Burnet's Professor Margaret Hellard hosts a panel discussion.
The efforts to eliminate hepatitis C virus (HCV) in Australia are inspiring, focused and achievable, if the commitment expressed by experts presenting at today’s World Hepatitis Symposium: Preventing Disease, Preventing Deaths in Melbourne is any indicator.
“Australia is ahead of the game (in eliminating hepatitis C),” Dr Joseph Doyle told the packed audience who attended this special post-World Hepatitis Day event hosted by Burnet Institute, The Alfred, Monash University, and the Australian Centre for Hepatitis Virology.
The symposium which shone a light on the progress being made towards elimination of hepatitis C, a disease which infects 70 million people across the world, and an estimated 180,000 Australians, attracted speakers from across the sector including physicians, public health researchers, primary care workers, community organisations, research scientists, and advocates for people living with hepatitis.
Primary care treatment is feasible: co-EC Study
Senior Lecturer at The Alfred and Monash University Department of Infectious Diseases and Burnet Institute’s Deputy Director, Disease Elimination Program, Dr Doyle said
one of the lessons learned from the HCV-HIV co-infection co-EC Study was that primary care treatment is feasible, with just under 20 per cent of patients needing to be referred to a specialist.
The co-EC Study, established in 2015, aimed to enhance hep C treatment amongst people with a HIV.
“At the time it seemed really at the edge and novel because we talked about getting nurses and transparent care out into the community. Australia was ahead of the game through this study, which tried some proof of the principle that we could work out who the defined population was and we could get them all diagnosed and then treat them,” Dr Doyle said.
“The novel aspect at the time which has now become much more standard, is that we were going to push care from the hospital, where HIV patients used to come for their hep C treatment, out into the community. The hep C nurses would support primary care treatment doctors and visa-versa,” he said.
“We recruited 200 people into the project and most of them into treatment. The cure rates were great. Of the people who turned up 99 percent were tested, and cured, with only two people with a known relapse.”
Hepatitis C elimination in Australia: What trajectory are we on and where can we improve?
Most telling was the mathematical modelling undertaken by Burnet’s econometrician, Dr Nick Scott about how more lives could be saved if there was a 50 per cent increase in testing.
His presentation, Hepatitis C elimination in Australia: What trajectory are we on and where can we improve? reinforced the need to reach undiagnosed people and those most at risk.
“We know we could reduce the estimated people with HCV in Australia from around 230,000 in 2015 to around 125,000 by 2030,“ Dr Scott said.
“Many in the sector may think that is a pretty pessimistic outlook given the treatment numbers and believe we could do better than that. What if we could maintain the treatment numbers?"
Using mathematical modelling, Dr Scott was able to show what would happen if Australia maintained the current treatment numbers of 20,000 people per year.
“This would initially have a much greater impact and reduce the numbers of people with HCV until 2025, but then we would run out of diagnosed people to treat,“ he said.
“The reason for this is that they are not diagnosed – based on current testing practices – and this highlights an important gap.
“Amongst people who inject drugs we are on track to have a substantial impact on incidence and prevalence.
“But if we don’t increase testing for those most likely to be undiagnosed they will be continue to be most at risk of infection. Even with a 50 per cent increase in testing we can have a significant additional benefit on these indicators."
“On the care cascade we need to get as many people as possible to be tested in order to be diagnosed and then treated. On the current trajectory we can halve the numbers of people living with HCV by 2030, but if we do more testing we can achieve even better (towards elimination),“ Dr Scott said.
“These are national projections for Australia. It is what we should be doing not the ‘how’. They do not take into account the many differences across states and regions, such as types of service provision, different models of care, pathways and access to treatment, stigma and a range of other issues.”
Australia’s elimination targets
Burnet’s Senior Research Fellow, Disease Elimination Program, Dr Alisa Pedrana, said Australia has very clear elimination targets set.
“Since March 2016 we’ve had universal access to direct-acting antiviral treatment (DAAs) for all patients chronically infected, regardless of disease severity and transmission.
We’ve also had guidelines to support prescribing specialists, general practitioners and nurse practitioners. And we have community-based treatment programs available through primary care and in prisons,” she said.
Dr Pedrana said the sector needed to be continually looking at the key targets and tracking them to achieve elimination.
“We’ve initiated over 58,000 people onto treatment which accounts for about 26 percent of the people living with hepatitis C. The majority of people accessing treatment are male and are over the age of 50,” she said.
“But recently we’ve seen declines in the numbers of treatments being initiated. We need to keep up momentum and make sure that we continue to increase our treatment numbers.
“In terms of the second target – reducing deaths by 65 percent – there is some encouraging news. In terms of the second target – reducing deaths by 65 percent – there is some encouraging news. We’ve seen a decrease in the numbers of hepatitis C-related deaths but the data is old, from 2015 so its just an estimate.”
The role of vaccines
A preventative vaccine will be needed by many countries to achieve elimination targets and according to Burnet’s Disease Elimination Program Director, Associate Professor Heidi Drummer, they are essential for a global hepatitis C elimination program.
“Vaccination for hepatitis B is highly effective at preventing infection and consequently reduces the long term risk of developing liver cancer 10-fold. For hepatitis C, we need to get as many people onto treatment as possible to reduce their risk of liver cancer,” Associate Professor Drummer said.
“A low cost, highly effective vaccine to prevent hepatitis C is urgently needed to prevent primary infection and reinfection in those who have already cleared virus with therapy.
“In low and middle income countries, without good harm reduction or a high prevalence of hepatitis C, we are unlikely to make an impact on the number of people living with hepatitis C with DAAs alone. We especially need a vaccine in these scenarios to significantly reduce the number of people living with HCV and prevent liver cancer”
Where to from here?
“It’s not necessary for anyone to die anymore from hepatitis B or C,” Burnet’s Deputy Director, Professor Margaret Hellard said in the closing statement.
“People need to be aware that they might be at risk and be tested. People with both diseases may not seek care and there’s a range of reasons why,” she said.
“There’s the issue of stigma - both internal and external. If we are not part of the affected community we can still provide care and support.
“The issue of blaming a patient or a health practitioner is not helpful. We are all in this together if we are to achieve elimination of hepatitis B and C as public health threats in Australia.”
Hepatitis C is a blood-borne infectious disease that mainly affects the liver. In Australia, 90 percent of new infections occur in people who inject drugs.
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