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Treatment and access to treatment in low and middle income countries

ANRS-NIDA Joint Satellite Drug Use and HIV and HCV Infection: The Challenge and The Potential Solutions. Treatment and access to treatment in low and middle income countries. Adeeba Kamarulzaman University of Malaya Kuala Lumpur, Malaysia.

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Treatment and access to treatment in low and middle income countries

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  1. ANRS-NIDA Joint Satellite Drug Use and HIV and HCV Infection: The Challenge and The Potential Solutions Treatment and access to treatment in low and middle income countries AdeebaKamarulzaman University of Malaya Kuala Lumpur, Malaysia

  2. Global Estimates of HIV-Viral Hepatitis Coinfection

  3. HCV Prevalence in Asia, Africa and Eastern Europe • Dakar area – UDSEN study3 • est.sizeIVDUs: 1324 • P(HIV): 5,2% • P (HCV): 23,3% 1Madhava V. Lancet 2002. 2Nelson P, Lancet 2011. 3Ba I, ICASA 2012 7

  4. HCV Ab prevalence among people who inject drugs is high Source: Nelson PK et al. Global epidemiology of hepatitis B and hepatitis C and people who inject drugs. Lancet 2011: 278:571

  5. Estimating HIV Prevalence in Malaysia Method Multi-parameter evidence synthesis methods were applied to combine all available relevant data sources Results • An estimated 454,000 (95% [CrI]: 392,000 to 535,000) HCV Ab positive individuals were living in Malaysia in 2009 • 2.5% of the adult population • Route of probable transmission - active or a previous history of IDU • Females represented 1% (95% CrI: 0.6 to 1.4%) of all HCV infections, 92% (95% CrI: 88 to 95%) were attributable to non-drug injecting routes of transmission SA McDonald, A Kamarulzaman et al. Submitted for publication

  6. Liver-relateddeath: Leading cause of death in HIV-HCV patients 43 % 12 % 8 % 5 % 4 % 4 % 4 % 2 % 6 % 7 % Decompensatedcirrhosis HCC Post-transplantation Cirrhotic Patients: > 50% deathsrelated to HCV Non cirrhotic patients : 60% deaths non related to HCV nor HIV 1HSogni P. Conference on French HIV-HCV Consensus Guidelines, 2012 13

  7. ? 95-100% SVR 2014 90 2011 80 70 60 2002 50 % of patients with sustained virological response (SVR) 40 30 1999 20 10 PEG-IFN +RBV +new PI Telaprevir OrBoceprevir INF-freeregimens 12 weeks 0 IFN 24 W IFN +RBV 24 W IFN +RBV 48 W PEG-IFN +RBV 48 W IFN 48 W IFN = Interferon-α PEG-INF = Peg-Interferon-α RBV = Ribavirin PEG = PEG-IFN-α

  8. New Anti HCV Therapy • PHOTON 1 & 2 – Sofosbuvir + RBV • ERADICATE Study - Sofosbuvir + Ledipasvir • C-WORTHY Trial - PI MK-5172 + NS5A inhibitor MK-8742, with or without ribavirin • TURQUOISE 1 – ABT-450/r/Ombitasvir,Dasabuvir + RBV

  9. Estimated proportion of persons with chronic HCV receiving treatment in selected European countries in 2010 Treatment coverage remains very low, even in high-income countries Source: Razavi et al J Hepatol. 2013;58(Suppl 1):S22–3

  10. Estimated number of PLHIV and of people on ART in 10 countries in Asia-Pacific, 2012 A The range of uncertainty reflects the degree of uncertainty associated with estimates and defines the boundaries within which the actual numbers lie (see http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/ 2013/gr2013/20131118_Methodology.pdf, accessed 1 June 2014). Source: UNAIDS 2013, World Bank 2012) PLHIV=People living with HIV

  11. Number of people who inject drugs (PWID) on ART per 100 HIV+ PWID Less than 25% of HIV+ PWID are on ART in Asia and Pacific < 25 25-75 PWID present but ART program data not available Source: Beyrer, Baral No PWID reported > 75 PWID=people who inject drugs

  12. Multiple Barriers at Multiple Steps of the Continuum of Care Adaptedfrom G. Matthews

  13. Barriers to HCV Treatment in Low/Middle Income Countries • Lack of Awareness • Late Diagnosis • Poor Treatment Literacy • Multiple Comorbidities – TB • Lack of Access to OST • Limited Range of ARVs

  14. Treating HCV in Resource-Poor Settings CID 2012:54 (15 May) d 1465

  15. Lessons from HIV • Reducing Cost of Treatment • Simplifying Model of Care • Service Integration • Task Shifting • Surveillance, Evaluation and Research • Patient & Community Engagement • Political and Financial Commitment

  16. OvercomingProvider Barriers Rapid Testing1 - Point-of-care tests - Salivary rapid testing • Easier assessment of the infection • and the liver disease2 • Dry-blood spots (HCV viral load • quantification/genotyping) • - Portable Fibroscan (Echosens) • - Portable sonography • Mostlyunavailable in RLS 47 1Yaari A, J Viral Methods 2006. 2Tuaillon E, Hepatology 2010

  17. Overcoming the CostBarrier  History of HIV http://www.medicinespatentpool.org 48

  18. Viral Hepatitis

  19. Acknowledgements • Karine Lacombe, Inserm • Ying-Ru Lo, WPRO WHO • Joe Sasadeusz, Alfred Hospital, Melbourne

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