Alcohol Drugs and Hepatitis C, Brewing up a perfect storm COSLA Haymarket, Edinburgh 24 June 2015 Epidemiological overview Professor David Goldberg, Health Protection Scotland and GCU, Hamish Innes, GCU

Scotland’s Hepatitis C Action Plan AIM: Reduce HCV morbidity/mortality OBJECTIVE : Make Prevention/Diagnosis/Treatment Services Optimal INTERVENTION : £100 million additional investment SETTING : Scotland:5,000,000 :NHS since 1948 :GDP £23,000 POPULATION :38000 (0.8%) HCV infected (90% PWID) and those at risk of infection RESEARCH Q : What is the impact of the intervention and what are the lessons? APPROACH:Numerous Observational Studies

Scotland’s Hepatitis C Action Plan of Impact of Investment Scotland’s Hepatitis C Action Plan Evidence of Impact of Investment Category & Outcome Indicator Outcome New Intervention Prevention Transmissions/yr * Improved Harm Reduction Measures (esp. paraphernalia for PWID) Diagnosis % of Infected Population Diagnosed 39% 55% Awareness Raising Dried Blood Spot Testing Treatment Initiations/yr Workforce Development (esp. nurse specialists) Improved Access to Therapy Prevalence Numbers Infected Without Action Plan Coordination - ComprehensiveLocal & National Networks Evaluation: Monitoring/ Research Publications - Several published/ prepared Establishment of Research Team * Preliminary estimates: the reduction in transmissions are contemporaneous with, but not necessarily due to, the introduction of the stated new intervention

Number of people diagnosed with HCV (Ab+) and who had been hospitalised for the first time with severe liver morbidity* in Scotland * Relates to a primary or secondary ICD code of either ascites, hepatic encephalopathy, hepatic failure, hepatorenal syndrome, bleeding oesophageal varices or HCC. By Time since HCV diagnosis Update on HCV-related severe liver morbidity in Scotland

Estimates for Scotland, 2013 Estimates of HCV chronic population by disease stage 0 (N=10,300)

Hepatitis C Virus Infection and Alcohol: Challenges and Opportunities! What is the relationship between HCV infection and alcohol consumption, and what are the diagnostic implications? Does knowledge of one’s HCV status influence alcohol consumption? Can behavioural psycho-social interventions reduce alcohol intake in the HCV-infected person?

Hepatitis C Virus Infection and Alcohol: Challenges and Opportunities ! Is EAC a barrier to HCV-infected people getting into therapy? Does EAC impact on the effectiveness of HCV Therapy? Does HCV “cure” motivate people who drink excessively to reduce their intake?

Hepatitis C Virus Infection and Alcohol: Challenges and Opportunities! What do we know about the combined impact of Excessive Alcohol Consumption (EAC) and HCV Infection on liver disease progression? How important is it to understand the respective contributions of HCV and EAC when monitoring end-stage disease outcomes? Does EAC compromise the impact of SVR on liver disease progression?