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Hepatitis Treatment Services in London
Dr Ashley Brown
Imperial College Healthcare NHS Trust
HCV – The disease
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A blood-borne virus that targets the liver
Persistence of the virus leads to chronic inflammation
Over a period of 20-30 years, can lead to progressive fibrosis and ultimately
cirrhosis. This may be accelerated by concomitant alcohol misuse
In a proportion, will lead to liver failure, liver cancer, transplantation and
premature death
Few or no symptoms
The Facts
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Because it is a blood-borne virus, HCV
infection is common finding among IDU’s1
– At the first injection, 50% shared
preparation equipment;
– 22% borrowed and 26% lent injecting
equipment.
– 46% reported that they were HCVpositive
DBS testing for blood-borne viruses is now
common practice in DTU’s
1. Ann Med Interne (Paris). 2002 Jun;153(4):219-25
The Facts
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Because it is a bood born virus, HCV
infection is common finding among IDU’s1
– At the first injection, 50% shared
preparation equipment;
– 22% borrowed and 26% lent injecting
equipment.
– 46% reported that they were HCVpositive
DBS testing for blood-borne viruses is now
common practice in DTU’s
HOWEVER
• Not all IDU’s engage with DTU/substance misuse services
• Some service users decline testing
• Of those who test positive, few make it through to secondary care, and of
those who do, only a small number successfully complete antiviral therapy
• Many ex-users have disengaged with services and no longer consider
themselves at risk
1. Ann Med Interne (Paris). 2002 Jun;153(4):219-25
It’s not only intravenous drugs
Skin-popping
Contaminated ‘works’
Intranasal cocaine use
IM anabolic steroids
Treatment within Prisoners
• A significant proportion of IDU’s will spend
at least one period of imprisonment
• There is no universal screening programme
in prisons
• Equipment sharing is commonplace and
goes unmonitored
• Access to support, testing and treatment for
HCV within prisons is generally poor
HCV is a relatively new disease
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Harvey J Alter
First isolation of a cDNA clone from a blood-borne NANB
viral hepatitis genome1, and first assay for circulating
antibodies2 reported in 1989
Over the subsequent two decades there has been
significant advances in the treatment of hepatitis C
100%
90%
80%
70%
60%
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40%
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10%
0%
IFN Mono
IFN + RIBA
PEG Mono
PEG + RIBA
Genotype 1
Genotype 2&3
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Genotype 4
Choo et al, Science 1989 Apr 21;244(4902):359-62
Kuo et al., Science 1989 Apr 21;244(4902):362-4
The Cost of Treating HCV
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Treatment for HCV with pegylated Interferon and ribavirin has been shown
to be cost-effective1.
Treatment is approved by NICE and drug costs are reimbursable as a nonHRG cost from the PCT’s
1. Stein K, Rosenberg W, Wong J, Gut 2002;50:253-258
The Treatment
Treatment consists of a once-weekly selfadministered injection of peg-Interferon
together with twice daily ribavirin
Side-effects of treatment
• Peg-Interferon
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Flu-like symptoms.
Insomnia
Depression and mood changes
Nausea and vomiting
Skin rashes
Extreme tiredness
Anorexia and weight loss
• Ribavirin
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Anaemia
Headache, irritability and anxiety
Depression and suicidal ideation
Alopecia and pruritus
Insomnia
Arthralgia and myalgia
Anorexia, nausea and vomiting
Teratogenicity
Biopsy vs Fibroscan
• The requirement for liver biopsy has been perceived as a deterrent in the
past
• Development of new, non-invasive techniques for assessment of hepatic
fibrosis may prove a more acceptable option for many patients
Safety monitoring
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Regular monitoring of FBC is mandatory
as treatment can result in profound
anaemia (ribavirin), neutropaenia and
thrombocytopaenia (peg-interferon)
Many patients will have poor venous
access and/or needlephobia
Patients need a safe and clean
environment in which to inject peginterferon
Peg-interferon needs to be stored in the
refrigerator
The Cost of Treating HCV
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Treatment for HCV with pegylated Interferon and ribavirin has been shown
to be cost-effective1.
Treatment is approved by NICE and drug costs are reimbursable as a nonHRG cost from the PCT’s
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Drug costs alone
– 24 weeks of Peg-IFN + Ribavirin  £6,500
– 48 weeks of Peg-IFN + Ribavirin  £13,000
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Assuming an incidence in UK of 0.1%
– 60,000 people need treating
– = £8 billion
1. Stein K, Rosenberg W, Wong J, Gut 2002;50:253-258
The cost of NOT treating HCV
…and it’s all about to get much more
complicated!
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NS3/4A
Directly Acting Antivirals (DAA’s) when
used in combination with SOC offers the
possibility of increased cure rates and/or
reduced treatment duration
…and it’s all about to get much more
complicated!
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NS3/4A
Directly Acting Antivirals (DAA’s) when
used in combination with SOC offers the
possibility of increased cure rates and/or
reduced treatment duration
HOWEVER
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Side-effects are likely to increase
Costs have yet to be decided and may
be prohibitive
We are still some way off interferon-free
regimens
Importance of Adherence
SVR % (Number of Subjects)
PEG2b 1.5/R
(n=1019)
PEG2a/R
(n=1035)
n (%)
95% CI
n (%)
95% CI
Adherent: ≥ 80% of Both Drugsa
for ≥ 80% of Duration
70.0%
(319/456)
65.7, 74.2
61.4%
(324/528)
57.2, 65.5
Non adherent: <80% of Either Drug
for Subjects with Undetectable HCVRNA at TW 12 or TW 24, excluding
Treatment Failures
28.9%
(87/301)
23.8, 34.0
32.8%
(97/296)
27.4, 38.1
It’s a matter of teamwork!
The London Mosaic
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8 Mental Health Trusts
40+ substance misuse
services
6 prisons
31 PCT’s
43 NHS Trusts
7 Major HCV treatment units
plus a number of smaller
centres
A network of care?
Voluntary Sector
Secondary Care Trusts
Mental Health Trusts
Service User/Client/Patient
Primary Care Trust
Social Services
Not so much a network – more of a maze!
Voluntary Sector
Secondary Care Trusts
• Emotional support & counselling
• Advice and advocacy
• HCV treatment
• Liver services
Mental Health Trusts
• Substance misuse services
• Mental Health support
• Forensic psychiatry
• BBV nurses
Service User/Client/Patient
Primary Care Trust
• GP’s
• Methadone prescribing
• Referral to 2o care
• Associated health problems
• Prison healthcare
• Commissioning and budgets
Social Services
• Housing issues
• Benefits and DLA
• Asylum services
The solution
Thank You