Bloodborne Virus and Sexually Transmitted Infection Section

1
Hepatitis C and Injecting Drug Use what are
the key challenges?
Sharon Hutchinson
SDF conference, Feb 2007
2
Key questions

• How effective are services at preventing HCV
  infection among IDUs?
• How effective are services at identifying those
  infected with HCV?
• How effective are services at preventing those
  infected with HCV from developing severe liver
  disease?

3
Estimated prevalence of current injecting drug
users in Scotland, 2000 2003
2003 Estimated total 18,700 (95 CI 17,700 -
20,300)
2000 Estimated total 25,000
IDU prevalence (population aged 15 to 54)
gt1.2
0.91-1.2
0.61-0.9
0.41-0.6
?0.4
(Hay et al., 2005)
(Hay et al., 2001)
4
Prevalence of HCV among 2,141 IDUs in Scotland
who had a named HIV test, 1999-2000
HCV prevalence
? 50
30-49
lt 30
No data
Grampian (38)
Tayside (53)
Highland (31)
Forth Valley (23)
Argyll Clyde (31)
Fife (29)
Lothian (36)
Greater Glasgow (62)
Lanarkshire (41)
Ayrshire Arran (38)
Dumfries Galloway (28)
5
Number of needles/syringes (N/S) distributed
persons on methadone in Glasgow
1 million
6,000
0.8 m
4,000
Methadone Recipients
0.6 m
N/S distributed
0.4 m
2,000
0.2 m
1990
1992
1994
1996
1998
2000
2002
6
Number of needles/syringes (N/S) distributed
persons on methadone in Glasgow
1 million
6,000
0.8 m
4,000
Methadone Recipients
0.6 m
N/S distributed
0.4 m
2,000
0.2 m
1990
1992
1994
1996
1998
2000
2002
Estimated incidence of HCV and HIV among IDUs
(who had began injecting previous 2 yrs) in
Glasgow
100
80
HCV incidence
Percentage
60
40
20
HIV incidence
0
1990
1992
1994
1996
1998
2000
2002
7
Prevalence of current IDUs in Glasgow
8,000
6,000
N
4,000
2,000
0
1999
2000
2001
2002
2003
2004
2005
8
Needles/syringes distributed methadone
prescriptions in Glasgow
Prevalence of current IDUs in Glasgow
150
8,000
1million
0.8m
6,000
100
N
0.6m
Methadone prescriptions (000s)
N/S distributed
4,000
0.4m
50
2,000
0.2m
0
0
0
2000
2001
2002
2003
2004
2005
1999
2000
2001
2002
2003
2004
2005
9
Needles/syringes distributed methadone
prescriptions in Glasgow
Prevalence of current IDUs in Glasgow
150
8,000
1million
0.8m
6,000
100
N
0.6m
Methadone prescriptions (000s)
N/S distributed
4,000
0.4m
50
2,000
0.2m
0
0
0
2000
2001
2002
2003
2004
2005
1999
2000
2001
2002
2003
2004
2005
Uptake of prescribed methadone among IDUs in
Glasgow
100
Methadone (last 6 months)
80
60

40
20
0
1999
2000
2001
2002
2003
2004
2005
Injecting debut ?5 years
10
Needles/syringes distributed methadone
prescriptions in Glasgow
Prevalence of current IDUs in Glasgow
150
8,000
1million
0.8m
6,000
100
N
0.6m
Methadone prescriptions (000s)
N/S distributed
4,000
0.4m
50
2,000
0.2m
0
0
0
2000
2001
2002
2003
2004
2005
1999
2000
2001
2002
2003
2004
2005
Uptake of prescribed methadone and HCV testing
among IDUs in Glasgow
100
Methadone (last 6 months)
80
HCV tested (ever)
60

40
20
0
1999
2000
2001
2002
2003
2004
2005
Injecting debut ?5 years
11
Needles/syringes distributed methadone
prescriptions in Glasgow
Prevalence of current IDUs in Glasgow
150
8,000
1million
0.8m
6,000
100
N
0.6m
Methadone prescriptions (000s)
N/S distributed
4,000
0.4m
50
2,000
0.2m
0
0
0
2000
2001
2002
2003
2004
2005
1999
2000
2001
2002
2003
2004
2005
Uptake of prescribed methadone and HCV testing
among IDUs in Glasgow
Prevalence of risk behaviours among IDUs in
Glasgow
100
100
Methadone (last 6 months)
Shared N/S other equip (last month)
80
80
HCV tested (ever)

60
60

40
40
20
20
0
0
1999
2000
2001
2002
2003
2004
2005
1999
2000
2001
2002
2003
2004
2005
Injecting debut ?5 years
Scottish Drugs Misuse Database, ISD
12
Needles/syringes distributed in Glasgow
Prevalence of current IDUs in Glasgow
8,000
1million
0.8m
6,000
N
0.6m
N/S distributed
4,000
0.4m
2,000
0.2m
0
0
2000
2001
2002
2003
2004
2005
1999
2000
2001
2002
2003
2004
2005
Prevalence of risk behaviours among IDUs in
Glasgow
100
Injecting daily (last 6 months)
80

60
40
20
0
1999
2000
2001
2002
2003
2004
2005
Injecting debut ?5 years
13
HCV prevalence among IDUs in Glasgow (1999-2005)
100
80
60

40
20
0
1999
2000
2001
2002
2003
2004
2005
All IDUs and IDUs aged ?25 years, who had a
named HIV test
IDUs who started injecting ?5 years
(multiple-site/NE surveys)
14
Key questions

• How effective are services at preventing HCV
  infection among IDUs?
• How effective are services at identifying those
  infected with HCV?
• How effective are services at preventing those
  infected with HCV from developing severe liver
  disease?

15
Reasons for HCV Testing

• To identify those who are
• At risk of infection - of their HCV status so
  that they might change their behaviour.
• PCRve - so that harm reduction measures among
  them can be promoted.
• PCRve and ineligible for therapy - so that
  they can be monitored.
• PCRve and eligible for therapy - so that they
  can be offered treatment.

16
Annual and cumulative HCV diagnoses in Scotland
(to end of 2005)
Risk Group
2,000
20,000
Other
NK
1,500
15,000
IDU
Annual HCV diagnoses
Cumulative HCV diagnoses
1,000
10,000
500
5,000
0
0
2005
1991
1993
1995
1997
1999
2001
2003
Year of first positive specimen
17
Royal College of Physicians of Edinburgh
Consensus Statement Hepatitis C (2004)
Includes A high priority for case finding
should be given to former injecting drug users,
especially those over 40, who are likely to have
a stage of disease which would benefit from
treatment. Cost-effective methods of identifying
this group, through public awareness initiatives
in primary care settings, drug treatment services
and prisons, should be established.
18
Modelled distribution of former IDUs in
Glasgow by stage of HCV disease and current age,
in 2005
100
HCV uninfected
80
Recovered from HCV
Cleared HCV
60
Mean percentage of former IDUs
Mild disease
40
Moderate disease
Cirrhosis
20
0
lt30 (18)
40-49 (23)
30-39 (57)
50 (2)
Hutchinson et al. Hepatology 2005
Age in years ( of 22,500 former IDUs)
19
Cost effectiveness of testing for HCV in former
IDUs (HTA report, 2006)
20
HCV Epidemiological Landscape Scotland, 2005
Estimated size of Population
0
25,000
50,000
Living HCV Abve Ever IDU Male Diagnosed Chronic
HCV Ever IDU Former IDU Former IDU
(diagnosed) Ever Specialist Care Ever Antiviral
Rx
50,000
45,000
35,000
18,000
37,500
33,800
25,700
9,300
7,500
1,500
Goldberg et al. Recent advances in clinical
practice Hepatitis C (in press)
21
Key questions

• How effective are services at preventing HCV
  infection among IDUs in Scotland?
• How effective are services at identifying those
  infected with HCV?
• How effective are services at preventing those
  infected with HCV from developing severe liver
  disease?

22
Natural history of HCV disease
No infection
HCV
15-40 recover
Infection
40-70 by 20 years
Mild disease
5-10 by 20 years
Moderate disease
Severe disease (cirrhosis)
4-9 per year
Liver failure
Transplantation
Freeman et al. Hepatology 2001
23
Current burden of HCV among IDUs in Scotland, 2005
No infection
1,000-2,000 per year
HCV
Infection
Mild disease
Moderate disease
Severe disease (cirrhosis)
Liver failure
Hutchinson et al. Hepatology 2005
24
Development of Decompensated Cirrhosis (DC) among
all HCV diagnosed persons in Scotland
25
Observed and modelled annual incidence of liver
failure among HCV infected IDUs in Scotland,
1980-2030
300
Observed
250
Modelled
200
150
Mean incident number (95 CI)
100
50
0
1980
1990
2000
2010
2020
2030
Calendar year
Hutchinson et al. Hepatology 2005
26
Modelled prevalent number of HCV infected IDUs in
Scotland according to stage of HCV disease,
1960-2030
60
Recovered from HCV
50
Cleared HCV from treatment
Mild disease
40
Moderate disease
Living IDUs (thousands)
30
2005
Cirrhosis
20
10
0
1960
1980
2000
2020
Calendar year
Hutchinson et al. Hepatology 2005
27
Key Challenges

• The prevention of HCV among current IDUs
• While existing interventions have helped to
  reduce HCV incidence among IDUs, ongoing
  transmission among this group remains a serious
  problem

28
Key Challenges

• The diagnosis of HCV-infected persons,
  particularly those most in need of therapy to
  prevent severe disease
• In Scotland, thousands of past injectors (mostly
  aged 30-49 years) have chronic HCV and are
  undiagnosed
• Identifying the above group and considering
• individuals for therapy should be regarded a
  priority

29
Key Challenges

• The provision of adequate resources to ensure
  optimal management of patients through the
  diagnostic and clinical care pathway
• HCV-related end stage liver disease is not
  uncommon in Scotland, is increasing and is
  usually associated with an alcohol problem
• If current low levels of antiviral therapy do not
  increase in the future, the numbers developing
  severe HCV disease will increase considerably

30

• Acknowledgements
• HPS David Goldberg, Kirsty Roy, Norah Palmateer,
  Allan McLeod, Scott McDonald, Beth Cullen, Amanda
  Weir
• Paisley University Avril Taylor, Liz Allen
• Regional Virus Laboratories Sheila Cameron
  (Glasgow), Sheila Burns (Edinburgh), Pamela
  Molyneaux (Aberdeen), Paul McIntyre (Dundee)
• MRC Biostatistics Unit Sheila Bird
• Glasgow University Gordon Hay
• GGC NHS Board Louise Carroll Syed Ahmed
• ISD Drug Misuse Team Record Linkage Team