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HCV Elimination in Australia vs USA
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Download the PDF here
"Australia has had unrestricted government subsidised direct-acting antiviral therapy for HCV since March 2016. " http://www.natap.org/2019/EASL/EASL_114.htm
USA LAST IN WORLD in WHO HCV Elimination Track -
http://www.natap.org/2019/EASL/EASL_24.htm
HCV Elimination Off-Track WHO Targets/Countries Estimates - Global timing of hepatitis C virus elimination: estimating the year countries will achieve the World Health Organization elimination targets
Will hepatitis C transmission be eliminated by 2025 among HIV-positive men who have sex with men in Australia? http://www.natap.org/2018/IAC/IAC_108.htm
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HCV Elimination in Australia Where HCV Treatment is Unrestricted
Progress towards elimination of hepatitis C infection among people who inject drugs in Australia: The ETHOS Engage Study
Clinical Infectious Diseases - Heather Valerio,1 Maryam Alavi,1 David Silk,1 Carla Treloar,2 Marianne Martinello,1 Andrew Milat,3,4 Adrian Dunlop,5,6 Jo Holden,7 Charles Henderson,8 Janaki Amin, 1,9 Phillip Read, 1,10 Philippa Marks, 1 Louisa Degenhardt, 11 Jeremy Hayllar,12 David Reid,13 Carla Gorton,14 Thao Lam,15 Gregory J Dore1, and Jason Grebely1 on behalf of the ETHOS II Study Group
18 May 2020
In the context of HCV elimination, high treatment uptake across sub-populations was encouraging. These results highlight the successes of an unrestricted HCV treatment strategy in reaching marginalised populations of PWID and suggest progress towards achieving incidence-related HCV elimination targets. Although largely indicative of a good news story on the path towards elimination of HCV among PWID, challenges remain. It is imperative that innovative strategies and holistic approaches to improve linkage to HCV-related care are adopted to further enhance engagement with people living with HCV who may delay treatment for competing priorities. There is an urgent need for increased efforts to address the gaps in care highlighted here to ensure HCV elimination is equitable across all PWID in Australia and globally.
It is estimated that among the 93,500 people who have recently injected drugs in Australia, an estimated 37,500 are infected with HCV [2, 52]. As such, it will be critical to enhance efforts to engage with the most marginalised PWID sub-populations, including people who are homeless or incarcerated, to maintain this progress. To engage those who remain untreated and those who may require follow-up and retreatment, interventions which reduce barriers to testing and treatment
In this national, well-characterised sample of PWID attending drug treatment clinics and NSPs in Australia, 24% were currently infected with HCV and 66% of people who had previous chronic or current HCV infection had ever received HCV treatment. Indicators of higher marginalisation were negatively associated with HCV treatment, and positively associated with current HCV infection. This study provides important insight into the impact of unrestricted DAA access and will inform policies and targeted strategies to further facilitate HCV elimination in Australia and globally.
Current HCV infection was higher (31%) in participants who reported ≥daily injecting drug use. Given the potential for HCV treatment to prevent onward transmission of infection [5, 19], treatment scale-up among people with frequent injecting drug use combined with harm reduction (OAT and NSP) will be critical for HCV elimination, particularly in countries where the majority of new infections occur among PWID. Enhanced support within low-threshold and targeted primary health settings, including individualised, tailored adherence support and peer-to-peer education and has been positively associated with treatment uptake and adherence among people with frequent injecting drug use [20-24]. These strategies should be explored in the context of HCV treatment as prevention.
people who frequently inject drugs are more likely to experience barriers to healthcare access due to discrimination. Participants who were homeless were more likely to have current HCV infection and less likely to report HCV treatment.
1,468 participants in ETHOS Engage . Among all participants (n=1,443), 1,388 (96%) had valid Xpert Viral Load Fingerstick point-of-care results. Among those with valid results, 24% (n=331) were currently infected with HCV (HCV RNA detectable). In adjusted analyses, factors associated with current HCV infection included homelessness (aOR: 1.47, 95%CI: 1.00, 2.16), incarceration history (vs. never, >1 year ago: aOR: 1.79, 95%CI: 1.30, 2.45; within the last year: aOR: 2.03, 95%CI: 1.38, 3.01), and ≥daily injecting drug use (aOR: 2.29, 95%CI: 1.45 – 3.62) (Table 3). In adjusted analyses among people with injecting drug use in the previous month, factors associated with current HCV infection were unchanged (Supplementary Table 4). Overall, 55% (n=788) of participants had evidence of previous chronic (n=457) or current HCV infection (n=331). Among these (n=788, 55%; Table 3, Supplementary Figure 1), 66% (n=520) had self-reported ever initiating HCV treatment. (Table 2). The majority (85%) had initiated treatment in the DAA era (2016-2018) and 31% (n=162) reported receiving HCV treatment at a drug treatment clinic, 28% (n=148) from a hospital-based specialist clinic, 19% (n=100) from a general practitioner, 16% (n=85) in prison, 3% (n=14) within other community-based clinics, and 2% (n=9) within a NSP. In adjusted analyses, HCV treatment was less likely among females (aOR: 0.68, 95% CI: 0.48, 0.96), people who were homeless (aOR: 0.59, 95% CI: 0.36, 0.96), and people with ≥daily injecting drug use (vs. no injecting in last year, aOR: 0.51, 95%CI: 0.30, 0.86).
ETHOS Engage is an observational cohort study. Participants were enrolled between 28 May 2018 and 06 September 2019 from 25 sites, including opioid agonist therapy (OAT) clinics (n=21) and NSPs (n=4); in New South Wales (n=17), Queensland (n=4), South Australia (n=2) and Western Australia (n=2). .....Since March 2016, adults infected with HCV have access to government reimbursed direct-acting antiviral (DAA) therapy with no drug, alcohol, or fibrosis stage restrictions [8]. This public health approach in the provision of unrestricted DAA therapy.....ETHOS Engage was advertised in the weeks preceding recruitment with posters, information cards distributed with injecting equipment, and word of mouth. Recruitment spanned two to five days at each site. Peer-support workers were on-site encouraging participation.
Median age was 43 (IQR: 37, 50), 65% (n=932) were male, 74% (n=1,070) were receiving OAT, and methamphetamine was the commonest main drug injected (31%, n=449). Nearly two-thirds (64%) of participants injected drugs in the last month, and 30% ≥daily, (Table 1). Characteristics stratified by recent injecting drug use, OAT status, and gender are presented in Supplementary Tables 1, 2, and 3.
Conclusion: Unrestricted DAA access in Australia has yielded high treatment uptake among PWID attending drug treatment and NSPs, with a marked decline in HCV prevalence. To achieve elimination, PWID with greater marginalisation may require additional support and tailored strategies to enhance treatment.
Summary: Among this population of people who inject drugs in Australia, 24% were currently infected with hepatitis C virus. Of those who were ever infected,
66% had received treatment. Enhancing treatment uptake in key subpopulations is required to achieve elimination.
Despite favourable treatment outcomes among PWID [6], system, societal, provider, and individual barriers persist and hinder optimal HCV care [7].
Since March 2016, adults infected with HCV have access to government reimbursed direct-acting antiviral (DAA) therapy with no drug, alcohol, or fibrosis stage restrictions [8]. This public health approach in the provision of unrestricted DAA therapy engendered one of the highest HCV treatment uptakes globally, with Australia named as one of few countries on track to achieve the WHO target of reducing new infections by 2030 [9, 10].
This study evaluated progress towards HCV elimination among PWID in Australia among a large, national cohort of PWID recruited from drug treatment and needle and syringe programs (NSPs) during an unrestricted HCV treatment era. The primary aim of this study was to evaluate the proportion of people with current HCV infection and associated factors. A secondary aim was to evaluate the proportion of people who had received HCV treatment and associated factors.
Abstract
Background & Aims
Evaluating progress towards HCV elimination is critical. This study estimated prevalence of current HCV infection and HCV treatment uptake among people who inject drugs (PWID) in Australia.
Methods
ETHOS Engage is an observational study of PWID attending drug treatment clinics and needle and syringe programs (NSP). Participants completed a questionnaire including self-reported treatment history and underwent point-of-care HCV RNA testing (Xpert® HCV Viral Load Fingerstick).
Results
Between May 2018-September 2019, 1,443 participants were enrolled (64% injected drugs in the last month, 74% receiving opioid agonist therapy [OAT]).
HCV infection status was uninfected (28%), spontaneous clearance (16%), treatment-induced clearance (32%), and current infection (24%).
Current HCV was more likely among people who were homeless (adjusted odds ratio: 1.47; 95%CI: 1.00, 2.16), incarcerated in previous year (2.04; 1.38, 3.02), and those injecting drugs ≥daily (2.26; 1.43, 2.42). Among those with previous chronic or current HCV, 66% (n=520/788) reported HCV treatment. In adjusted analysis, HCV treatment was lower among females (0.68; 0.48, 0.95), participants who were homeless (0.59; 0.38, 0.96), and those injecting ≥daily (0.51; 0.31, 0.89). People aged ≥45 (1.46; 1.06, 2.01) and people receiving OAT (2.62; 1.52, 4.51) were more likely to report HCV treatment.
Conclusions
Unrestricted DAA access in Australia has yielded high treatment uptake among PWID attending drug treatment and NSPs, with a marked decline in HCV prevalence. To achieve elimination, PWID with greater marginalisation may require additional support and tailored strategies to enhance treatment.
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