1. No one gets left behind: Addressing the hidden burden of hepatitis C related advanced liver disease in PWID in the community John S Lambert, MD, PhD Professor of Medicine and Consultant Infectious Diseases, Dublin, Ireland
Session organized by

2. Nothing to disclaim
This meeting is part of the joint action ‘ / HA-REACT,’ which has received funding from the European Union’s Health Programme ( ).

3. HCV in Ireland 30,000 in Ireland with HCV
Ireland has ‘ringfenced’ 30M annually for tx
Ireland one of first to sign EU manifesto, ‘HCV elimination by 2030’
2000 have been treated to date with new DAAs
9000 are in OST of whom 60% are HCV positive
850 HCV are on the ‘waiting list’ of the 9 ‘treating hospital centres’ in Ireland
Fibroscan has replaced liver biopsy to assess degree of liver disease
HCV clinical lead June 2016 ‘all cirrhotics are treated’

4. WHO strategy comes with targets, by 2030
Incidence targets
30% reduction in new HCV infections by 2020
90% reduction in new HCV infections by 2030
Mortality targets
10% reduction in mortality by 2020
65% reduction in mortality by 2030
Harm reduction
Increase in sterile needle and syringes provided per PWID/year from 20 in 2015 to: 200 by 2020 and 300 by 2030
Testing targets
90% of people aware of HCV infection by 2030
Treatment targets
80% of people treated by 2030

5. HEPCARE: A new Hepatitis C Care service model
VISION:
Create an innovative, integrated system for HCV treatment, based on the joint participation of primary and speciality care practitioners
OBJECTIVE:
Improve access to HCV testing and treatment among key risk groups, including drug users and homeless, through outreach to the community and integration of primary and secondary care services
Primary Care
Secondary care
WP4: HepCheck (screening)
WP5: HepLink (linkage to care)
WP 7: HepFriend
(peer advocacy support)
WP 6: HepED
(inter-professional education)
WP8: HepCost WP 1 Coordination; WP 2 Dissemination; WP3 Evaluation
HEPCARE EUROPE is a €1.8M 3-year EU-supported project at 4 member state sites
Consortium members: UCD (Ireland); SAS (Spain); SVB (Romania); University of Bristol (UK); University College London (UK)

6. Seek and Treat Community Fibroscan Project:
In Ireland there are large numbers of hepatitis C (HCV) positive patients receiving methadone substitution therapy in drug treatment centre (DTCs) and in GP OST prescribing practices who do not attend specialist hepatology or infectious diseases services.
Fibroscan™ (FS) used to assess the liver stiffness.
Three clinically relevant cut-offs are used for disease staging.
8.5 kPa, which allowed access to direct acting antivirals (DAAs) in Ireland before Feb 2017.
25kPa , which has a 90% positive predictive value for clinically significant portal hypertension.
35kPa, which is associated with a 10-20% risk of decompensation per year.

7. HepLink Study: Methods
Methadone prescribing GP practices in North Dublin were recruited from the professional networks / databases of the research team
Patients were eligible to participate if:
≥ 18 years of age
on MMT
attend the practice for any reason during the recruitment period
Baseline data on HCV care processes / outcomes were extracted from the clinical records of participating patients

8. Practice Flow Patient Flow
GP Practices recruited n=14
Patients recruited n= (14 practices)
Baseline Data Collected n= (14 practices)
GP Practices received HepLink intervention n=14
OST patients assessed by Nurse n=100
HCV positive patients undergone fibroscan n=45
Patients referred to secondary care n=21 8

9. Fibroscan Results
The integrated model of HCV care has been piloted in 14 practices
45 HCV Ab+ patients have undergone a fibroscan
21/45 (46.7%) scored ≥8.5 kPa
13/45 (28.9%) were cirrhotic, i.e. scored > 12.5 kPa 9

10. ‘Seek and Treat’ (6 DTC N Dublin)
Hidden burden of HCV: Results (1)
‘Seek and Treat’ (6 DTC N Dublin)
Total assessed (618)
75% male, mean age 38 ±7.2
HCV status known
(561)
HCV positive
(391)
Mean FS 11
Alcohol consumption
(136)
Mean FS 13.2
Abstinent
(255)
Mean FS 9.7
HCV negative
(170)
Mean FS 5.6
HCV status unknown
(57)
P = 0.001
P = 0.02

11. Hidden burden of HCV: Results (2)
391
HCV positive
128
FS ≥8.5 kPa 34
FS ≥25 21
FS ≥35

12. Summary of ‘Seek and Treat’
Hidden burden of HCV: Conclusions
Summary of ‘Seek and Treat’
A large number of HCV+ patients did not attend specialist infectious diseases/hepatology services yet qualified for DAA treatment.
Within this group there were significant numbers of patients at high risk of decompensation.
On-going alcohol use was associated with a significantly higher FS score.
While these patients may have significant comorbidities, including addiction, which limits access to specialist hospital services

13. Summary of HepCare Europe Dublin:
We have performed pilot community ‘Seek and Treat’ studies, and estimate there are at least 2200 out there in the community with significant liver disease due to HCV not accessing care
HepCare Europe is establishing a model for partnering the community with the hospital services
Patients do not attend the hospital for HCV care: go to them
The process of ‘HCV viral elimination by 2030’ in Ireland will require a new model of care, and new ways to find patients at risk.
The DAAs are safe and efficacious and can be delivered safely in the community

14. Acknowledgements
Co-funded by the European Commission through its EU Third Health Programme and Ireland’s Health Services Executive
Participating GPs, Addiction Services, and patients
Our partners: UCL, Bucharest, U Bristol, SAS Seville

15. Action plan for the health sector response to viral hepatitis
Transmission of new viral hepatitis infections is halted, testing is accessible, and people living with chronic viral hepatitis have access to care and affordable and effective treatment
2030 Vision
Elimination of viral hepatitis as a public health threat by 2030 through:
reduction of transmission
reduction in morbidity and mortality
ensuring equitable access
2030 Goal
Frameworks for action: universal health coverage, the continuum of services, a public health approach
The vision is a WHO European Region in which the transmission of new viral hepatitis infections is halted, testing is accessible, and people living with chronic viral hepatitis have access to care and affordable and effective treatment.
Our goal is aligned with the global goal of elimination of viral hepatitis as a public health threat by 2030 through:
- reduction of transmission;
- reduction in morbidity and mortality due to viral hepatitis and its complications;
- ensuring equitable access to comprehensive prevention, and recommended testing, care and treatment services for all.
The Action plan is built on three organizing frameworks for action: universal health coverage; the continuum of services; and the promotion of a public health approach.