Integrating antiviral

1
Integrating antiviral substance dependence
treatment for injecting drug users

• Presenters
• Mark Stoové, Jenny Kelsall, Pheobe
  Spry-Bailey
• In collaboration with
• Nick Walsh, Katrina Watson, Damon Brogan
  Nick Crofts
• Turning Point Alcohol Drug Centre, VIVAIDS,
  St. Vincents Hospital

2
Integrating antiviral substance dependence
treatment for injecting drug users

• HCV epidemiology
• HCV antiviral treatment
• Treatment among IDU
• Barriers to HCV treatment among IDU
• Profile of TP clients
• Who have we seen so far?
• Health Liver Clinic rationale
• Model of clinical care
• Peer-based model of care

3
Global HCV Epidemiology

• 170 million infected worldwide
• 3-4 million new infections annually
• 60-80 IDU infected in most countries

Reprinted from Cohen J. Science. 199928526.
4
Australian HCV Epidemiology

• Hepatitis C notifications, 1990-2002

Source NCHECR Annual Surveillance Report 2003
5
Australian HCV Epidemiology

• Estimates of Hepatitis C incidence, 1961-2001

Law et al Int J Epidemiol 2003
6
Australian HCV Epidemiology

• Risk factors for newly acquired Hepatitis C

Sexual 2
Other 3
Tattoos 2
Unspecified 11
IDU 82
Robotin et al JGH 2003
7
Australian HCV Epidemiology

• Hepatitis C prevalence among IDU in annual NSP
  survey

Source NCHECR Annual Surveillance Report 2003
8
Australian HCV Epidemiology

• Estimates of people with Hepatitis C by disease
  stage

• gt35,000 eligible for treatment (stage 1 fibrosis
  mod inflammation or stage 2 fibrosis)
• 2,000 receive treatment annually

Dore et al J Clin Virol 2003
9
HCV Antiviral Treatment

• Australian Hepatitis C treatment
• Federal Government funded program (S100)
• Interferon ribavirin combination approved for
  treatment naïve patients in May 2001
• Pegylated interferon ribavirin combination
  approved for treatment naïve patients in November
  2003
• Inclusion criteria abnormal ALT, chronic HCV,
  stage 1 fibrosis moderate inflammation or
  stage 2 fibrosis
• Recent or current IDU removed as exclusion
  criteria in May 2001
• Liver biopsy removed as inclusion criteria April
  2006

10
HCV Antiviral Treatment
People receiving government-funded IFN
ribavirin therapy, 1999-2003
NCHECR Annual Surveillance Report 2003
11
HCV Antiviral Treatment

• History of HCV antiviral therapy

12
HCV Antiviral Treatment

• History of HCV antiviral therapy by genotype

13
HCV Antiviral Treatment

• History of HCV antiviral therapy by genotype

14
HCV Antiviral Treatment Among IDU

• Active IDU excluded from treatment
• Evidence base changed this
• Dispersion of HCV treatment delivery away from
  hospital setting
• Community-based shared care therapy since 2003
• General lack of uptake since
• Few programs offer pharmacotherapy and HCV
  treatment in combination

15
Barriers to HCV Antiviral Treatment Among IDU

• Diagnosis, referral treatment by IDU status

Stoové et al 2005
16
Barriers to HCV Antiviral Treatment Among IDU

• Diagnosis, referral treatment by IDU status

Stoové et al 2005
17
Barriers to HCV Antiviral Treatment Among IDU

• HCV treatment attitudes IDU - clinic-based survey
  of current IDUs in Sydney (N100)

18
Barriers to HCV Antiviral Treatment Among IDU

• HCV treatment attitudes

19
Barriers to HCV Antiviral Treatment Among IDU

• Consideration of HCV treatment by age

20
Barriers to HCV Antiviral Treatment Among IDU

• Barrier to HCV treatment offered and refused
  (n30)

21
Profile of TP Clients

• Age of commencement of pharmacotherapy

22
Profile of TP Clients

• Adherence by age of commencement of
  pharmacotherapy

23
Profile of TP Clients

• Adherence to methadone maintenance therapy

24
Profile of TP Clients

• Adherence to buprenorphine maintenance therapy

25
Clients we have seen so far
18 patients have been screened
26
Healthy Liver Clinic Rationale

• Over 90 of HCV from IDU
• 60 of IDU in Victoria are HCV positive
• Community based treatment more accessible
• Peer support validates the treatment process
• Pharmacotherapy maybe an important adjuvant

27
Peer-Based Model of Care

• The peer component of the Healthy Liver Clinic
  is one of its unique aspects
• The involvement of VIVAIDS ensures ongoing peer
  input focus on consumer perspectives
• The peer component of the model will be
  monitored closely its efficacy assessed

28
MISSION STATEMENT VIVAIDS AIMS TO PROVIDE A VOICE
FOR PEOPLE WHO INJECT OR USE OTHER DRUGS TO
ADDRESS THE HEALTH AND SOCIAL JUSTICE ISSUES
EXPERIENCED BY PEOPLE WHO INJECT OR USE OTHER
DRUGS
29
Peer-Based Model of Care

• The aims
• To develop deliver peer based HCV education,
  support awareness for drug users/pharmacotherapy
  clients
• To identify address barriers to the uptake of
  HCV treatment for drug users/pharmacotherapy
  clients
• To devise ways to respond more sensitively to the
  needs of drug users seeking HCV treatment

30
Peer-Based Model of Care

• The Healthy Liver Clinic
• Access to specialist consultation care
• A D clinicians
• Psychiatrist
• Testing serology
• Pre post test counselling
• Hepatitis A B immunisation
• Opioid pharmacotherapy onsite pharmacy
• NSP
• Hepatitis C Treatment follow-up
• Ongoing peer-based information, education
  support

31
Peer-Based Model of Care

• Expected Outcomes
• Increased access uptake of Hepatitis C
  treatment by drug users/pharmacotherapy clients
• Improved HCV treatment responses regimes for
  drug users pharmacotherapy clients

32
Peer-Based Model of Care

• We have found
• Significant interest in treatment among clients
• Many clients are unaware of the availability of
  treatment for Hepatitis C
• Many are unaware of the high success rate (or
  Sustained Virological Response) of treatment
  especially for genotypes 2 3.
• Many clients think that they have Hepatitis C
  when they test anti-body positive (i.e. but HCV
  RNA -)
  
  
  
  
  
  
  
  
  
  
  
  

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Peer-Based Model of Care

• Hepatitis C is an abstraction for many users,
  especially younger users
• Many users list other more pressing concerns
  before Hepatitis C
• There is an air of fatalism everyones got it
• Mostly older users who are considering the option
  of treatment