Micro-elimination. A path to global elimination of hepatitis C. Prof Jeffrey V. Lazarus

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1 Micro-elimination A path to global elimination of hepatitis C Prof Jeffrey V. Lazarus [Jeffrey.Lazarus@isglobal.org] Associate Researcher/Assoc Professor, ISGlobal, Hospital Clínic, University of Barcelona CHIP, Rigshospitalet, University of Copenhagen, WHO Collaborating Centre on HIV and Viral Hepatitis 1 - Hep-Micro-elim 2017

2 Meeting two types of challenges Biomedical Public health Hepatitis C DAA breakthrough: 2013 Access Coverage ELIMINATION 2 - Hep-Micro-elim 2017

3 Elimination is Daunting Cost of implementing the WHO global health sector strategy on viral hepatitis, Challenging Costly Complex 3 - Hep-Micro-elim 2017

4 Micro-Elimination A New Concept? When eating an elephant take one bite at a time - Creighton Abrams (US General) 4 - Hep-Micro-elim 2017

5 Micro-Elimination in Other Infectious Disease Polio Countries Regions HIV PMTCT Fast-track cities 5 - Hep-Micro-elim 2017

6 HCV (micro-) elimination in certain populations is feasible in the short-tomedium term Decompensated cirrhotics Veterans Patients with haemophilia Transplant patients PWID, prisoners HIV/HCV co-infected 6 - Hep-Micro-elim 2017 Source: Lazarus JV, Wiktor SZ, Colombo M, Thursz M. Micro-elimination a path to global elimination of hepatitis C. Journal of Hepatology, July 2017.

7 Eliminate late presentation Source: Mauss et al. BMC Med, Hep-Micro-elim 2017

8 Haemophilia Source: Irish Examiner, 22 Dec Source: Department of Health, 22 Dec Hep-Micro-elim 2017

9 Advantages of Micro-Elimination Realistic targets/goals Pragmatic Time to achievement is shorter Tailored strategy Cost can be predicted Prevention of re-infection in a target group Micro-elimination projects may generate a template in a small geographically-defined population which may then be used to model services for larger intervention programmes Micro-elimination could address low-hanging fruit, which would encourage further public health efforts 9 - Hep-Micro-elim 2017

10 Every country needs a bespoke strategy to reduce disease burden and eliminate HCV Public health threat 2. Treat high incidence Prevent new infections, contain the epidemic 3. Non-PWID screening and treatment Elimination Burden of disease threat 1. Treat F3/F4 patients Prevent mortality and morbidity High incidence population Slow progression population Advanced population Risk of onward transmission Risk of mortality and morbidity F0 F1 F2 F3 F4 One approach does not fit all Context matters! 10 - Hep-Micro-elim 2017 Source: Grebely et al. Elimination of Hepatitis C Virus Infection Among People Who Inject Drugs Through Treatment as Prevention: Feasibility and Future Requirements. CID 2013.

11 WHO Global Health Sector Strategy on Viral Hepatitis May 2016: The first of its kind, WHO publishes a global strategy aiming for elimination of viral hepatitis as a public health threat by 2030 Source: WHO Global Health Sector Strategy on viral hepatitis. Available at: (Accessed August 2016) 11 - Hep-Micro-elim 2017

12 Global Health Sector Strategy HCV targets at a glance Incidence targets 30% reduction in new HCV infections by % reduction in new HCV infections by 2030 Mortality targets 10% reduction in mortality by % reduction in mortality by 2030 Harm reduction Increase in sterile needle and syringes provided per PWID/year from 20 in 2015 to: 200 by by 2030 Testing targets 90% of people aware of HCV infection by 2030 Treatment targets 80% of people treated by 2030 Source: WHO GHSS. (Accessed August 2016) Hep-Micro-elim 2017

13 The global cascade of care for chronic HCV infection in 2015 Adapted by Macmillan Publishers Ltd, part of Springer Nature with permission, from Global Hepatitis Report, 2017, World Health Organization, page 30, figure 8, Source: Lazarus JV. et al. Many European countries flying blind in their efforts to eliminate viral hepatitis. Nat. Rev. Gastroenterol. Hepatol. doi: /nrgastro Hep-Micro-elim 2017

14 The continuum of viral hepatitis services and the retention cascade Source: WHO Global Hepatitis Report, Available at (accessed May 2017) Hep-Micro-elim 2017

15 People-centred health systems See: Hep-Micro-elim 2017

16 A people-centred health system for hepatitis elimination Effective surveillance/monitoring of loss to follow up? National strategy/plan incl stakeholder input eg patients, risk groups, clinicians? Strategies for engaging eg key affected populations? Workforce needed to achieve elimination? Capacity to monitor disease progression? Budget for provision of testing & treatment? 16 - Hep-Micro-elim 2017

17 Table 1. Target populations for microelimination of hepatitis C in X Sub-group Estimated or reported # of chronically HCVinfected people Children (under age 15) 35 Coinfected with HIV 423 Generational cohorts of high No data prevalence (born ) Haemodialysis patients 67 Haemophilia patients Men who have sex with men No national data; 19 at one site No data Migrants from high-prevalence 12,607 countries Patients with advanced liver 56,340 (0.57%) including (19.4%) F3 and disease (9.2%) F4 People who inject drugs 5,743 Prisoners 1, Hep-Micro-elim 2017 Transplant patients No national data; 9 at one site Source: Lazarus et al. In press 2018

18 Some countries may achieve the WHO targets by or even before 2030 Iceland Georgia Australia National plan to treat all HCV patients according to Icelandic guidelines over 3 years Prioritisation of active PWID and patients with moderate-to-severe fibrosis Jan to Dec 2016, 1/3 of the HCV population were treated Georgia HCV Elimination Program Prioritisation of patients with advanced liver disease April 2015 to April 2016, 8448 people treated, a 400% increase in the number patients treated over the previous 4 years Public health policy 2016, 15% (33,560 patients) of the HCV population were treated No disease stage restrictions No drug or alcohol use restrictions GPs can prescribe Sources: Gottfredsson F, et al. HIV and Hepatitis Nordic Conference 2016; Abstract #O5; Gvinjilia L, et al. MMWR 2016;65:1132 5; Monitoring hepatitis C treatment uptake in Australia. Issue #5, September Available at: (accessed Aug 2017) 18 - Hep-Micro-elim 2017

19 International Viral Hepatitis Elimination Meeting 2018 Est Nov 2017 Price BREAKING NEWS--? is the first country to eliminate hepatitis C among? 19 - Hep-Micro-elim 2017

20 Some questions to discuss What is micro-elimination and why is it important? What examples of successful micro-elimination exist? Why focus on a micro-elimination endeavor rather than a larger elimination goal? How does micro-elimination inform a larger elimination project? How do you prioritize a micro-elimination project within a larger elimination goal? For example, do you eliminate HCV in a subset of a population that contributes to incidence increases? Or do you focus on a subset of a population who is at greatest risk of mortality or morbidity from HCV? 20 - Hep-Micro-elim 2017

21 Acknowledgements The EASL International Liver Foundation and in particular Massimo Colombo, Mark Thursz, Stefan Wiktor Kelly Safreed-Harmon, ISGlobal, Hospital Clínic Contact: 21 - Hep-Micro-elim 2017