplantation. Unfortunately it is not possible to predict whether reactivation will occur and how severe it will be, but some agents do seem to make it more likely. For instance, when chemotherapy was given with steroids, reactivation was more common than chemotherapy given without steroids. One of the newer agents used in cancer therapy, the monoclonal antibody Rituximab seems to be particularly associated with HBV reactivation with one paper recording it occurring in 1/20 patients with resolved HBV infection.

Professor Bassendine then discussed the role of screening for resolved HBV infection before giving patients immunosuppressive therapy noting the lack of consistency between HBV clinical guidelines which recommend screening, and oncology guidelines which don’t explicitly recommend screening, but leave it at the clinician’s digression. This is concerning as 20% of oncologists have been recorded never screening patients. Professor Bassendine then concluded the presentation by a making call for universal screening to be included across all national and local guidelines and suggesting the clinicians in the audience start by investigating the current screening practices in their own local hospitals.

Tagged in: VH 2014

The 9th Australasian Viral Hepatitis Conference has offered up a variety of lessons learnt from trials and piloted services. The question is, which model/s will be taken on if we are to massively scale up our response to hepatitis B (HBV)?

During the proffered papers session on Clinical Care for HBV, Thursday, 18 September, Tracey Cabrie addressed the topic of improving quality of care for people living with HBV in primary care, with some preliminary data from the Integrated Hepatitis B Service, run out of the Royal Melbourne Hospital. Tracey works as a Hepatitis B Integrated Care Nurse in the Service, a role which is shared, and funded for 0.8 FTE.

The Integrated Hepatitis B Service provides support to high case load GP clinics, through capacity building, developing clinical pathways, and supporting the increase in testing and vaccination. Through the Hepatitis B Integrated Care Nurse, the service has engaged 45 primary care professionals within 5 primary care clinics in 2 years. Within these clinics, 830 patient records have been audited, with 328 patients identified as having chronic hepatitis B (CHB).

Cabrie’s team collected baseline and follow up data at 18 months at 2 clinics. Of patients with CHB, the majority were in the immune control phase. At follow up, the majority were managed by their GP, compared to the majority at baseline being managed by a specialist. There were improvements in rates of annual LFTs and DNA in both clinics at follow up. Between 20-30% improvements in liver ultrasounds for HCC (in line with the guideline) at follow up.

Lessons learnt?

Relationship building with the clinicians was essential to capacity building

Patient-centred care is vital, and therefore service delivery should be varied, as each practice is different, and each patient's needs are different

The audit of patient records supported the idea of developing systems, and the need to provide or link in training and resources

Guideline-based CHB management is achievable in a primary care setting

In short, it seems there’s “no such thing as a model of care” – real quality care needs to be flexible, responsive and appropriately resourced. CHB management is complex and therefore requires a nuanced and multi-faceted intervention. 

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One clear message weaved throughout the World Indigenous Peoples’ Conference on Viral Hepatitis is the need for work within Indigenous communities (worldwide) to come from or through members of those communities. And, as one speaker pointed out, it is – in order to make a culturally appropriate impact – just common sense.

A very promising example of this in practice was presented during the proffered paper session on Hepatitis C – Leadership, Support & Education, on Tuesday, 16 September 2014. Damien House, Hepatitis Peer Educator/Aboriginal HEO at the Sydney Local Health District (LHD), in NSW, Australia, presented his work on “Aboriginal hepatitis C Peer Education in Inner West Sydney”.

Within 2 years working at Sydney LHD, House has developed a highly successful model of care to work with people on an individual basis, to engage them with testing and treatment services. Using House’s model of care, patients within his care have, to date, achieved a 100% rate of sustained virological response to antiviral therapy.

Damien is openly a person who lived with hepatitis C. Damien was fortunate enough to beat hepatitis C with antiviral therapy. It is undoubtedly due to Damien’s personal experience, and his capacity to connect to members of his community, that enables him to help people through their treatment journey. Damien's key message to patients is that hepatitis C is a curable disease, and you shouldn't just live with a curable disease, you should treat it.

Damien’s inspirational story has been made into a DVD and may be ordered (subject to availability) via Damien at the Sydney LHD

Tagged in: VH 2014

On Monday, 15 September 2014, at the World Indigenous Peoples’ Conference on Viral Hepatitis, the Centre for Social Research in Health (CRSH) launched the results of a study examining the experiences of Aboriginal Australians living with hepatitis C (henceforth HCV) and their experiences of healthcare. A study of Aboriginal people in NSW living with hepatitis C: A report to community was conducted with 203 participants across NSW.

Professor Carla Treloar outlined the key findings of the research at yesterday’s launch, primarily the impacts of stigma and discrimination, with specific reference to the entangling nature of racism and HCV. Participants of the study described their experiences of health care workers expecting Aboriginal patients to have “these things”, referring to HCV.

Treloar explored the notion of ‘overlapping stigma’: Aboriginal Australians living with HCV can experience a combination of stigmas, such as the stigma of living with HCV, which can be linked to the stigma attributed to being  a person who injects drugs (based on assumptions regarding the mode of transmission) and additionally associated stigmas that society projects on Aboriginal people. Stigma influences patient decisions to disclose their HCV status to family and friends. Deciding not to disclose denies patients potential support networks which are vital during treatment.

The detrimental effects of stigma are evident at an individual and societal level. Treloar identified that experiences of stigma increase the burden of disease for the individual, and stigma on a population level increases health inequalities for minority groups.

Findings indicate that participants who thought that their diagnosis was delivered in a culturally appropriate manner were more likely to consider and commence treatment. These findings reinforce the need for health professionals to have culturally appropriate pre and post test discussions in order to increase rates of Aboriginal and Torres Strait Islanders receiving HCV treatment. Similarly, participants emphasised the need for health care professionals to adequately discuss HCV when diagnosis is delivered rather than numerous reports of being given pamphlets and denied an opportunity for further discussion.

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