Hepatitis C: Reducing Incidence Brian R. Edlin, MD, FACP, FIDSA Senior Principal Investigator National Development and Research Institutes Associate Professor of Medicine Weill Cornell Medical College New York, New York National Summit to Improve Access to HCV Testing, Treatment, and Cure Centers for Disease Control and Prevention Atlanta, GA June 17-18, 2014 `
Hepatitis C Control Pillars of Disease Control Epidemiology Prevention Testing Treatment Surveillance Research
Hepatitis C Control National Summit to Improve HCV Testing, Treatment, and Cure Epidemiology Prevention Testing Treatment Surveillance Research
Hepatitis C Control National Summit to Improve HCV Testing, Treatment, and Cure Epidemiology Prevention Testing Treatment Surveillance Research
People Who Inject Drugs: the Core of the Hepatitis C Epidemic Largest group of infected persons Source of most HCV transmission Highest prevalence (50%-90%) Highest incidence (10%-40% per year) Approx. one million people who inject drugs in U.S. have hepatitis C. Few people who inject drugs are in care; even fewer receive treatment.
Effective HCV Prevention Interventions Community-Based Outreach Education Sterile Syringe Access Voluntary Testing and Counseling Treatment for Substance Use
HCV Antibody Prevalence, Urban Health Study, San Francisco, 1987 Percent anti-hcv positive 100 50 Year of Testing 1987 0 0 1 2 3 4 5 Duration of Injection Drug Use (Years) Lorvick Am J Public Health 2001;91:46-7.
HCV Antibody Prevalence, Urban Health Study, San Francisco, 1987 Percent anti-hcv positive 100 50 Year of Testing 1987 Prevalence > 80% after 1 year of injecting Incidence = 15 per 100 person-months 0 0 1 2 3 4 5 Duration of Injection Drug Use (Years) Lorvick Am J Public Health 2001;91:46-7.
HCV Antibody Prevalence, Urban Health Study, San Francisco Bay Area, 1987, 1998-2001 100 Percent anti-hcv positive 50 Year of Testing 1987 1998-2001 0 0 1 2 3 4 5 Duration of Injection Drug Use (Years) Lorvick Am J Public Health 2001;91:46-7, Tseng Hepatology 2007;46:666-71
Changing Risk of Acquiring HCV Infection, Street- Recruited PWIDs, San Francisco, 1990-2000 Odds Ratio Bacchetti BMC Infect Dis 2007; 7:145 Year
HCV Antibody Prevalence, Street-Recruited People Who Inject Drugs, New York, 2005-2012 Percent anti-hcv positive 100 50 Swan Project 0 <1 1 2 3 4 5 6-10 11-14 15+ Duration of Injection Drug Use (Years)
HCV Prevalence among Young People Who Inject Drugs Author Location Study Year Time to 50% Prevalence Garfein Baltimore REACH 1988 <1 year Lorvick San Francisco UHS 1987 <1 year Thorpe Chicago CIDUS 2000 7 years Diaz New York CIDUS 2001 4 years Hahn San Francisco UFO 2001 5 years Garfein Am J Public Health 1996;86:655. Lorvick Am J Public Health 2001;91:46. Thorpe J Infect Dis 2000;182:1588. Diaz Am J Public Health 2001;91:23. Hahn Hepatology 2001;34:180.
Effect of HIV Prevention Interventions on HCV Transmission 1980 s: 80% infected/6-8 mos. = 15%-20%/month 1990 s and 2000 s: 10%-25%/year Edlin Nature 2011; 474: S18-9
Effect of HIV Prevention Interventions on HCV Transmission 1980 s: 80% infected/6-8 mos. = 15%-20%/month 1990 s and 2000 s: 10%-25%/year Introduction of evidence-based HIV prevention interventions: Community-Based Outreach Testing and Counseling Sterile Syringe Access Substance Use Treatment Edlin Nature 2011; 474: S18-9
Effect of HIV Prevention Interventions on HCV Transmission 1980 s: 80% infected/6-8 mos. = 15%-20%/month 1990 s and 2000 s: 10%-25%/year Introduction of evidence-based HIV prevention interventions: Community-Based Outreach Testing and Counseling Sterile Syringe Access Substance Use Treatment Edlin Nature 2011; 474: S18-9 Insufficient Ineffective
Hepatitis C: Where is it Spreading? People who inject drugs HIV-infected men who have sex with men Unsafe injection practices in medical settings Vertical transmission Young people using pharmaceutical opioids Yaphe Sex Transm Infect 2012;88:558. Thompson Ann Intern Med 2009;150:33. Perz Clin Liver Dis 2010;14:137. Benova Clin Infect Dis 2014. Suryaprasad Clin Infect Dis. OHAIDP 2013. Havens Am J Public Health 2013;103:e44. Young Epidemiol Infect 2013;141:402. Bruneau Addiction 2012;107:1318. MMWR 2012;61:358. MMWR 2011;60:1457. MMWR 2008;57:517.
Nonmedical Opioid Use and Sequelae, United States, 1999-2010 Volkow ND et al. N Engl J Med 2014;370:2063-2066. Source: CDC, SAMHSA, DEA
Reaching Newly Affected Groups Prescription Opioid Users Five million young people used pharmaceutical opioids in past year Many are in rural and suburban locations Transition to heroin injection is common Opioid overdoses are epidemic and signal HCV transmission HCV outbreaks reported to CDC in 13 states We can intervene now or watch the epidemic unfold.
Effective HCV Prevention Interventions Community-based outreach Education Sterile syringe access Other injection equipment Voluntary testing and counseling Treatment for substance use (buprenorphine) Pharmacy syringe access and education Internet and social media Law enforcement, jails, prisons Multicomponent interventions Harm reduction Peer-driven interventions Financial incentives Antiviral treatment Education to prevent reinfection
Effective HCV Prevention Interventions Community-based outreach Education Sterile syringe access Other injection equipment Voluntary testing and counseling Treatment for substance use (buprenorphine) Pharmacy syringe access and education Internet and social media Law enforcement, jails, prisons Multicomponent interventions Harm reduction Peer-driven interventions Financial incentives Antiviral treatment Education to prevent reinfection
Reaching Newly Affected Groups Prescription Opioid Users Multicomponent interventions Outreach, education, counseling, testing, linkage to care Test negative prevention Test positive treatment Epidemiology and surveillance simultaneously with providing services We can intervene now or watch the epidemic unfold.
Reaching Newly Affected Groups Prescription Opioid Users Collaboration (and cross-training): Federal, state, local public health agencies Harm reduction and outreach experts Hepatitis C specialists Mental health and substance use treatment providers Primary care Pharmacists Law enforcement authorities Criminal justice Affected communities (people using illicit drugs)
Reaching Newly Affected Groups Prescription Opioid Users Harm reduction Respect, nonjudgment, cultural competence Persons in target groups are the experts Full collaboration of affected communities in defining and implementing needed interventions
Hepatitis C Virus Incidence in Young People Who Inject Drugs The Swan Project, New York, 2005-2012 N Person- Days HCV HCV incidence per 100 person-years (95% CI) P Age 0.001 18-21 years 78 11,235 11 35.8 (19.8, 64.6) 22-25 years 74 12,333 10 29.6 (15.9, 55.0) 26-29 years 55 10,227 5 17.9 (7.4, 42.9) 30+ years 42 9,535 0 0.0 (0.0, 0.0) Duration of injection drug use 0.006 <0.5 years 22 1,394 3 78.6 (25.4, 243.7) 1 year 56 6,310 6 34.7 (15.6, 77.3) 2-9 years 144 26,855 16 21.8 (13.3, 35.5) 10+ years 37 8,771 1 4.2 (0.6, 29.6) Total 224 43,330 26 22.4 (14.9, 32.2)
Hepatitis C Virus Incidence in Young People Who Inject Drugs The Swan Project, New York, 2005-2012 N Person- Days New HCV Infections HCV Incidence per 100 person-years (95% CI) P Sex 0.25 Men 151 28,393 21 27.0 (17.6, 41.4) Women 68 13,778 5 13.3 (5.5, 31.8) Follow-up (after enrollment) 0.005 0-60 days 216 10,973 15 49.9 (30.1, 82.8) 60-120 days 148 7,209 4 20.3 (7.6, 54.0) >120 days 128 25,148 7 10.2 (4.8, 21.3) Total 224 43,330 26 21.9 (14.9, 32.2)
Effective Outreach to Hidden Populations Field Methods Community-based locations Environment free of judgment, shame, or stigma Staff knowledgeable about drug use and users and hepatitis C Client-centered focus Services counseling, testing, harm reduction Cash incentives Hard-to-reach populations are easy to reach when programs are designed to meet their needs.
Reaching Newly Affected Groups Prescription Opioid Users Antiviral Treatment Everyone who is infected needs access to treatment To prevent disease, treat those at risk of progression To prevent spread, treat those at risk of transmission Governments, payers, and pharmaceutical industry must agree: Everyone who needs antiviral therapy for hepatitis C must have access to it. Education to prevent reinfection
Preventing HCV Reinfection after SVR in People Who Inject Drugs Author Year N Reinfections Rate per 100 person-years (95% CI) Backmund 2004 18 2 3.9 (0.5,14) Dalgard 2002 27 1 0.8 (0.0,4.7) Currie 2008 9 1 2.6 (0.1,15) Grebely 2010 35 2 3.2 (0.4,12) Grady 2012 42 1 0.8 (0.0,4.2) Aspinall 2013 131 7 2.4 (0.9,6.1) Choices (NY) 15 1 2.2 Aspinall Clin Infect Dis 2013;57:S80
Hepatitis C: Preventing New Infections New regimens offer the promise of eliminating HCV A national consensus is needed to make this happen. Outreach Seek Test Treat Cure Prevent Intervention will require effort and resources. We can intervene now or watch the epidemic unfold.