Integrating hepatitis C treatment in a regional setting The Cairns Experience. DANA 2018 Morag Goodinson

Transcription

1 Integrating hepatitis C treatment in a regional setting The Cairns Experience DANA 2018 Morag Goodinson

2 I would like to acknowledge the Traditional Owners of the land, and pay respect to Elders past, present and future.

3 Disclosures Support to attend training and conferences - Gilead Sciences Payment ( to CHAT) for participation in market research - AbbVie

4 Hepatitis C Liver disease caused by the hepatitis C virus Transmitted by exposure to infected blood Estimated 71 million people affected globally Acute infection is usually asymptomatic 25% of people will clear the virus spontaneously Significant numbers of people with chronic HCV will develop cirrhosis or liver cancer There is no vaccine - The majority of new infections are attributable to injection drug use - Sharing or reusing other peoples needles and syringes or injecting equipment - Over 50% of people entering OST programs have chronic HCV

5 In Australia Around Australians were living with chronic hepatitis C 50-60% prevalence in people accessing NSP 90 % of new infections are in people who inject or have a history of injecting Treatment uptake before the new DAAs was low Increasing morbidity over time had cirrhosis - over 600 people died each year The focus of local A&D services was on preventing new infections, testing and slowing disease progression

6 The arrival of the Direct-acting antivirals 2014 The new generation treatments are far more effective, easier to take and have fewer side-effects than the older medications. Can cure more than 95% of infections Target the HCV lifecycle and disrupt viral replication For most people 1-2 tablets once per day for 12 weeks Available in Australia - In clinical trials - Compassionate access Added to the WHO Model list of essential medicines

7 While we were waiting for PBS listing

8 Then. December 20 th 2015 : the Federal Government announced unrestricted access to the new DAAs on the PBS from March 1 st 2016

9 World Health Organisation Elimination of Hepatitis C as a major public health threat By % of people treated 80 % reduction in the spread of the virus

10 Cairns Hep-C Free by 2020 Campaign The Collaborators Cairns sexual Health Service Liver Clinic Prison ATODS Rural and Remote services General practice Community (CHAT) Local pharmacy

11 Cairns Hep-C Free by 2020 Increase community awareness Newspapers : radio (CHAT) Education sessions - General Practice - ATODS - Sexual Health Access to fibroscan machines ( CSHS) Trained fibroscan operators Developed local pathways to treatment

12 Cairns ATODS Engaging leaders : - Harm minimisation philosophy - treatment as prevention Raising awareness - NSP - Education and information - On site screening Fibroscan clinics Treatment via OST Case finding via hospital CL service Referral to partners - GP - Liver clinic ( cirrhotic patients) - Sexual health

13 From living with HCV to Cure

14 Stage matched intervention Pre contemplation Contemplation Preparation Action & Maintenance Information Raise awareness Lifestyle issues Harm minimisation Relationship building Motivational interviewing Raise importance Build confidence Goal setting Highlight barriers Logistics Identify supports Problem solving Managing adherence Managing side effects Lost scripts / missed doses

15 Education and Information Information on the new treatments Emphasising the difference from interferon regimens - Tolerability - Minimal drug Interactions - Costs and access Acknowledge possibility of treatment failure there can be other options

16 Barriers to treatment It won t happen to me! I guess I harboured that very human delusion and simply thought that it wouldn t happen to me to someone else perhaps, but not me I ve got plenty of time I was too busy (for treatment) I don t drink! They wont be able to get blood Telling Irony at the Heart The Thoughts of Jenny Kelsall

17 Addressing barriers to treatment Offer treatment at the AOD clinic - Prescribe in collaboration with specialists reduce need to refer on Difficult veins - Use pathology with ultrasound - Onsite blood tests and standing orders for testing ( allows for opportunistic testing) - Bleed once only Disease staging - Onsite fibroscan - APRI scores as an alternative Collaboration with pharmacies to support adherence - Checking supply - Webster packs - Daily dosing with OST? - Prescription posted to pharmacy? Consultation with specialists and other providers - Sharing information : reduce duplication of testing Enlist Peer support

18 Checklist -Planning for treatment Check HCV genotype viral load and baseline screening Assess liver fibrosis /cirrhosis Detect other causes of liver disease Viral co-infection ( HIV / HBV) Alcohol intake Fatty liver Check for other co-morbidities Renal impairment mental health Review previous treatment Check for drug interactions Contraception / pregnancy Consider barriers / challenges to adherence

19 Bleed once only communicate results sensitively and accurately The Antibody (Ab) test A positive HCV Ab result only indicates that the person has been exposed to the virus at Some point in their life. Does the person currently have HCV? The RNA Test - Genotype - Viral load General Liver health - LFT and FBC ( APRI score) Test for co infection - HBV - HIV

20 Disease staging Feedback from Fibroscan

21 Disease Staging APRI scores

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23 People treated in the first 12 months Liver Clinic (Cairns Hospital) 500 Sexual Health Clinic 125 Prisoners (Lotus Glen Correctional Centre)100 Opiate substitution therapy (ATODS) 30 Remote Far North Qld 50 General practice (solely) 100 Darren Russel CSHS

24 Lessons Learned A small group of committed people can make a big difference to patient outcomes Providing accessible HCV treatment in AOD services is acceptable to patients We can all influence change It starts with us People prefer a one stop shop where possible - Sexual health - ATODS Engage local GPs to improve overall health care Engage the community - CHAT To sustain change :- Take the whole team along Integrate testing and treatment into standard care Monitor progress

25 12 months on We can say that virtually all the people in Cairns and surrounds - and further north - who know they have hepatitis C and want treatment, have been treated ( Darren Russel Cairns Sexual Health Service ) We can probably say that most people on OST who know they have hepatitis C and want treatment, have been treated

26 Cairns ATODS - Dr Greg Spice - Luke Carroll - Sarah Rogers - Gulliver Welch Cairns Hepatitis Action Team : CHAT Acknowledgements Cairns sexual Health service - Rhondda Lewis - Darren Russel Cairns Liver Clinic - Penny Fox Cairns Hospital - Dr Josh Hanson Hepatitis Queensland

27 What's New Simplified treatment regimens - Pan genotype treatments Increased pool of prescribers - Nurse Practitioners Potential for point of care testing

28 Keeping up the momentum in Australia More than 30,000 people were treated in the first year Very high cure rates - Including people who inject drugs Reduced uptake in the last 12 months - Need to treat 20,000 per year to keep on target Ongoing targeting of at risk populations is needed to keep on track - Prisons - People who inject drugs - OST programs More inclusive GP screening is warranted - the majority of people living with chronic HCV have never injected a drug or if they did it was a long time ago

29 Ramping up the Cairns campaign? Raising awareness in the general community old school advertising Re focus on testing Brief Interventions - FRAMES Opportunistic fibroscanning Expand prescribing to general ATODS clients - Expand Nurse practitioner prescribing More staff training Access young injectors Access people not engaged with ATODS - in hospital and Emergency Department

30 Educate patients about re-infection Treatment does not provide immunity Reminders about HCV transmission Treatment of injecting partners Encourage retesting annually Harm reduction programs Re-treatment is possible

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33 It starts with us! Give Hep C the Boot

34 Training Resources

35 Resources