Transcript
MIC CAVAZZINI: Welcome to Pomegranate Health. I’m Mic Cavazzini for the Royal Australasian College of Physicians. Today’s podcast comes from a presentation about the progress of Hepatitis C elimination strategies in New South Wales. I’ve decided to brand pre-recorded content like this as Guest Lectures to help you filter new episodes as they are released. Along with podcasts flagged [Journal Club] or [Case Report], this is an example of content generated by RACP members and will typically have a strong clinical focus. This is in contrast to the episodes you’ll see labelled by Ep number, which are the slightly more produced documentaries about “the culture of medicine.” I’m always happy to receive suggestions for any of these formats from RACP Fellows or Trainees via the email address podcast@racp.edu.au.
So, today’s guest lecture was recorded on July 28. This wasn’t just World Hepatitis Day but also the launch of the 2nd Monitoring and Evaluation Report on Hepatitis C Elimination, which you’ll find linked in the show notes. This work was commissioned by the NSW Ministry of Health and conducted through the Kirby Institute under the guidance of Professor Greg Dore. Professor Dore is an infectious diseases consultant at St Vincent’s Hospital, Sydney, and he paid tribute to his research colleagues Marion Barault, Heather Valerio and Shane Tillakeratne.
The publication of this M&E report comes in the context of three parallel hepatitis C elimination strategies, variously at state, federal and global levels. NSW Health has a year 2025 target of reducing the incidence of new infections by 60% over 2022 levels. The National target for 2030 is to bring new infections to between 5 and 8 per 100,000 population. Meanwhile the WHO’s Global Health sector targets has an upper bracket for its target range of 13 infections per 100,000 by the same date.
I’ve edited Greg Dore’s talk down for brevity and clarity. And following Professor Dore, you’ll hear about the delicate process of surveillance, treatment and education within correctional facilities.
GREG DORE: This is a presentation of the key findings from the second hepatitis C elimination in New South Wales monitoring and evaluation report. The first report was in 2019 and we had planned to do a report every second year. This little thing called a pandemic got in the way of that, but we're hopefully back on track, and hopefully we'll continue to monitor things closely, because this is a really crucial next six or seven years for the response to hepatitis C.
What I wanted to do is go through not all the data that's in the report, but some really key findings in in each section. So, we'll start with, really importantly, primary prevention and harm reduction. The WHO target for the number of needle and syringe distributions per person who injects drugs is 300 needle and syringes distributed per injector per year. So, Australia and New South Wales have been above that target for the last decade and probably longer than that. So, we can tick that target off. It doesn't mean that we can't improve things in terms of coverage and reducing needle sharing, but we can, I think, be quite proud that Australia has been really internationally leading in terms of this aspect.
If you then look at data in terms of the proportion of people who inject, who report sharing needles and sharing over the previous month, it's been pretty stable over the last sort of seven or eight years. So, around about that 17 to 20% mark. So that's a significant proportion of people who do report needle syringe sharing. This is community based data. Clearly that proportion will be higher in correctional settings, and I'm sure we'll sort of talk about that later on. What about data on opioid agonist therapy uptake? So, this is data that we get from New South Wales Health, and it gives us information on the number of people receiving OAT on a census day, which is, I think, the end of June every year, there's a census date, and we get an estimate of the number of people receiving OAT. You can see this encouraging increase over the last decade. And increase both in terms of number of people in the community and more importantly, the marked increase in the number of people in the correctional setting that are receiving OAT; more than a doubling over the period from 2015 to 2023 so
MIC CAVAZZINI: Just a quick explainer. OAT stands for opioid agonist therapy. The number of individuals in the community receiving OAT increased from under 20,000 in 2015 to 24,475 in 2023.In the correctional setting the number has risen from 1604 to 3606, an increase of 125% mostly in the last four years.
In that period, buprenorphine has become the agonist therapy of choice, now outpacing methadone by a ratio of 4 to 1 in correctional settings. Professor Dore attributes this largely to the arrival of depot buprenorphine, a slow-release formulation that is delivered subcutaneously, either as a weekly or monthly dose. In the community, however, methadone still represents more than half of OAT doses. Another acronym you'll hear used in this talk is NSP for needle and syringe exchange program.
GREG DORE: Moving on to hepatitis C testing and diagnosis, this is data from AusHep, that's a prison surveillance project, and this is information on hepatitis C testing among AusHep participants with a history of injecting drug use. So, this is self-reported information on ever hepatitis C tested, and you see the vast majority of people report testing, and most of that testing has been done in the prison setting. Obviously, some in the community and some having had testing in both settings.
So, even though we've done pretty well in terms of the proportion of people diagnosed, there is a significant minority of people that have what we describe as late hepatitis C diagnosis. So that's categorized as people who present to hospital with liver failure or liver cancer—so decompensated cirrhosis or hepatocellular carcinoma—and have only been diagnosed with their hepatitis within two years prior to that hospital admission. So, we see this as a missed opportunity, many of these people may not have had time to have effective intervention to prevent that advanced liver disease complication. Now there's some improvement, so from 2015 to 2018 it's reduced from 19% to 16%. The overseas born members of the community have a somewhat higher, but not markedly higher rate of late diagnosis. What we found was the key sort of area of diversity in terms of late diagnosis proportion was when we looked at it by geographical area of residence. So, people that are residing in the rural areas, 22% of people presenting with liver failure or liver cancer are only diagnosed with hepatitis C very late, and that's twice as high as the metropolitan areas. So, 22% rural, 16% outer metropolitan and 11% in the metropolitan areas. So, really, some work to do there in terms of trying to lift diagnosis in rural areas and prevent these advanced liver disease complications.
What about treatment? I just wanted to go through how we're estimating treatment coverage, because there's been some differences in how people have tried to work at what's the treatment coverage. So, if you think of a high risk population—a population, say, of people who inject drugs—there's a proportion of people that have never been infected, relatively small proportion. Then you've got a proportion of people who have been infected but have spontaneously cleared the virus. And then people that have chronic infection, most of those, thankfully, now have received treatment. And then you've got a proportion of people who RNA positive, obviously, some having received treatment and either developed treatment failure or reinfection. And some people who are RNA positive, so current infection but have never been treated.
So, in terms of the people that we're interested in, in terms of the treatment-eligible population, those are clearly people that have been treated—so, assuming that they were eligible at the time they received treatment, I think that's a reasonable assumption—they're included in the denominator and people that have current infection. So that's our denominator for treatment eligible. And then we look at the uptake, so the participants that have ever received hepatitis C treatment among this denominator population, and in this example, it's 85% have received therapy. So we’ve looked at this in a number of different studies, and the news is pretty encouraging. So, you can see data from the needle and syringe program survey, from Ethos engage (a community based observational cohort), the National Program point of care testing project and Search 3x (which is a project of hepatitis C screening in emergency departments). And in the period 2022 to 2024 all above 80%. Now the who target is to treat 80% of people diagnosed. So, some of these studies are actually 80% of all people eligible, including proportion of people that are undiagnosed. So, we're doing pretty well in terms of what the WHO target is.
What about data specifically within the prison setting. So, this is data from the AusHep prison surveillance system, and you can see that the proportion of people who are eligible that have ever been treated; 84%. Let's look specifically at some of these studies in a bit more detail. So, this is Ethos Engage, this is an observational cohort that recruits people through drug treatment and NSP sites. It's a national study, but we're focused on data from New South Wales, obviously, for the report. And you can see the treatment coverage increasing to 89% in 2023. So, really quite impressive treatment coverage.
We were a bit worried about women having a lower treatment coverage, but they're sort of catching up, so it's not far behind the male treatment coverage in the most recent sort of period. We were a bit worried about younger people; Would they get the sort of treatment coverage that the older cohorts were getting? And you can see the equity across by age? We were also clearly concerned about whether we were getting good treatment coverage in Aboriginal and Torres Strait Islander peoples within New South Wales. And you can see this data demonstrating equity compared to non-Indigenous population. What's an interesting finding is that of all the sort of characteristics, there is somewhat lower treatment uptake in people whose major drug injected is opioid. So, I'll show you some further data a bit later on that bears that out in other studies.
This is the overall trends in terms of the number of people initiating therapy since 2016 when we had PBS listing for the DAA therapies, and the number of people being retreated. So, as I said, I don't think this is necessarily a negative thing that we're seeing increasing retreatment for infection. I think it's part of the response to the hepatitis C epidemic, that we really need to detect those cases and get them onto therapy
MIC CAVAZZINI: Professor Dore presented some data regarding initiation on direct acting antivirals therapies or DAAs. Nine of these were listed on Australia’s Pharmaceutical Benefits Scheme in 2016, although some were delisted with the later arrival of combination therapies glecaprevir plus pibrentasvir, sofosbuvir with velpatasvir and a second line agent that also contains a third molecule on top of this. While not cheap, DAAs have been proven to be cost-effective.
In the reported data, the number of individuals initiated on DAAs was about 11,300 in 2015 and about 3000 in 2023. But before you get too alarmed by this, it maps to the estimated decline in prevalence of hepatitis C infections in the population you’ll hear about in a minute.
GREG DORE: Moving on to people living with hepatitis C. We showed you some data on treatment coverage, obviously, increasing treatment coverage and scaling up and curing lots of people, you would expect a reduction in the RNA prevalence, so the prevalence of current infection. So, this is data from the NSP survey from 2015, the year before DAA therapy became PBS-listed, when around about a half of the people who inject drugs, who were being surveyed through the Needle and Syringe Program survey with a dry blood spot sample and tested for RNA had active infection. And those sort of high levels across all the key demographic characteristics.
And this is a pretty amazing response, we've seen progressive decline in the proportion of participants that have active infection down to a level just below 10% in 2022. And reasonable sort of equity across those key demographic characteristics. Good reductions in women as well as men, low prevalence now in the younger age group, and also low prevalence in Aboriginal and Torres Strait Islanders participants. So, look another sort of indication of why we should be proud of the response in terms of providing pretty equitable access to these highly curative therapies for marginalized populations.
And it’s pretty remarkable. The NSP survey is telling us we’ve gone from half the people having active infection to ten percent. I mean that is incredible reduction in seven years. Now is that reflective of the broader population? Our mathematical modelling in terms of the modelled ouputs is telling us we’ve only halved the number of people with current infection. Have the models got some things wrongs that we need to look at more closely? Is there too much duplicate notification into the system? I think Miriam’s project Search 3x through the emergency departments is really crucial because it gets to that broader population, so it’s not a high risk population targeted surveillance. So one of my solutions is to expand that type of surveillance to include outer metropolitan, rural areas. So we know from the plenary data that it looks pretty good from metropolitan, at elast South Western Sydney. Is that going to be true across Sydney? Is that going to be true in Dubbo, in Wagga, in Lismore? So they’re the sort of questions we really need to try and answer.
Similar data from Ethos engage, so all of those measures being now less than 10% but this sort of one group I've talked about before, this is people who where the major drug injected, were opioids. Significantly lower prevalence of current infection in those injecting stimulants. So I think that's some data that we need to sort of explore a bit further to find out exactly what's behind that finding.
What about prevalence of current infection in the prison setting? In people that reported history of injecting drug use the overall prevalence was 17%. And there is a concerning sort of finding here that those that identified as Aboriginal and Torres Strait Islander had significantly higher prevalence of current infection within the prison setting around about sort of 22%. So, still reflective of the work that we need to do, particularly in in correctional settings.
We've been running a project called CEASE for several years. That's been led by Gail Matthews and Marianne Martinello, looking at the prevalence of hepatitis C in people with HIV. So initially, people were enrolled who were antibody positive for both HIV and hepatitis C, and the large majority of those pre DAA therapy had current infection. Obviously, some had spontaneously cleared the virus, but more than 85% had current infection. You can see this pretty amazing decline in current infection prevalence to less than 1% in the most recent period that was surveyed through the CEASE. And to show you what happens when you get the current infection prevalence down, you turn off the tap of transmission. So, this is the estimated incidence of reinfection within the CEASE cohort, which was around about four per 100 person years, so a 4% annual risk back in the pre DAA era down to basically zero. So, we're just not seeing cases of new infections within people with HIV. And that's both reinfection and acute new infection, we just do not see them very often at all. So, really incredible sort of response within the population of people with HIV.
Some more data around incidence; This is mathematical modelling data that estimates the current hepatitis C incidence, which has around about halved over the period from 2016 to 2022. So, 60% reduction over that period from 26 down to 11 per 100,000 total population. And the relevance of that is the WHO target is to get that incidence down to less than five per 100,000 population. So, we're sort of on track, I think, to reach that target certainly before 2030, maybe a few years even earlier in New South Wales.
This is younger age notifications. This is not necessarily new infections, but we use notifications in the younger age group as a surrogate of transmission, because most of these people would have been infected in the in the several years, at least. So, the trends in these notifications are important, and you can see this progressive decline in those notifications since the DAA era. But what's been interesting is that there has been an uptick in the overall notifications in 2023. And if you look at those notifications, where that increase has been, has been in Justice Health. Now, does that mean that there's been increased incidence of infection? I'm not sure. I think it's more reflective of increased screening in Justice Health identifying those cases. So, I don't that's a negative finding. I think it's probably a positive finding in terms of the activity, in terms of hep C screening in correctional settings.
Moving on to morbidity and mortality. This is data through our linkage project, where we link all Hep C notifications with a range of administrative data sets, including hospitalizations. So, these are people being admitted with liver failure, decompensated cirrhosis and a really encouraging downward trend since 2015. These are numbers of people with being admitted with hepatocellular carcinoma. Less impressive downward trend, and I think the reason for that is that many people with cirrhosis have been cured, but they remain at some risk of liver cancer, albeit a reduced risk because they're being cured of infection. We do see many cases of HCC in people that are being cured. So, it'll take a bit longer to get that trend moving down more rapidly.
And this is overall liver-related deaths, and it's now at 3.8 per 100,000 total population. WHO target of less than 2per 100,000 population liver related deaths. So, we've got a bit more work to do there to reach that target, there's several things I think we could really focus on. What about the overall cascade of care? This is mathematical modeling data and we can see the number of people living with hepatitis C in New South Wales has halved from around about 60,000 to 30,000 most of those people are living with hepatitis C now have been diagnosed. About three quarters have been RNA tested and confirmed with infection. And you can see the cumulative number of people treated over the DAA era and the cumulative estimate of number of people cured.
Some other cascade of care information, I think, is really, really important, is the data coming through from Search 3x and I mentioned that was a hepatitis screening project in emergency department settings. So there's been three of six emergency departments that have been involved in the project so far, Fairfield, Liverpool and Campbelltown, with three more, Canterbury Bankstown and Dubbo to come through over the next 12 months. And what that does is screens the large majority of people coming through emergency departments. We've found a bit over 300 people that are hep C antibody positive. The large majority of those, really encouraging, have had known hepatitis C. And then we've looked at the proportion that are treatment eligible and the proportion that receives therapy. So again, very encouraging diagnosis rates, not perfect, but encouraging and very encouraging treatment coverage.
Still a proportion of people RNA positive, but the large majority of those who've had RNA testing amongst the antibody positive are RNA negative, reflecting treatment induced clearance and a bit of spontaneous clearance. So, look overall, I think the message the news is good. Lots of organizations have contributed data. Really thankful for everyone that sent the data in and worked with us over many years, and really appreciate the involvement of all members of the working group.
MIC CAVAZZINI: Greg Dore’s overview of hepatitis C in the state of NSW was followed by a closer look at correctional settings which typically have high rates of transmission. This is due the amount of injecting drug use that takes place there coupled with a lack of needle exchange programs. Understandably, prison administrators are wary of allowing access to anything that could be used as a weapon or for self-harm. Presenting on this subject was Colette McGrath who is General Manager of Population and Preventative Health for Justice Health NSW. She’s been with NSW Health since 1996 and Justice Health since 2016.
Colette McGrath began by describing the scale of this setting. There are 39 prisons in the NSW correctional system housing almost 13,000 inmates at any one time. But the number of people why cycle through in a years is about 30,000. That’s because so many people are now held on remand. That’s to say, they’ve been charged with a violent crime and not been granted bail while they await court. Remandees now make up more than half the prisoner population, and their rapid movement through the correctional system presents a challenge for public health trying to stem the transmission of hepatitis C.
COLETTE McGRATH: The average amount of movements per year is about four, but it can often be more. Sometimes we find patients who've been moved 15-20, times across the state. So, you can imagine, I thought it was going to be really easy when I first started there, but keeping track is not always as easy as you think. Our current positivity rate is now around 6 to 8% which is decreased from about 13 to 15. Although when we do targeted testing, it's definitely higher—that's usually when we do our high intensity campaigns in one big prison, so incorporating everybody.
Just some numbers; Over seven and a half 1000 patients we've treated since the initiation. And last year we did 1179. Still can't quite hit the target, but we did get a massive increase. We really dropped down during COVID because we're also a public health unit but we're back on track, and happy to say. In terms of testing modalities, like everybody, point of care, antibody test and RNA, dry blood spot and venipuncture. And we have a variety of models of care. We've got the rapid point of care RNA testing machines in situ in larger prisons, both male and female. We also have a roaming team of two nurses who conduct mass testing events across the state with support from staff on site. So we generally, run about two of those a month. And we do it everywhere in the prisons, where we can, basically. In the health centres, in the yards, the pods, the cells, the wings; wherever we can get a patient to stop long enough, is really our aim.
And then we also have our high intensity campaigns, which includes a lot of harm reduction education and support in partnership with hepatitis New South Wales, and we aim to do at least three of those a year. We also have the rapid point of care antibody test in which we use in the mass testing and our intensity events and for all patients. And that's generally just mass testing for anybody who wants it. And we do, obviously not get the same prevalence that we do when we do targeted, but you certainly pick up patients who actually had no idea, don't remember, didn't think that they had it, so it's still absolutely worth us doing, particularly in those late diagnoses, I think. And then, of course, the rapid RNA testing is conducted.
The dry blood spotting is blood spot test has also been really useful for us, particularly in the early days, and in hopefully, when we can bring it into receptions once it gets licensed. In the sense that it's just, it's not a needle, it's not a big needle. We used to get a lot of opposition from Corrective Services about bringing needle into the yards or areas where there wasn't enough supervision. And because that was just a finger prick, it was just so much easier. So that was a bit of a game changer for us.
And also, of course, we’ve produced numerous hep C resources and the HCV patient experiences, and that's really to push demand from our patients. We've only recently, in the last couple of years, been able to get some video experiences onto the patient digital platform. That's very new, it was really pushed out by Corrective Services through COVID. Before that, we were reliant on paper and leaflets. Everybody else in the world has gone to social media, TV campaigns, we were still really reliant on posters and paper and word of mouth. But we're slowly getting to change, so we're very happy with that.
Other elimination strategies, as I said, we've introduced now rapid antibody testing for all of our patients who enter the drug court program, and the testing is now conducted by our drug and alcohol staff. It's a nice thing being in the one directorate, we can kind of work very closely together. And then the positive patients will receive the pocked RNA conducted by the pop health team. And we've now got two trained drug and alcohol nurse practitioners, who are scaling up now, who are actually training to be able to prescribe for hepatitis C. The second one's just completed. So, it's very exciting not having to rely just on the pop health team or our pop health doctor. So that's fantastic, and I think they've got three other NPs, so I've got my eye on them as well. We'll see how we go. We have a Aboriginal chronic care team, and they're certainly now starting to become more engaged with us in terms of being able to do rapid antibody testing and the dry blood spot testing. Again, we don't necessarily see everybody, so we're trying to just get our fingers out as far as we can.
We've piloted harm reduction hepatitis peer programs in three prisons now, because we know the importance of peers and getting that message out, particularly when there's issues around stigma, discrimination, and so that's been really successful. We've now got a really exciting program where we partnered with Corrective Services to roll out, also educating peers in the prison. And they're actually going to get paid by Corrective Services, an enhancement on their current wages to be peers in terms of harm reduction and encourage people. So, that's hopefully starting this year, we're just in the kind of getting position descriptions ready and getting people to apply within the prison, which is fantastic.
We've also got a hepatitis linkage to primary care program funded by the Primary Health Care Network. This can sometimes be a challenge for us. Patients leave, often very quickly, sometimes without any address to go to. So just really trying to make sure we don't lose people if we've tested them, but we haven't managed to treat them. Again, particularly with them, people coming in and out very quickly in relation to remand. They can be there for a week or two weeks, sometimes longer, but sometimes really short. So again, something that we're really trying very hard not to lose people.
We also have Hepatitis C referral pathways for patients exiting custody, with all LHDs across the state. So again, when we can link them in to make sure they're followed u for follow up treatment or needing retesting, just to make sure they have cleared. And hopefully we've treated most. And also we will look at how we can increase the pilot of the rapid HCV antibody and the RNA testing, particularly at remand and reception centres.
And we have a three year project to also address our HCV retreatment, particularly amongst First Nations people. We've got a huge overrepresentation, and they're also where there’s the biggest overrepresentation of reinfections. Now that may be because they're rural. A lot of a lot of our patients come from rural areas, but also a lot of our Aboriginal patients, anecdotally, said things like, “I waited till I come to prison to get treated”. So they might know, but they know that they can get treated very easily. They don't have to travel in the same way. So, we really try and do a lot of high intensity and roaming testing in our rural prisons, nd thank you for the Ministry for funding that and supporting us for the next three years. So, we're really excited to work on that. We've also got a consumer advisory group being set up in and outside the prison to guide and inform Justice Health and that plan.
I guess harm reduction is really important. One of the challenges, of course, is that we don't have an NSP. It's a prison. It's very difficult. It's a very difficult concept to introduce, but we're currently at least trying to get across the line looking at sort of different types of disinfectant. We know that our patients find Fincol really, really hard to use. It's very complex, and they don't use it correctly. And so Corrective Services are certainly open to us now looking at some other alternatives, and hopefully we'll get some traction on that.
I think that's all I've got, really. Just thank you everybody for inviting me, and again, thank you for all the support we get in Justice Health. Because when I came there, it was like, how hard can it be? Everybody's in the one place, but it's a lot harder than I expected. But I think, we're getting a lot of support from everybody in the state. So thank you very much.
MIC CAVAZZINI: Before signing off, I’ll just paraphrase some other points that come up at this event. You can watch the full talks with slides at the Kirby Institute’s YouTube channel.
An important finding from the Ethos Engage surveys was about stigma and discrimination, which can be a barrier to health seeking. A third of people with a Hepatitis C infection who were injecting drug users reported having such experiences often or sometimes in relation to their drug use. Just under 20% had had such experiences simply because of their diagnosis.
A converse of that survey was to ask members of the public or the health workforce about their feelings towards people with needle acquired hepatitis C infections. 60% of the public and 45% of health workers reported they had negative feelings “Sometimes.”
Another speaker at the event was public health physician Dr Kerry Chant, who has been the NSW Chief Health Officer since 2008. She noted, again, that since 2016 over 35,000 people in NSW have been treated for Hepatitis C. But to reach the more vulnerable cohorts required a doubling down of efforts. Through Aboriginal Controlled Health Organisations, Sexual Health and Drug and Alcohol services, general practices, especially in regional and rural settings. Dr Chant said that each might require a different testing and treatment model, and that patience was needed before it garners enough social licence to be effective.
Dr Chant also touched on the licencing of the Dried Blood Spot Testing we heard about earlier. It’s currently still handled essentially like a research tool, given it was developed by SydPath at St Vincent’s Hospital. But TGA registration and a Medicare subsidy are being sought so that assays can be turned around more quickly at any pathology lab, and the data more readily integrated.
Kerry Chant highlighted how this could aid development of a real-time notifications database, that linked clinical records and pathology data systems. This would allow public health staff to keep a better census, and to detect outbreaks as soon as they emerge. Collette McGrath pointed out that such outbreaks are often associated with an influx of drug supply and therefore consumption at a particular prison. Understanding these patterns can help hone tools for screening and education.
Many thanks to the Communications and Engagement Team at the Kirby Institute for recording this seminar and allowing me to share it with you. You’ll find a full transcript, links to the video to the 2nd Monitoring and Evaluation Report on Hepatitis C Elimination at our website, racp.edu.au/podcast.
If you’ve got a penchant for infectious diseases medicine, there’s are over fifty specialty lectures in our College Learning Series. And in the Medflix video library are explainers on preparing for exams on HIV medicine. You’ll find both of these resources at elearning.racp.edu.au.
This podcast was recorded on the lands of the Gadigal and the Bidjigal clans of the Yura nation. I pay respect to the elders who have watched over this country for thousands of years. I’m Mic Cavazzini. Thanks for listening.