Hepatitis C among people who inject drugs (PWID)

in India:

High burden but limited access to care

Shruti H. Mehta, PhD MPH

Professor, Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology

Baltimore, MD

July 21, 2014

Hepatitis C and injection drug use in India

Limited surveillance data

Estimated prevalence of HCV In the general population: 1- 2%

Predominantly HCV genotype 3 infection

Estimated 1.1 million PWID in India

Aceijas 2007; Sievert 2011; Chakravarti 2005

Presentation outline & Data sources

1. Burden of HCV and liver disease among PWID in India

2. Access to care and treatment for HCV among PWID in India

3. Challenges / opportunities

• The India IDU Initiative – Cross-sectional sample of

14,481 PWID from 15 sites (~1000 per site) from Dec 2012 – Dec 2013

– Recruited using respondent-driven sampling (RDS)

• Diversity of HCV among PWID– 810 HIV-infected persons

sampled across 15 sites from 2009 – Jan 2011

• Chennai HIV, HCV and Eeral (liver disease) study[CHHEERS]

– ~800 PWID sampled in Chennai

– Detailed characterization of liver fibrosis

Chennai (CHE)

Established epidemics Large cities Emerging epidemics (documented) Emerging epidemics (anecdotal)

High burden of hepatitis C infection and HIV/HCV coinfection in India (n=14,481)

Hepatitis C antibody prevalence HCV/HIV co-infection prevalence

Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

Tamil Nadu

Rajasthan

Mizoram

Manipur

West Bengal

Uttar Pradesh

PunjabNew Delhi

Subtype 1aSubtype 1bSubtype 3aSubtype 3bSubtype 6n

Predominance of genotype 3 HCV infection but variability by region

Solomon CROI 2013

High burden of liver fibrosis / cirrhosis

HCV RNA- HCV RNA+ / HIV-

HCV RNA+ / HIV+ CD4>500

HCV RNA+ / HIV+ CD4 200-

500

HCV RNA+ / HIV+ CD4 <200

0%

20%

40%

60%

80%

100%

No / mild fibrosis Moderate fibrosisSevere fibrosis / cirrhosis

Chronic HCV HIV / HCV co-infection

Mehta EASL 2014; Solomon et al AIDS 2009

Moderate fibrosis (LSM 8-12.3 kPa)

Severe fibrosis / cirrhosis (>12.3

kPa)

  Odds ratio

95 % CIOdds ratio

95% CI

Age (per 5 years) 1.05 0.92 – 1.19

1.24 1.06 – 1.46

Body mass index (per 2 kg/m2)

1.13 1.01 – 1.26

1.15 1.02 – 1.32

Hepatitis C virus Negative HCV RNA<2.8 log10IU/ml HCV RNA 2.8 – 5 log10IU/ml HCV RNA 5 – 6 log10IU/ml HCV RNA > 6 log10IU/ml

10.630.432.662.21

0.28 – 1.430.05 – 3.551.26 – 5.641.34 – 3.65

12.033.146.696.49

0.88 – 4.670.69 – 14.32.92 – 15.43.58 – 11.7

Hepatitis B Surface Antigen+

2.08 1.04 – 4.12

2.40 1.09 – 5.31

HIV Negative HIV + CD4 >500 cells/ul HIV+ CD4 200 – 500 cells/ul HIV+ CD4 <200 cells/ul

11.390.970.57

0.57 – 3.370.50 - 1.900.12 – 2.69

10.610.541.87

0.16 – 2.320.23 – 1.270.62 – 5.68

Fibrosis, cirrhosis associated with traditional risk factors…

Moderate fibrosis (LSM 8-12.3 kPa)

Severe fibrosis / cirrhosis (>12.3 kPa)

  Odds ratio

95 % CIOdds ratio

95% CI

Alcohol dependence None Harmful drinking Hazardous drinking/dependence

11.021.61

0.47 – 2.230.93 – 2.77

12.353.16

0.95 – 5.821.10 – 6.37

Insulin Resistance (HOMA-IR >2)

1.68 1.06 – 2.64

2.33 1.38 – 3.95

Steatosis None Mild Moderate

11.552.96

1.01 – 2.401.47 – 5.96

11.532.65

0.92 – 2.541.10 – 6.37

…but also strong associations with metabolic cofactors

Rapid HCV disease progression?

No/mild fibrosis at baseline: Fibroscan <8 kPa• 31% experienced progression to

moderate fibrosis• 12% experienced progression to

severe fibrosis/cirrhosis

Moderate fibrosis at baseline: Fibroscan 8-12.3 kPa• 47% experienced progression to

severe fibrosis/cirrhosis

The hepatitis C care continuum (aka CLIFF)n=5,777

HCV infec

ted

HCV diagnosis

Linke

d to ca

re

Treatm

ent in

itiation

Viral c

learan

ce0

102030405060708090

100

Perc

ent

Minimum MaximumSolomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

Variability by stage of drug use epidemic…

HCV di

agno

sis

Link

ed to

car

e

Trea

tmen

t ini

tiatio

n

Vira

l cle

aran

ce0

2

4

6

8

10

12

Established epidemics Large Cities Emerging Epidemics (documented)Emerging Epidemics (anecdotal)

Perc

ent

Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

…but no variability by stage of liver disease

HCV an

tibod

y po

sitiv

e

HCV ch

roni

c in

fect

ion

HCV di

agno

sis

Link

ed to

car

e

Trea

tmen

t ini

tiatio

n

Vira

l cle

aran

ce0

20

40

60

80

100

No fibrosis Mild / moderate fibrosisSevere fibrosis / cirrhosis

Perc

en

t

Barriers to HCV+ diagnosis

14,450 persons

13,178 (91%)NEVER tested for HCV

1,272 (9%)EVER tested for HCV

6721 (51%)NEVER heard of HCV

6,457 (49%)Heard of HCV

• 73% cited low risk perception

• 14% did not know where to get tested

• 53% wanted to know their status

• 25% were referred by a physician

• 44% tested in private/NGO testing centers / 41% in government centers

• Testing more common in sites with established epidemics

Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

Facilitators of HCV+ diagnosisUnadjusted Odds Ratio

(95% CI)Adjusted Odds Ratio

(95% CI)

Age (per 10 year increase) 1.21 (0.94, 1.57) 1.14 (1.00, 1.29)

Marital Status• Never married• Currently married

11.30 (0.83, 2.04)

-

Education• Primary• Secondary• High School graduate

12.04 (1.32 - 3.13)4.54 (2.71 - 7.63)

11.92 (1.24, 2.97)4.01 (2.35, 6.84)

Ever visited OST center 2.95 (1.76, 4.93) 1.87 (1.02, 3.41)

Ever tested for HIV 8.08 (5.15, 12.68) 3.58 (2.40, 5.33)

Knowledge of HIV status• Positive and unaware• Positive and aware• Negative

19.06 (3.99, 20.6)1.48 (0.62, 3.53)

15.51 (2.57, 11.83)1.18 (0.48, 2.92)

Region of Residence• Northeast• Large cities• Emerging epidemics

(documented)• Emerging epidemics

(anecdotal)

10.18 (0.09, 0.35)0.24 (0.08, 0.73)0.06 (0.02, 0.21)

10.28 (0.11, 0.75)0.27 (0.16, 0.46)0.11 (0.04, 0.28)

Note: also examined gender, years of drug use, lifetime frequency of injection, needle sharing, utilization of other services (SNEP, TB treatment, etc.)Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

Challenges

Co-factors complicate disease progression & treatment response– Metabolic co-factors (e.g., steatosis, insulin resistance)– High burden of alcohol use

Subtype diversity– Access to HCV genotype testing important for

management

Low levels of knowledge: start with HCV literacy

Limited access to care & testing locations Cost

Opportunity: Integrate HCV testing & treatment with HIV and harm reduction services

Services to be delivered

HCT

Antiretroviral therapy (ART)

Testing for sexually transmitted infections

Opiate substitution therapy (OST)

Needle & syringe exchange (NSEP)

Condom Promotion

Information Education and Counseling

Testing of Spouses

Counseling for depression/substance abuse

TB treatment (via DOT)

ClinicalTrials.gov Identifier: NCT01686750

Hepatitis B vaccination

HCV testing & Treatment

Acknowledgements

Funding sources– NIDA (DA12568,

DA032059, DA026727)

– OAR (I to I program)– ICMR

Johns Hopkins– Sunil Solomon– Gregory Lucas– David Celentano– Allison McFall– Mark Sulkowski– Dave Thomas

NACO, India

YRGCARE– Suniti Solomon– AK Srikrishnan– M Suresh Kumar– AK Ganesh– S Anand– P Balakrishnan– CK Vasudevan– Accounts– Data Team– Lab Team

Site staff & participants