How aspirations can be built and levels of performance can be assured: Learning from the Scottish Action Plan

Professor Sharon HutchinsonLJWG LDAPF Conference

Hepatitis C in London – practical steps to eliminationLondon, 17th November 2014

Scotland’s Hepatitis C Action Plan

To prevent the spread of Hepatitis C, particularly among people who inject drugs (PWID)

To diagnose Hepatitis C infected persons, particularly those who would most benefit from treatment

To ensure that those infected receive optimal treatment, care and support

Aims

Scotland’s Hepatitis C Action Plan

Phase I 2006-08 The Business Case

Phase II 2008-11 Investment to improve

services

Phase III 2011-15 Continuing investment

Phase IV 2015-20 ???

Hepatitis C Landscape in Scotland, 2006

Phase I: Key evidence

0 20,000 40,000

Living with Chronic Infection

Diagnosed (ever)

Attended clinic (in 2006)

Started Treatment (in 2006)

38,000

14,500 (38% of chronics)

3,500 (9% of chronics)

450 (1% of chronics)

Ever injected drugs 34,000

Estimates

Phase I: Key evidenceProjected number of PWID (ever injected)

in Scotland developing liver failure each year with different Rx rates

2010 2020 20300

50

100

150

Uptake of HCV Rx:225 PWID per year

1,000 PWID per year

2,000 PWID per year

N

Increasing uptake of antiviral therapy to 2,000 per year could prevent in excess of 5,000 cirrhosis

cases (incl. 2,700 liver failures) during 2008-30

Scotland’s Hepatitis C Action Plan

Phase I 2006-08 The Business Case

Phase II 2008-11 Investment to improve

services

Phase III 2011-15 Continuing investment

Phase IV 2015-20 ???

Phase II: Principles & Characteristics

Based on extensive evidence base & consultation process

Involved high level actions Adopted multidisciplinary approach Strong governance / clear accountability Leadership (e.g. national coordination lead by

HPS) Agreed outcomes / performance monitored

(e.g. targets on treatment) Good coordination/communication (e.g.

national / local networks) Supported by serious investment

(£100million during 2008-15)

Phase II: Key Actions

Prevention : Improvements in Injection

Equipment Provision

Diagnosis : Awareness raising initiatives: Finger prick sampling

in non-clinical settings

Treatment : Increase in clinical capacity: Funding for treatment

and national procurement of antiviral therapy

Prevention of Infection in Scotland: Progress

*

Incidence of HCV infection among PWID in Scotland

(derived from PCR data)

0%

5%

10%

15%

20%

25%

2008/09 2010 20132011/12

Palmateer et al; PloS One, 2014 (plus updated data for 2013)

Provision of Key Interventions to PWID

Year 2008/09 2011/12

Needles/syringes (N/S) distributed

4.4 million

4.7 million

Paraphernalia* distributed

0.4 million

2.5 million

On methadone 50% 64%

Initiated on HCV therapy among PWID <30 yrs

~50 ~100

* Cookers/Filters

Diagnosis: Overall Progress

Number of new HCV diagnoses per year in Scotland

N

0

500

1,000

1,500

2,000

2,500

2006 2008 2012Phase II onwardsPhase I

20102004Pre

2005 2010 2015 2020 20250

20

40

60

80

100

%

Year

Scotland: Estimated: 2006-13 Projected: 2014-25

Progress In Drug Services

% Infected Popln diagnosed

Number of people tested for HCV in drug services

(Scotland’s 4 largest NHS Boards)

Dried Blood Spot Testing

(introduced into drug services during 2009)

Drug services referred 16% of new HCV diagnoses in Scotland during 2009-13 (McLeod et al. JECH 2014)

Test

ed

Test

ed P

ositi

ve

500

1500

400

800

00

1000

2000 1000

600

200

1999

2001

2003

2005

2007

2009

2011

International Context

0 10 20 30 40 50 60 70 80 90 100Czech Repub

PortugalEnglandAustria

SwitzerlandSpain

BelgiumScotland

GermanyDenmark

FranceSweden

Estimated % infected popln diagnosedRazavi et al. J Viral Hepat. 2014

Scotland’s Hepatitis C Action Plan

Phase I 2006-08 The Business Case

Phase II 2008-11 Investment to improve

services

Phase III 2011-15 Continuing investment

Phase IV 2015-20 ???

Phase IV Government is supportive

Principles for HCV diagnosis and treatment in Scotland, in the context of the new highly effective therapies, to be published in 2015

Modelled incidence of HCV-related (i) Severe Liver Morbidity and (ii) chronic infection in Scotland, according to different treatment

strategies and 2,000 treated per year (Innes et al. Gut 2014)

40

80

120

160

200

IFN-free therapy

Inci

dent

case

s

Status-Quo Target Active PWID (13% 33%)

Target Advanced Fibrosis (40%60%)

2010 2015 2020 2025 2030 2010 2015 2020 2025 20300

100

200

300

400

500

600

IFN-free therapyIn

cide

nt ca

ses

(i) Severe Liver Morbidity (ii) New infection

Aim going forward in Scotland

To rapidly control the number of people who develop HCV related liver failure and/or

hepatocellular carcinoma and the number of people who die from HCV related disease