Saturday, September 28, 2013

Hepatitis C in Addiction

Hepatitis C in Addiction

Sept 28, 2013

Mark Hull MHSc FRCPC

Lecture given at the Canadian Society of Addiction Medicine, Vancouver, 2013
My poor rough notes just give a slice of the wealth of information presented by this cutting edge researcher, clinician and remarkably fine communicator. I trust this will help someone appreciate the depth and breadth of information available and the extraordinary work and advances being made.  

Hepatitis C Overview

HCV is a RNA virus
single strang Rna 3000 amino acid
North Amer - 1 a and 1 b dominant straints

Overlapping Global HCV and HIV
  • 8 million co infection
  • 33 mill HIV
  • 170 million Hep C

BC Chronic HCV rates
  • gradual decrease since 2002
  • increasing number of women
  • originally male
  • baby boomers with increased elderly

High Prevalance of HCV among PWID Worldwide
Injection drug users in canada make up 60% of HCV

VIDUS Youth   
CEDAR Youth/youth/young adults
Miller C CAn J. Public Health 2005
Spittal P BMC Public Health 2012

Risk for acquiring HCV rises dramatically after 2 years of IV drugs

Harm Reduction and HCV
-number of syringes - associated with decrease in HCV - free needle programs

Harm Reduction and HCV
effect of opiate subtitution treatment on HCV incident
-80% reduction in risk of HepC with OAT
Turn, K et al Addiction 2011

HCV Surveillance - Corrections Canada
Seroprevalence people entering jail fairly high compared to general population but very flat over years
 -about 30% - higher than community
-jail amplifier - New infections acquired in jail
-new infections with tattooing and Intravenous drug use

HCV prevalence by birth cohort in USA
-prevalence in baby boomer 5x higher than others 
-amstrong , G An. Int Med 2010
-most don’t know - may have got young and may have been victim of poor blood transfusion, or very young , or other ways

HCV Natural History
-75 to 85% patient develop chronic infection
20% develop cirrhosis after 20 years

Estimated reduction in morbity by birth cohort
-recommending routine screening if baby boomer - birth 1945 to 1955

Ontario Burden of Infectious Disease Study 2010
-Hep C the most burdensom infectious disease - loss of life and disability - HIV far less

Mortality in Canadian HIV/HCV Co Infection Cohort Study
-rate of death due to liver disease extremely high
-escallates liver disease
-Klein, M

Baseline Assessment
-All PWID (Persons with Injection Drug Use) should be screened for HCV 
-HCV antibody
-if negative, re screen every 6 months if still at risk
-if HCV Antibody positive
--HCV RNA PCR/genotype
--vacinate for Hepatitis A, B if non-immune
-pneumoccocal vacine
-alcohol cessation treatment

Staging of Liver Disease
-all patients should undergo staging of liver disease - cirrhosis - (clinical, laboratory, radiography)
Use of non invasive techniques - fibroscan (transient elastography 
alternative to Biopsy
Stebbing, J et al, J Clin Gastro 2010
biopsy is still used occasional

Evaluation of HCV treatment
Absolute contraindication to treatment
Strong contraindication
  • active autoimmune
  • hepatic decompensation
Relative contraindication
-major depression
-major psychosis
-renal failure

Ideal study - Peg IFN alfa -2a vs Peg IFN alfa-2b 

Serious side effects
 -Neuropsychiatric symptons
20-30 % severe depression

Benefits of successful treatment
  • Van der mer, Jama 2012
  • all-cause mortality reduce- increases long term survival, regeneration of liver

Pegylated Interferon and ribavirine for genotype 2/3
24 weeks if RVR
48 week

Boceprevir - SPRINT2 overal SVR Rates - doubling of response
Telaprevir - 75% cure rate - revolutionary over last 2 years

These drugs also have this effect with those who have relapsed after previous response

There is a very minor subgroup of non responders that are still a tricky problem but hopefully will respond to new drugs.

Now responses to 6 month of treatment excellent

Integrate Models of Care
-Community based multidisciplinary team - grebel, Eur J Gastroenterology Hep

HIV treatment as prevention BC
Patients currently on HAART

HIV engagement in care
HCV Engagement in CAre 

Decreased mortality and morbidity
decrease sero prevalence
Hepatalogy - Martin, n et al 2013 -

PWID have high burden of HCV disease and should be screened routinely 
Treatment uptake is low among PWID
Use of HCV DAA’s have substantially altered treatentn paradigms and success rates will continue to improve
Treatment as PRevention models suggest populations level benefits to improved therapy 

Q&A Periods

1)System failing - British Columbia - restriction on treatment meaning that our patients aren’t being treated.
Reduces morbidity and mortality for individual but also stops spread at population level
Pharmacare is recognising fibroscan - it’s as acceptable as biopsy
Cost effectiveness of dx and treatment to health care system

  1. Viremia - clear and negative tests - might have negative test this month but negative 6 months - want 4 negative tests over 3 years q 6 months
  2. Fatty liver - first nations - seems almost all my patients have - aboriginal care giver gave - results in poorer response to treatment, mortality worsened, 
some treatment programs in us are treating metabolic syndrome as well as liver
4) lady with seizure disorder, socially unstable, on methadone, continues to inject cocaine and heroin - should I treat hep c early - or should I just continue to work at treatment of her addiction - if you waited a year unstable - and stabilize for this year then treat -

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