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How aspirations can be built and levels of performance can be assured: Learning from the Scottish Action Plan Professor Sharon Hutchinson LJWG LDAPF Conference Hepatitis C in London – practical steps to elimination London, 17th November 2014 Scotland’s Hepatitis C Action Plan Aims To prevent the spread of Hepatitis C, particularly among people who inject drugs (PWID) To diagnose Hepatitis C infected persons, particularly those who would most benefit from treatment To ensure that those infected receive optimal treatment, care and support Scotland’s Hepatitis C Action Plan Phase I 2006-08 The Business Case Phase II 2008-11 Investment to improve services Phase III 2011-15 Continuing investment Phase IV 2015-20 ??? Phase I: Key evidence Hepatitis C Landscape in Scotland, 2006 Estimates 0 20,000 40,000 38,000 Living with Chronic Infection Ever injected drugs Diagnosed (ever) Attended clinic (in 2006) 34,000 14,500 (38% of chronics) 3,500 (9% of chronics) Started Treatment (in 2006) 450 (1% of chronics) Phase I: Key evidence Projected number of PWID (ever injected) in Scotland developing liver failure each year with different Rx rates Increasing uptake of 150 antiviral therapy to 2,000 per year could prevent in N 100 excess of 5,000 cirrhosis Uptake of HCV Rx: 225 PWID per year 50 1,000 PWID per year 2,000 PWID per year 0 2010 2020 2030 cases (incl. 2,700 liver failures) during 2008-30 Scotland’s Hepatitis C Action Plan Phase I 2006-08 The Business Case Phase II 2008-11 Investment to improve services Phase III 2011-15 Continuing investment Phase IV 2015-20 ??? Phase II: Principles & Characteristics Based on extensive evidence base & consultation process Involved high level actions Adopted multidisciplinary approach Strong governance / clear accountability Leadership (e.g. national coordination lead by HPS) Agreed outcomes / performance monitored (e.g. targets on treatment) Good coordination/communication (e.g. national / local networks) Supported by serious investment (£100million during 2008-15) Phase II: Key Actions Prevention : Improvements in Injection Equipment Provision Diagnosis : Awareness raising initiatives : Finger prick sampling in non-clinical settings Treatment : Increase in clinical capacity : Funding for treatment and national procurement of antiviral therapy Prevention of Infection in Scotland: Progress Provision of Key Interventions to PWID Year 2008/09 2011/12 Incidence of HCV infection among PWID in Scotland (derived from PCR data) 25% 20% Needles/syringes (N/S) distributed 4.4 million 4.7 million Paraphernalia* distributed 0.4 million 2.5 million 10% On methadone 50% 64% 5% Initiated on HCV therapy among PWID <30 yrs ~50 ~100 0% * Cookers/Filters 15% 2008/09 * 2010 2011/12 2013 Palmateer et al; PloS One, 2014 (plus updated data for 2013) Progress In Drug Services Number of new HCV diagnoses per year in Scotland Dried Blood Spot Testing 2,000 (introduced into drug services during 2009) N 1,500 1,000 0 2004 2006 2008 2010 2012 Pre Phase I Phase II onwards % Infected Popln diagnosed 100 80 60 40 20 0 2000 1000 800 600 400 200 0 1500 1000 500 0 1999 2001 2003 2005 2007 2009 2011 500 % (Scotland’s 4 largest NHS Boards) Tested 2,500 Number of people tested for HCV in drug services Tested Positive Diagnosis: Overall Progress 2005 Scotland: Estimated: 2006-13 Projected: 2014-25 2010 2015 Year 2020 2025 Drug services referred 16% of new HCV diagnoses in Scotland during 2009-13 (McLeod et al. JECH 2014) International Context Sweden France Denmark Germany Scotland Belgium Spain Switzerland Austria England Portugal Czech Repub 0 10 20 30 40 50 60 70 80 90 100 Estimated % infected popln diagnosed Razavi et al. J Viral Hepat. 2014 Scotland’s Hepatitis C Action Plan Phase I 2006-08 The Business Case Phase II 2008-11 Investment to improve services Phase III 2011-15 Continuing investment Phase IV 2015-20 ??? Phase IV Government is supportive Principles for HCV diagnosis and treatment in Scotland, in the context of the new highly effective therapies, to be published in 2015 Modelled incidence of HCV-related (i) Severe Liver Morbidity and (ii) chronic infection in Scotland, according to different treatment strategies and 2,000 treated per year (Innes et al. Gut 2014) (i) Severe Liver Morbidity (ii) New infection 600 Incident cases Incident cases 200 160 120 80 500 400 300 200 100 40 2010 IFN-free therapy 2015 2020 2025 Status-Quo 0 2030 IFN-free therapy 2010 2015 2020 Target Advanced Fibrosis (40%60%) 2025 2030 Target Active PWID (13% 33%) Aim going forward in Scotland To rapidly control the number of people who develop HCV related liver failure and/or hepatocellular carcinoma and the number of people who die from HCV related disease