Hepatitis C among people who inject psychoactive drugs in the UK: insights from national survey data and the way forward

Ellen HeinsbroekIDU team, National Infection Service, Public Health England

Ellen.Heinsbroek@phe.gov.uk IMS Users Annual Meeting, 18th July 2017

Outline• Hepatitis C in people who inject drugs

• Insights from the unlinked anonymous monitoring (UAM) survey• Anti-HCV testing results• Self-reported HCV VCT• Access to care

• Way forward• Global health sector strategy• New Direct-Acting Antivirals• Treatment as prevention• Enhancing the UAM survey

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Hepatitis C• Bloodborne virus: 6 genotypes

• Often asymptomatic until severe liver damage• End-stage liver disease (ESLD)• Hepatocellular carcinoma (HCC)

• Curable

• No vaccine

• UK: estimated 214,000 chronic cases

• At risk: people who inject drugs (PWID)

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*PHE, Hepatitis C in the UK, 2016 report

Insights from the unlinked anonymous monitoring (UAM) survey

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The Unlinked Anonymous Survey of People Who Inject drugs• Recruits people who inject psychoactive drugs across England,

Wales & Northern Ireland

• Sentinel surveillance by voluntary recruitment at collaborating drug agencies.

• First established in late 1980s as part of HIV monitoring

• Participants• Complete a short behavioural questionnaire • Provide a Dried Blood Spot sample: HIV, HBV, HCV

• An unlinked and anonymous methodology

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UAM Survey Aims:

1. Measure the prevalence of blood borne viral infections among PWID (HIV, HBV, HCV).

2. Monitor changes in both risk and protective behaviours related to drug taking.

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0

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0.9

1

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Prop

ortio

n w

ith a

ntib

odie

s to

hep

atiti

s C

and

test

ing

upta

ke (%

)

Survey year

Hepatitis C testing uptake

Proportion with hepatitis C

Trends in Hepatitis C prevalence and voluntary and confidential HCV testing uptake* among PWID in EW&NI:1998/2000 - 2015

Source: Survey data tables PHE, 2015 *Self reports

0%

20%

40%

60%

80%

100%

NorthEast

NorthWest

London East ofEngland

SouthEast

SouthWest

WestMidlands

Yorkshire& Humber

EastMidlands

Proportion with antibodies to HCV in 2015 by region

NW (2015): Anti-HCV prevalence 68%HCV VCT uptake 90%

HCV testing / access to care

Unpublished results removed for public access: please contact ellen.heinsbroek@phe.gov.uk for information

8 Hepatitis C testing and access to care among people who inject psychoactive drugs in the United Kingdom (UK): insights from national survey data.

Way forward: national picture

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Direct-acting antiviral (DAA) therapy • Sofosbuvir / Ledipasvir

• Oral

• Shorter treatment duration

• Improved side effects

• High sustained viral response (~cure) rates• >90% genotype 1

• Cost: 12/24 week course of Sofosbuvir: £35,000/£70,000

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NICE technology appraisal guidance 330: Sofosbuvir for treating chronic hepatitis C. 2015.

Global Health Sector Strategy • WHO Global Health Sector Strategy (GHSS) on viral hepatitis for

the period 2016-2021

• First-ever global targets for viral hepatitis control

• “Eliminate viral hepatitis as a major public health threat by 2030”

Impact• Reducing HCV-related morbidity and mortality

• 10% reduction in HCV mortality by 2020, 65% by 2030

• Reducing the number of new (incident) chronic infections• 30% reduction in HCV incidence by 2020, 80% by 2030

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Global Health Sector Strategy Key interventions PWID• Harm reduction

• 200 needles and syringes per PWID per year in 2020, and 300 in 2030

• Increased proportion diagnosed• 30% in 2020, 90% in 2030

• Increasing proportion and number treated• 80% of eligible persons in 2030

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Increased number treated

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PHE, Hepatitis C in the UK, 2016 report

Provisional UK-wide estimates of numbers initiating HCV treatment

Increased proportion diagnosed

14 Adapted from: PHE, Hepatitis C in the UK, 2016 report

2011 2013 2015 2020* 2030Year

Estimated UK-wide proportion of PWID aware of their HCV infection, 2011-2015, and targets for 2020-2030

100

90

80

70

*2020 target met in 2011-2015

Pro

porti

on a

war

e of

thei

r HC

V s

tatu

s (%

)

Reducing HCV mortality

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Deaths from ESLD or HCC in those with hepatitis C mentioned on the death certificate in the UK, 2005-2015

Adapted from: PHE, Hepatitis C in the UK, 2016 report

x: 2020 target

x: 2030 target

Reducing the number of new chronic infections

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Preliminary estimates of incidence of HCV-related ESLD/HCC: 2010-2015, and 2020 and 2030 targets

x: 2020 target

x: 2030 target

Adapted from: PHE, Hepatitis C in the UK, 2016 report

Reducing the number of new infections

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Adapted from: PHE, Hepatitis C in the UK, 2016 report

Estimated UK-wide incidence of HCV among PWID 2011-2015, and goals for 2020-2030

2011 2013 2015 2020 2030Year

Directly acting antivirals and Treatment as Prevention

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InfectionEarly entry to care

Early diagnosis

Early DAA treatment CURE

HCV morbidity

Transmission

Treatment as prevention

Modelling study: impact treatment severe / moderate / mild disease

• Severe (3500/yr): • ESLD/HCC incidence from 1240 cases in 2015 to 630 (95%CI 530-770) in 2020 • Negligible preventative impact

• Mild (2500/yr):• Negligible impact on ESLD/HCC incidence within 15 years• Annual prevalence/incidence from 34%/5% in 2015 to 11%/1.4% in 2030

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Harris et al, J Viral Hep, 2016 23, 631–643

Modelling studies

20 Harris et al, J Viral Hep, 2016 23, 631–643

Measuring hepatitis C incidence

All UAM samples from 2017 onwards will be routinely tested for HCV RNA.

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Uninfected

RNARNA positive,

antibody negative

(51-75 days)

AvidityHCV antibodies with weak avidity

(2-6 months)

Established infection

Discussion• Fluctuations in incidence

• Incidence unstable in cross-sectional surveys• Transient state of incident infections/outbreaks

• Trends in incidence need longer-term monitoring and mathematical modelling

• Importance of avidity/RNA for monitoring incidence, chronic prevalence, reinfection

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Conclusion• +/- 50% PWID infected with HCV

• Little change in key indicators 2011-2015

New opportunities

• Direct-acting antivirals

• Global Health Sector Strategy (GHSS)

• Change required to reach GHSS targets 2020 & 2030

• Treatment as prevention expected to reduce incidence

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Thank you for your attention

We are grateful to the survey participants and collaborating sites across the UK for their support of the UAM Survey of PWID

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Acknowledgements PHE: Vivian Hope, Monica Desai, Rachel Glass, Claire Tanner, Jackie Njoroge, Ross Harris, Samreen Ijaz, John Parry, Katelyn Cullen, Fortune Ncube, Jason Shute, Sema Mandal, Helen Harris

Adequate harm reduction

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PHE, Hepatitis C in the UK, 2016 report

Estimated UK-wide proportion of PWID reporting adequate needle and syringe provision, 2011-2015

Trends in equipment sharing among current* PWID in EW&NI: 1991 - 2015

* Those who had last injected in the four weeks preceding participation in the survey.Source: Survey data tables PHE, 2016

0%

20%

40%

60%

80%

100%

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Prop

ortio

n re

port

ing

shar

ing

(%)

Survey Year

Sharing of needles and syringes

Sharing of needles and syringes as well as other injecting paraphernalia

NW (2015):Needles and syringes 15%Other injecting equipment too 34%