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Treatment and access to treatment in low and middle income
countries
Adeeba KamarulzamanUniversity of Malaya
Kuala Lumpur, Malaysia
ANRS-NIDA Joint Satellite
Drug Use and HIV and HCV Infection: The Challenge and The Potential Solutions
Global Estimates of HIV-Viral Hepatitis Coinfection
HCV Prevalence in Asia, Africa and Eastern Europe
1Madhava V. Lancet 2002. 2Nelson P, Lancet 2011. 3Ba I, ICASA 20127
Dakar area – UDSEN study3
-est.size IVDUs: 1324- P(HIV): 5,2%- P (HCV): 23,3%
Bulgaria
Greece Ita
ly
Cyprus
Austria
Romania
0
20
40
60
80
20052010
ThailandNepal
PakistanMacau
MyanmarIndonesia
VietnamPhillipinesCambodia
ChinaMalaysia
JapanKorea (Republic of)
AustraliaBangladesh
SingaporeIndia
TaiwanAfghanistan
Maldives
0 10 20 30 40 50 60 70 80 90 100
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
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
Liver-related death: Leading cause of death in HIV-HCV patients
Unknown
Other
Suicide
Overdose
lung
non HIV infections
Cardiovscular
HIV
Cancer (non HIV non HCV)
Liver (including HCC)
0 5 10 15 20 25 30 35 40
43 %
12 %
8 %
5 %
4 %
4 %
4 %
2 %
6 %
7 %
Decompensated cirrhosisHCCPost-transplantation
Cirrhotic Patients: > 50% deaths related to HCVNon cirrhotic patients : 60% deaths non related to HCV nor HIV
1HSogni P. Conference on French HIV-HCV Consensus Guidelines, 2012
13
% o
f pati
ents
with
sus
tain
ed v
irolo
gica
l res
pons
e (S
VR)
IFN
24 W
70
50
30
20
10
60
40
IFN
48 W
IFN+RBV
24 W
IFN+RBV
48 W
PEG-IFN+RBV
48 W
0
80
90
IFN = Interferon-αPEG-INF = Peg-Interferon-αRBV = RibavirinPEG = PEG-IFN-α
2002
2011
1999
2014
PEG-IFN+RBV
+new PI Telaprevir
Or Boceprevir
INF-free regimens12 weeks
? 95-100% SVR
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
Estimated proportion of persons with chronic HCV receiving treatment in selected European countries in 2010
Source: Razavi et al J Hepatol. 2013;58(Suppl 1):S22–3
Treatment coverage remains very low, even in high-income
countries
Total population (2012)
Estimated number PLHIV (all ages, 2012)
Reported number of adults receiving ART
(2012)
Coverage (range of
uncertaintyA)
Cambodia 14,864,64 76,000 44,318 82% [60%->95%]
China 1,350,695,000 780,000 151,519 Not available
India 1,236,686,732 2,100,000
570,620 51% [44%-57%]
Indonesia 246,864,191 610,000
29,960 18% [12-25%]
Malaysia 29,239,927 82,000 14,594
41% [32%-52%]
Myanmar 52,797,319 200,000
49,676 46% [41%-51%]
Nepal 27,474,377 49,000
7,168 33% [28%-40%]
PNG 7,167,010 25,000 11,042 84% [73%->95%]
Thailand 66,785,001 440,000 232,816
76% [71%-80%]
Vietnam 88,772,900 260,000 68,883 58% [19%->95%]
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
Number of people who inject drugs (PWID) on ART per 100 HIV+ PWID
Source: Beyrer, Baral
Less than 25% of HIV+ PWID are on ART in Asia and Pacific < 25
25-75
> 75
PWID present but ART program data not available
No PWID reportedPWID=people who inject drugs
Multiple Barriers at Multiple Steps of the Continuum of Care
Adapted from G. Matthews
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
Treating HCV in Resource-Poor Settings CID 2012:54 (15 May) d 1465
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
Overcoming Provider Barriers
Easier assessment of the infection and the liver disease2
-Dry-blood spots (HCV viral load quantification/genotyping)- Portable Fibroscan (Echosens)- Portable sonography
Rapid Testing1
- Point-of-care tests- Salivary rapid testing
1Yaari A, J Viral Methods 2006. 2Tuaillon E, Hepatology 2010
47Mostly unavailable in RLS
Overcoming the Cost Barrier
http://www.medicinespatentpool.org
48
History of HIV
Viral Hepatitis
Acknowledgements
• Karine Lacombe, Inserm• Ying-Ru Lo, WPRO WHO• Joe Sasadeusz, Alfred Hospital, Melbourne