#79 HepSA Community News

#79 • September 2018

Community News

Research Update

plus The Missing Millions and more

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Editor: James Morrison

Contents

1 The Missing Millions 2 Mortality Rates Drop 4 Anne’s Story

Chair Arieta Papadelos

7 Heart Health

Vice Chair Bill Gaston

10 Improving Treatment

Secretary Lindsay Krassnitzer Treasurer Sam Raven Ordinary Members Catherine Ferguson Ratan Gazmere Kirsten Hicks Sharon Jennings Maggie McCabe Kerry Paterson (EO) Deborah Perks

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8 Treating Hep C in India

Uptake

12 Hep B Fund Raiser 13 New Liver Cancer Markers 14 In our Library BC What’s On? Disclaimer: Views expressed in this newsletter are not necessarily those of Hepatitis SA. Information contained in this newsletter is not intended to take the place of medical advice given by your doctor or specialist.

We welcome contributions from Hepatitis SA members and the general public.

SA Health has contributed funds towards this program.

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The Missing Millions

The barriers to diagnosis

World Hepatitis Alliance President Michael Ninburg addressed the 11th Australasian Viral Hepatitis Conference in August. The conference, held at the Adelaide Convention Centre, focused on the theme ‘No One Left Behind’. Michael used his speech to highlight the low diagnosis rates globally and to speak about the Find the Missing Millions campaign, launched on World Hepatitis Day.

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iral hepatitis elimination will not be achieved without involving the people and communities who are affected by the epidemics.

Even if we treated everyone who was diagnosed with viral hepatitis, we would still only be at the tip of the iceberg of the global hepatitis burden because only 1 in 10 people are aware of their illness. Without an increase in diagnosis we won’t be able to progress to the next step of elimination. We have parts of the world that are struggling more than others to test and diagnose people, Australia is a notable exception in this.

‘Find the Missing Millions’ is a campaign to put patients and the community at the centre of the issue to address the barriers to diagnosis. The first phase of the campaign, launched in 2018, looked to work with partners and civil society to identify the barriers to diagnosis.

Phase two will be looking to work with some of our member states to set up replicable projects that will support countries find the undiagnosed whilst keeping

the patient and civil society front and centre of the elimination strategy.

Many Alliance members are working hard to find the missing millions, and over the next few years we will be working with them to help grow those projects and gain government backing.

Australia is one of the countries leading the way, in part due to the recognition of the need for access to harm reduction for people who inject drugs. This has been a huge step in the right direction.

I have been greatly impressed by this Australasian delegation which brings

together, patients, civil society and public health clinicians, to really have a vibrant discussion between critically important groups in getting to the root causes of the epidemics of hep B and hep C and most importantly the solution on how we are going to get to the target of elimination of these viruses by 2030. I think the focus on the patient has been absolutely critical. I think the organisers of the conference have done a great job at having the patient voice front and centre throughout the conference, and that is one of the things that I have appreciated more than anything. v

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Death Defying

Australia’s hep C mortality rates see dramatic plunge

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here has been a 20% decline in deaths from hepatitis C, new Kirby Institute data presented at the Australasian Viral Hepatitis Conference in Adelaide shows. The decline, based on New South Wales

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data from more than 100,000 people with a hepatitis C diagnosis, is the first largescale evidence of the impact of new hepatitis C treatments on liver-related mortality in Australia. In the decade before new treatments

were available, there had been a horrifying tripling in the number of people with hepatitis C dying from liver failure and liver cancer.

“This decline reflects the high uptake of direct-acting antiviral therapies among

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people with hepatitis C, particularly those with more advanced liver disease,” said Professor Dore, head of the Viral Hepatitis Clinical Research Program at the Kirby Institute, based at UNSW Sydney.

“Since 2016, around 60,000 Australians have been treated with these highly curative therapies, and now for the first time, we are seeing fewer people dying of hepatitis C-related causes.”

“The data we’re presenting today directly relates to people with hepatitis C-related liver damage that have started treatment since 2016, so we can expect to see further reductions in mortality,” said Professor Dore. “But, more broadly, only 30% of people living with hepatitis C in Australia have been treated, so we need to continue to raise awareness about these life-saving treatments.”

Australia is one of the only countries in the world to offer hepatitis C treatments at low cost, without restrictions based on a patient’s stage of liver disease or injecting drug use behaviours, and where general practitioners can also prescribe.

People who inject drugs are a key population for hepatitis C treatment and prevention, and related Kirby Institute research has shown that prevalence of hepatitis C infection among this group declined from 43% to 25% between 2015 to 2017.

Dr Jennifer Iversen from the Kirby Institute analysed national data from people who inject drugs attending needle syringe programs, and presented the results at the conference in Adelaide.

“Over the past two years, the proportion of people who inject drugs with hepatitis C who have initiated treatment has increased dramatically, from 10% to 41%,” she explained.

“This, combined with the reductions in prevalence of hepatitis C infection, tells us that people who inject drugs are not only taking up

hepatitis C treatment, but that they are also seeing their treatment through, and being cured of hepatitis C. “This is life-changing news for the individuals who’ve been cured of hepatitis C, but it has important populationlevel impacts, because when there are fewer people with hepatitis C infection, there is a decreased risk of transmission occurring.”

The findings on the reduced numbers of people dying from liver disease and the burden of hepatitis C among people who inject drugs, mean Australia is in a good position to meet World Health Organization hepatitis C elimination targets, which are to reduce deaths by 65% and new infections by 80% before 2030. Increasing treatment above current levels will achieve these targets even earlier. v

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The End of the Nightmare Anne’s Story

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y name is Anne. I am 44, and a Kaurna, Narangga and Ngadjuri woman. I became a positive speaker at Hepatitis SA to encourage more people from the Aboriginal community to seek treatment for hepatitis C, as it is now a simpler treatment than it was before.

I was diagnosed with hep C in the late 1990s, which wasn’t a shock to me, as my partner had hep C, and I was a drug user at the time. My mum’s family are all from medical backgrounds, and my uncle, who was a doctor, died of hepatitis. So hepatitis was something I was very conscious of.

In my younger days, I was a big drinker. I wanted to get tested to see what my liver function was. I was 99% sure I had hepatitis C. I got tested at my local GP, and at my next appointment, he said my results were positive for hep C. It wasn’t a shock, it was like, “OK.” I told my partner and my parents. I did used to tell people, “Look, if I have an accident, and there is blood, let me clean it up myself.”

I was very aware of blood contact. Not long after, I got a job in a hotel behind the bar with some kitchen work. I

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told the manager that I was hepatitis positive, so that if I did cut myself in any prep in the kitchen, they would let me clean it up myself.

My hours then got cut, and I ended up losing my job.

The manager had told all the kitchen staff about my hep status, and they then treated me like I had the plague. I would walk past them, and they would step away from me. They would work on the other side of the bench from me as though I was contagious or something.

My hours got cut because no one wanted to work with me in the kitchen. They couldn’t just get rid of me immediately, so they just cut my hours until there were none left. I couldn’t take them to any tribunal because I was casual. If I said it was discrimination, they could just say, “She was the last to be employed, so the first to go.” After that experience, I didn’t tell any employer of my hepatitis status. I didn’t tell anyone.

I am forever looking after children, everyone else’s kids for days and weeks at a time.

How was I to provide when you need nappies, clothes, formula, food and school lunches? I felt that shoplifting was my only option.

I don’t have any children on my pension card, so I am not eligible for anything. I was on quite a few shoplifting charges, and I had got to the point where I breached so many good-behaviour bonds that I was looking at jail.

However, I had heard they were not putting anyone in jail that was on hepatitis treatment, due to the interferon injection. My partner’s lawyer had just got someone a suspended sentence because of hep C treatment. So that I wouldn’t go to jail, I started seeing a counsellor and went to the doctor to say that I wanted to go on treatment, so that the courts would see that I was actively seeking help.

If you start rehabilitation, the courts will take that into consideration.

I went through the Aboriginal Sentencing Court—Nunga Court—and I had an aunty on the panel who could confirm that I was looking after all these kids. She vouched for me.

When it came to sentencing I had started going to the Nunkuwarrin Yunti health service doctor and started doing all the pre-treatment stuff like seeing the psychologist, psychiatrist,

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My nephew had just been born. I was now caring for three schoolchildren, and a newborn baby. I was taking the old treatment— four tablets a day and one injection a week for six months—so it was hard. It was early winter. I would get up in the morning, get the boys ready for school. I’d have all their lunches and uniforms done the night before. I had no car, so we would jump the bus, because I couldn’t afford the fare. I would get them to school, and then walk home, put baby down to sleep, and then I would sleep. Get up for baby’s lunchtime feed, then rest again. Walk to pick the boys up from school, and we would all walk home.

dinner, and then I was in bed by 7pm. The boy’s bedtime was 7.30, and I would hear them say, “It’s 7.30 now, TV off, we’re going to bed.” That was my routine.

The treatment made me so sick. I dropped a third of my body weight, and I was very weak. I was having blood tests every two days as my platelets had dropped so low, they were scared I may need a transfusion. Nunkuwarrrin Yunti has a transport service, so they would come pick me and the baby up and take us to my appointments.

Sometimes I was too sick, so they would come to my house to do the blood tests.

Now there are the the new DAA treatments, I’m telling

people, “Do it! It’s so easy!

It’s not hard anymore! There aren’t the side effects like I had!

It’s simple. It’s just tablets. It’s 12 weeks and you’re done!”

After the treatment, I did feel a lot better. Especially getting that final blood test to say I am cured. I actually put it on Facebook, I was so happy.

This horrible nightmare was finally over!

One of the barriers to treatment, I think, is people are still using, and they become forgetful unless someone gives them support at all times. Unfortunately, on weekends and in the middle of the night, there isn’t support. Local GPs need to offer that phone call reminder a week before, then

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Photo CC Mike Cogh (flickr.com/photos/mikecogh)

the dietician, and the liver specialist. And I got a suspended sentence! At that stage, I could have just stopped, because I had got what I wanted, I didn’t get jailed. But I decided to keep going because then I thought of my family, and of being there for my family, so I kept on with treatment.

They would take off their uniforms and make a snack while I lay down. They were so helpful with everything.

I would get up and cook

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spread of HBV and HCV

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the day before, and even in the morning of, to say, “Look, you have your appointment today.”

Some health services offer transport, but with local GPs it’s not always viable.

Cabcharges, bus tickets and reminder phonecalls are very important. Even if you gave people a cheap phone, they are not going to pawn them, and they can receive these reminders. Offering incentives like a $50 voucher on completion of treatment at the final blood test would help people dramatically.

Others people who still use drugs have heard stories that this treatment cost thousands of dollars, so you only get once chance.

It was really pushed on me that if I stuffed this up, it was my one chance, so if I kept using it wasn’t worth doing treatment. People still think this is true—they don’t understand that now you can still get treatment if you are using, and that you can do treatment again if need be.

I want to talk publicly about this because the rates of hep C are rising in the indigenous community.

There is a lack of information and education in many local GP clinics.

This isn’t the case with Aboriginal health services, but not every Aboriginal

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person goes to an Aboriginal health services. So all doctors need to be aware of events and services that Aboriginal health services and Hepatitis SA offer. Refer them! Have posters and flyers available, not just in the waiting room, but in the surgery as well, as some people are ashamed to pick up a flyer in front of other patients. Be flexible, as some patients do miss appointments due to arrest or jail, and are too ashamed to admit it to their doctors.

I hope my story has helped others understand some of the barriers indigenous people face. It is up to the community

as a whole to join forces to lower the rates of hep C. I would like to thank my counsellor, Elka, from Nunkuwarrrin Yunti for always being there for me, not just while I was on treatment, but always. Also, I would like to thank Nunk for all their support and services—not just for me, but for my partner too. If it wasn’t for this fantastic health organisation, I don’t think I would be the person I am today. And a big thanks to Hepatitis SA for giving me this opportunity for getting my story across. I would also like to thank my partner, Daniel. v Anne Mitchell

Nunkuwarrin Yunti Clinics nunku.org.au

182-190 Wakefield Street Adelaide Phone: (08) 8406 1600 Services available: GP and Health Worker Clinic, Dental Clinic, Liver Clinic, Podiatry Clinic, Paediatrician, Psychiatrist, Psychologist, Dietician 28-30 Brady Street Elizabeth Downs Phone: (08) 8254 5300 Services available: GP and Health Worker Clinic, Paediatrician, Psychiatrist, Dietician, Cardiologist

17 Beach Road Christies Beach Phone: (08) 8392 3500 Services available: Mental Health Recovery, Stolen Generation Support Services, Narrative Practitioner counselling service 94 Grand Junction Road Kilburn Phone: (08) 8169 7200 Services available: Tackling Tobacco

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HCV

Heart Health & Hep C your money on vegetables instead.

There’s an association between hep C and an increased risk of developing heart disease, so two recent articles about heart health caught our eye. Rose Magdalene explains:

Apparently the widespread belief that fish oil tablets are beneficial stems from early positive reports that were then capitalised on by manufacturers.

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he Heart Foundation says that the public, especially men, have gotten the wrong message about reducing the risk of having a heart attack or a stroke.

When men were asked what they thought placed a person at risk they mentioned poor diet, lack of exercise and being overweight. However, the Heart Foundation says that while these lifestyle factors can contribute to the risk, the most important things to manage are high blood pressure and high cholesterol.

Their recent study showed that although over 50% of men aged 45-74 had been told by their doctor that their blood pressure or cholesterol was high, only 1 in 20 of them took steps to address these conditions. This is especially worrying because it’s estimated that there are 1.4 million men in Australia who have a 1 in 10 chance of having a heart attack in the next 10 years. Unfortunately,

Takeaway messages Fish oil tablets for heart health are a waste of money— buy (and eat) more veggies instead. men are twice as likely to die from preventable heart attacks as women.

The Heart Foundation recommends that everyone over 35 (for Aboriginal or Torres Strait Islander people) or 45 (for non-Indigenous people) visit their GP for a heart health check. This is especially important for people with hep C who are at increased risk.

The second article reported on a major review of fish oil tablets which found that taking them regularly (even over a number of years) made no difference to the risk of having a heart attack. The author’s suggestion for people buying the tablets? Spend

Eating better and exercising more (for those who can) is always a good idea but visit your GP for a heart health check to find out whether you are at risk if you are aged over 35 for Aboriginal or Torres Strait Islander people, or over 45 for non-Indigenous people.

However, if you have ever experienced any symptoms don’t delay visiting your GP regardless of your age.

Finally, successful treatment of hepatitis C decreases the risk of developing heart disease – just one more reason why treating your hep C is a good idea.

For more, read Hep C: new cardiovascular risk? on our website, at bit.ly/hepsahcvcardiorisk. v

References •

www.hepmag.com/article/hepatitis-c-increase-risk-heart-disease

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www.heartfoundation.org.au/news/australian-men-are-gambling-with-their-heart-health

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The Final Frontier

Treating hep C under ‘impossible’ conditions

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ven in a country like Australia, with a high standard of living and a socialised health system, the battle to eliminate hepatitis can be challenging. So what is it like in a country like India, where poverty, population pressures and lack of health funding and education make every medical challenge so much harder?

Dr Sunil Solomon is Associate Professor of Medicine at the prestigious John Hopkins University School of Medicine. He spoke at the Australasian Viral Hepatitis Conference in Adelaide about his work on eliminating HCV among people in India who inject drugs.

“The first thing to remember is that in India itself there are approximately 6.3 million HCV-viremic persons.

And across India, primary modes of transmission

are contaminated medical injections, which account for the majority of our cases; blood and blood products, which is reducing because of increasing screening efforts; and, of course, injection drug use.

“India is right in the middle of the two largest heroinproducing regions in the world. We have the Golden Crescent on one side, and the Golden Triangle on the other side, and so we really have a lot of drugs coming into India from different parts of the country, and it’s estimated there are as many as 1.1 million injection drug users across the country.

“In India it’s predominantly genotype 3. In the northeastern states of the country we see a lot more genotype 6 because of an influx of drugs from Thailand, and we also have genotype 1 and

genotype 4 in some regions, so India is really one of the settings which is perfect for a pan-genotypic medication regimen, a medication that works no matter what type of HCV a person is infected with.”

Dr Solomon noted that until 2015 interferon was the standard method of treatment, but then cheap pan-genotypic direct-acting antiviral generic drugs started being produced by Indian drug companies. But despite having all this access to free or low-cost hepatitis C treatment, there is still a lot of debate within the Indian government on what is the best way to treat drug users.

“The other thing that’s also very critical to know about India is that we have a long-standing tuberculosis program, and our standard strategy for the delivery

The scene in the street outside Dr Solomon’s Chennai clinic during the floods which disrupted the study

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of TB treatment is directly observed therapy. There are over 1500 directly observed treatment centres for TB across the country, and that’s pretty much how we treat most of our TB. “So our hypothesis was directly observed therapy will be associated with high rates of frequent completion, and we wanted to try this with hepatitis C in people who inject drugs.”

Dr Solomon’s work focused on people who inject drugs living in Chennai, India.

Some clients were active drug users, and some of them had a past history of drug use.

Some were homeless, while others were working and couldn’t come into the health centre, so Dr Solomon’s team had field workers who would go and meet them at a venue of their choice—their house, a friend’s home, a bus stop or some other public place which they found was convenient.

“We also used biometrics, so when a field work outreach worker met the participant he actually had to scan his fingerprint. That’s one way of us knowing that they actually saw the participant instead of just telling us they gave the medicine to the participant, because we know people always fudge records to make it look like they’re

doing a really good job, and we wanted to be sure that participants were actually getting their medications.

“People who had to come into the clinic were compensated 100 rupees for their travel and their time.

The study didn’t concern itself with genotypes, and performed relatively few blood tests.

“We did one HCV RNA test at the start and we only did one HCV RNA test at SVR12 (a check to see if the virus is still undetectable 12 weeks after finishing treatment).

We did a blood check every four weeks just to check there were no toxic responses to the medication, and liver function tests were done every 12 weeks. And we saw no serious adverse events during the course of the trial.”

Those being treated in the study recorded extremely high levels of success, with the main problems being from a completely unexpected direction: the weather.

“Massive floods happened right after we started our study, right outside our clinic. We had boats going through the city streets, and our airport turned into a harbor. When things like this happen we really can’t get the treatment to those participants. Most people

who were on treatment during this flooding in Chennai missed about four to five doses. These are things we don’t plan for, but it is something we should consider when we’re planning strategies.”

Another unexpected aspect was psychological, based on cultural expectations about medicine. “Just to give you an example of what happens in India, patients getting pills only in a study like this were very upset that they were not getting injections.

It’s part of the Indian culture that injections are believed to work better, even though if we didn’t have medical injections in India we wouldn’t have so much hep C to begin with. Patients on interferon would tell us, ‘The medicine’s working—I’m having a fever!’ So they actually felt that there was something happening, which those on DAA pills do not.”

Despite the study’s success, Dr Solomon can still see better results in the future.

“With poverty, with homelessness and the environment—the floods and so forth—I can say that the shorter the treatment the better our results will get, so that people don’t have the opportunities to miss their pills. So a DAA that takes only eight or even four weeks to work, that’s my dream.” v

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Treatment Uptake

Improving opportunities for people who inject drugs

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he breakthrough in hepatitis C treatment with direct-acting antiviral medicines and their listing on the Pharmaceutical Benefits Scheme sets the trajectory to achieve national

Hepatitis C treatment Peer insights on barriers and motivators to Direct-Acting Antiviral (DAA) treatment uptake

prevalence and transmission targets. The uptake of treatment among people who inject was promising at the onset but evidence is emerging that uptake is plateauing and in some areas slowing, including amongst people who inject drugs. And so different strategies may be

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required to engage with these people, who are reluctant or sceptical about the new DAA treatment or may have barriers to accessing treatment.

People who inject have different experiences in their engagement with treatment. These differences relate to whether they have undergone treatment, or know of peers’ experiences with treatment, and how much treatment information they have. A new study by the Australian Research Centre in Sex, Health and Society (ARCSHS) talked to focus group participants who had undergone treatment.

Participants overwhelmingly agreed that they were relieved that DAA treatment was straightforward, with limited side effects, and minimal interference with daily activities. For the most part, this was the experience that was shared with peers. However, peer workers reported that some people in their networks had been told that there were no side-effects but then did experience side-effects.

While this would not deter them from promoting the treatments to their peers,

they expressed a need for treatment information from health services and promotional resources to be more accurate or nuanced, i.e. to include details of common side-effects.

Peer workers also reported that there are people who inject that have little knowledge about treatment due to not having access to needle and syringe programs (NSPs), peer workers or harm reduction services, or that may access those services but do not engage or connect with treatment information. “There’s a heck of a lot of people that are hep C positive that are just living with it because they think that because they’re still using they’re not going to be able to [go on treatment], or you know like I said they still know about the old treatment, and there’s that fear about it,” explained one participant.

Similar concerns were raised about whether being on an opioid substitution therapy program would preclude them from accessing treatment. There was also concern about affordability, and the cost of treatment was generally

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not known or perceived to be expensive. There was a perception that if people did not have a Medicare card this would exclude them from subsidised health services.

Furthermore, for many people who inject drugs, having their blood drawn for tests caused great anxiety due to previously painful and difficult experiences. This was a major deterrent, and participants would ‘search for’ or stick to nurses or medical workers who were skilled in venipuncture. One peer worker mentioned if their preferred nurse was not available they would rather return at another time than to endure a potentially uncomfortable procedure.

The continued encounters with prejudice and discriminatory behaviour by many people who inject in their daily lives, including with some health services, were identified as a major deterrent to them interacting or engaging with treatment providers. Participants spoke of the stigma attached to hepatitis C, and the pervasive negative stereotypes attached to people who inject drugs.

Hepatitis C stigma can also occur within the injecting

community. One person described being socially isolated and losing friends: “People found out because I was sick, and the minute they found out that it was to do with hep C I lost a lot of friends.”

Participants made a number of recommendations to improve treatment uptake rates: • Prompt and user-friendly assistance and support at treatment sites – a nonjudgemental approach to people who inject and a credible record of working with PWID demonstrates assurance of quality of service provision. This could include a workforce that comprises of peer workers and an in-house phlebotomist experienced with drawing blood from damaged veins.

• Peer workers positioned as integral in the development of strategies to promote DAA treatment, such as in the design of resource materials and service delivery modalities, peer education, and outreach. The meaningful participation of peers signals to the injecting

community that a service is informed by, and values, the expertise of people who inject.

• Consistency and alignment across all sectors in conveying information about the direct-acting antiviral medications. Specifically, the messaging should include who can access treatment (e.g. people who are currently injecting drugs), the treatment side-effects, the type of medicines and how they are administered, and post-treatment follow-up.

• Existing campaigns and messages promoting treatment, such as posters or information included in fit packs, while highly visible at treatment sites, i.e. NSPs and hospitals, only reach people who access those sites. Hepatitis C health promotion material should be wide-spread in other health service provision sites, pharmacies and in public spaces such as train stations and entertainment outlets.

Read more about the study at bit.ly/2xAKsJR. v

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Chinese Community Rises to the Challenge

$16,000 raised for Chineselanguage hep B service

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generous donation from a local doctor, support from a Chinese community association and donations from the community has ensured the continuance of an important hepatitis B service for another year.

The Chinese-language information and support service was set up in 2016 as part of a 2-year hepatitis B community education project funded by the Australian government via Hepatitis Australia. Funding ended in June 2018.

In its first two years the service had over 1,185 contacts with people seeking support after diagnosis, information on treatment and testing or

looking for help in getting appointments with health services.

Between 6% and 10% of Chinese Australians have chronic hepatitis B, compared to less than 1% in the wider population.

About 14,500 South Australians live with hepatitis B and more than a fifth (22%) of these people are from the Chinese community. Almost half don’t know they have it.

Left unmanaged, hepatitis B can lead to liver cirrhosis or cancer.

Hepatitis SA Hepatitis B Project Officer Chen Bin said it was important that the service continued uninterrupted.

CASA President Tan Tar Kim, past treasurer Siew Lim (standing, left to right); Hepatitis SA Board Chairperson Arieta Papadelos, Hepatitis SA EO Kerry Paterson and Dr Lee Wah Hin (seated, left to right)

“An interruption could lead to confusion, loss of confidence in our reliability and some people being left in the lurch,” she said.

“Even if we were to get funding later to restore the service, we would have to start from scratch because of the loss of confidence.

With support from the Chinese Association of South Australia (CASA), Hepatitis SA approached the community for donations to tide the service over while more secure funding was being sought.

Dr Lee Wah Hin kick-started the campaign with $10,000; a second donation of $5,000 from CASA and a further $1,100 from other individuals in the Chinese community brought the total funds raised to $16,100, thus seeing a basic service through for another 12 months.

Hepatitis SA would like to thank Dr Lee Wah Hin, CASA President Tan Tar Kim, Immediate Past President Julie Li, the CASA central committee, the CASA social committee and all the people who generously supported us with their time and money. v Cecilia Lim

More information about the project is available in the Viral Hepatitis 2018 conference presentation slides at buff.ly/2xwPwz3.

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New Hope with New Markers

Australian scientists identify new way to predict liver cancer Photo CC telemachus [flickr.com/photos/telemachus]

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ustralian researchers have found a way to predict the risk of liver cancer in people with chronic hepatitis B, promising earlier diagnosis, better management and potentially better prevention of hepatitis B-related liver cancer.

For some time now scientists have known that when the hepatitis B virus (HBV) replicates it leaves behind bits of its DNA in string form, different to its original circular shape. They refer to this as “splicing”.

They also noticed that higher viral load results in more splicing; and retrospective examination of blood samples showed that splicing increased each year prior to the development of liver cancer.

It has been noted that Asians with chronic hepatitis B are more likely to develop liver cancer. Asian hepatitis B genotypes (B and C) have

significantly greater levels of splicing than European genotypes (A and D) 1.

Presenting these findings at the recent Viral Hepatitis 2018 conference, Associate Professor Peter Revill from the Doherty Institute said one explanation of how the hepatitis B virus causes

cancer in the liver is that the double-stranded linear DNAs resulting from HBV splicing are more easily integrated into the similarly shaped human DNA. Researchers compared the levels of spliced HBV by

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Treatment & More Integrating treatments for opioid use disorder and infectious diseases Z Masoud, Infectious Disease Advisor, NY 2018. 2p article overview.

With so much activity taking place around treatment options it’s a good time to look at some of the surrounding issues, such as • •

concerns for specific population groups additional beneficial outcomes from treatment

All healthcare providers have a role in combating the opioid use disorder (OUD) epidemic and its infectious disease (ID) consequences, according to an article published in Annals of Internal Medicine. The US Dept of Health and Human Services recently developed 5 actions to support the development of good practice in this area: these 5 actions are described in this review. bit.ly/opioid_diseasetreatment

There is increasing evidence and understanding that the benefits of such an effective range of treatments are far reaching – and that the effort to connect with groups that still need to be treated should be just as far reaching.

The following resources describe some of the current thinking and activities around these topics.

The article overviews are a cost-free method of accessing information from the original subscription articles. If you are unable to access these online resources please contact us (ph 8362 8443 or email Cecilia@hepsa.asn.au)

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Additional benefits found in HCV eradication E. Kukielka, MD News, Intellisphere, Plainsboro NJ, 2018. 2p article overview.

therapy,’ published online in Alimentary Pharmacology and Therapeutics.

Participants who cleared the virus through treatment experienced a number of good outcomes including a reduction in insulin resistance which effects hepatic steatosis and a decrease in ALT as a measure of good liver function. bit.ly/hcveradication DAA therapy may improve select cognitive domains in HCV-infected patients V. Schad, Infectious Disease Advisor, New York: 2018. 2p article overview.

“Treatment ... appears to have a positive effect in some cognitive domains, which may lead to an improvement in mental health and fatigue, according to a longitudinal analysis published in the Journal of NeuroVirology”.

The study noted that after treatment completion the participants showed significant improvements in visual memory/learning, executive functions, verbal fluency, processing speed, and motor skills. bit.ly/daa_cognition

A review of the study, ‘Viral eradication reduces both liver stiffness and steatosis in patients with chronic hepatitis C virus infection, who received direct-acting anti-viral

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DAA therapy highly efficacious for HCV treatment in older adults V. Schad, Infectious Disease Advisor, New York: 2018. 1p article review.

As one of the largest population groups in need of treatment older people may have specific treatment issues such as more advanced liver disease. This review looks at information contained in an article published in the Journal of American Geriatrics Society which found that “Direct-acting antiviral therapy is highly efficacious for the treatment of hepatitis C virus infection in individuals >65 years; but those >75 are more likely to be at risk for significant drug-drug interactions and experience adverse events during therapy.”

as interaction overviews and DAA factsheets) as well as videos of treatment case studies etc. bit.ly/liverpoolhepdrugchecker Yarnin about hep C Hepatitis NSW, Sydney, 2017.

31p booklet.

Information about what hepatitis is, how it’s transmitted, what testing involves, what treatment is available - and what to expect from it. Contains additional information for mums and bubs and juvenile justice systems. Produced with the assistance of the Aboriginal Health and Medical Research Council. With Aboriginal artwork by Jasmine Sarin. bit.ly/yarninabouthepc

bit.ly/hcvchildren Ledispasvir-Sofosbuvir effective in children with chronic HCV infection Infectious Disease Advisor, New York, 2018. 2p article overview.

Review of an article recently published in the journal Hepatology. Includes results from a study of 6 to 12 year olds diagnosed with chronic HCV: with relevant medical history, treatment regimen, adverse affects and outcomes. bit.ly/treatment_chn

bit.ly/daa_olderpeople

Patients with HBV, HCV should receive hepatitis A vaccination

Drug Interaction Charts (Hep C) Hepatitis Drug Interaction Team, University of Liverpool, Liverpool 2018. Website.

This searchable database contains listings of all current Hepatitis treatment medications and comedications. Users can select from the listings and view the likelihood of any negative drug interactions with backup information about the likely effects.

Results can be printed in PDF format. This website also contains printable prescribing resources (such

managing and treating hepatitis C. This chapter focuses on children from birth onwards. It contains up-to-date recommendations in easy to read charts with comprehensive supporting information and references.

HCV guidance: recommendations for testing, managing, and treating hepatitis C - HCV in children American Assoc for the Study of Liver Disease, Alexandria VA, 2018. 6p chapter.

This is a section of a larger guidance document that provides detailed information about transmission, testing,

Gastroenterology via Healio, Thorofare NJ, 2018. 1p article review.

“Physicians should consider administering hepatitis A vaccines to their patients with hepatitis B and those with hepatitis C, according to a commentary published in Gastroenterology.” This article outlines the issues and statistics around Hep A vulnerability and outcomes for people with underlying liver disease. bit.ly/hav_vaccination

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A segment of introduced viral DNA (blue/green) integrating into the human host’s DNA (red)

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(continued from p13) looking at blood samples from over 150 patients with liver cancer and 370 patients who have chronic hepatitis B but had not developed liver cancer.

Results showed that people with more than 10% spliced HBV were at least three times more likely to develop liver cancer than those with lower levels of spliced HBV. For people with over 20% spliced HBV, the likelihood of developing liver cancer rose to over 23 times more.

Furthermore, it was found that in people with liver cancer who have elevated levels of spliced HBV, the levels of these spliced variants started increasing five years

before their liver cancer was diagnosed.

by people living with chronic hepatitis B.

Assoc. Prof Revill said scientists have thus validated the association between spliced HBV variants and hepatitis-B related liver cancer.

The current approach to dealing with that risk is regular monitoring with blood tests and ultrasound scans.

These “striking findings”, he said, meant that researchers have identified a new biomarker for hepatitis-B related liver cancer.

Liver cancer is among the leading causes of cancer death worldwide and in 2015, hepatitis B virus was the leading cause of new cases of liver cancer and deaths2.

Liver cancer is, undoubtedly, the outcome most dreaded

The identification of these new markers in the blood means that by checking spliced HBV levels in the blood, doctors can identify those who need to be checked further, especially if they also have other risk factors.

Almost 240,000 Australians live with hepatitis B with an estimated 420 deaths in 20153. Globally, 880,000 people die each year from hepatitis B related cirrhosis or cancer. v Cecilia Lim

Other Virological Mechanisms: Prof. Stephen Locarnini, VIDRL, Doherty Institute at HBV Cure Workshop 2017, Toronto (regist2.virology-education.com/2017/4HBV/14_Locarnini.pdf)

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Global Burden of Disease Study Focuses on Liver Cancer – JAMA Network (media. jamanetwork. com/news-item/global-burden-disease-study-focuses-liver-cancer/) 2

kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_HepBandC-Annual-SurveillanceReport-Supp-2016.pdf

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Useful Services & Contacts Hepatitis SA Free education sessions, printed information, telephone information and support, referrals, clean needle program and library.

(08) 8362 8443 admin@hepatitissa.asn.au www.hepsa.asn.au Hepatitis SA Helpline 1800 437 222 (cost of a local call) Adelaide Dental Hospital A specially funded clinic provides priority dental care for people with hepatitis C with a Health Care Card.

Call Hepatitis SA on 1800 437 222 for a referral. beyondblue Mental health information line

Hutt St Centre Showers, laundry facilities, visiting health professionals, recreation activities, education and training, legal aid and assistance services provided to the homeless.

P.E.A.C.E. HIV and hepatitis education and support for people from nonEnglish speaking backgrounds.

258 Hutt St, Adelaide SA 5000 (08) 8418 2500

SA Sex Industry Network Promotes the health, rights and wellbeing of sex workers.

Lifeline National, 24-hour telephone counselling service.

(08) 8351 7626

13 11 14 (cost of a local call) www.lifeline.org.au

SAMESH South Australia Mobilisation + Empowerment for Sexual Health www.samesh.org.au

Mental Health Crisis Service 24 hour information and crisis line available to all rural, remote and metropolitan callers.

13 14 65

1300 224 636 www.beyondblue.org.au

MOSAIC Counselling Service For anyone whose life is affected by hepatitis.

Clean Needle Programs in SA For locations visit the Hepatitis SA Hackney office or call the Alcohol and Drug Information Service.

(08) 8223 4566

1300 131 340 Community Access & Services SA Alcohol and drug education; clean needle program for the Vietnamese and other communities.

(08) 8447 8821 headspace Mental health issues are common.

Find information, support and help at your local headspace centre 1800 650 890 www.headspace.org.au

Nunkuwarrin Yunti An Aboriginal-controlled, citybased health service with clean needle program and liver clinic.

(08) 8245 8100

Youth Health Service Free, confidential health service for youth aged 12 to 25.

Youth Helpline: 1300 13 17 19 Parent Helpline: 1300 364 100 Vincentian Centre Men’s night shelter run by St Vincent de Paul Society.

Assistance hotline: 1300 729 202

(08) 8406 1600 Viral Hepatitis Community Nurses Care and assistance, education, streamlined referrals, patient support, work-up for HCV treatment, monitoring and follow-ups. Clients can self-refer. Contact nurses directly for an appointment.

Central

Margery - 0423 782 415 margery.milner@sa.gov.au Jeff - 0401 717 953 North

Lucy - 0401 717 971 Michelle - 0413 285 476 South

Rosalie - 0466 777 876 rosalie.altus@sa.gov.au

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Affected by hepat

Affected by hepatitis C? Photo © S. Allen

Calming the C • Information and support in a confidential, friendly environment • Speak to others who have had treatment • Partners, family and friends welcome

HACKNEY: 3 Hackney Rd Now meeting at HACKNEY, ELIZABETH Calming the C at the Port and PORT ADELAIDE 12.30–2.30pm Christmas meeting For 25 information, 8362 8443 4 Dec, 12–2pm • Tuesday, September phone Tuesday, at Wonggangga Turtpandi, • Tuesday, 23 October See over for dates • Tuesday, 20 November • Tuesday, 18 December

Free, after-hours support is available for anyone struggling with addictive behaviour.

The SMART (Self Management and Recovery

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(formerly the Port Adelaide Primary Health Care Centre) cnr Church & Dale St, Pt Adelaide All welcome!

Training) Recovery group meetings run for 90 minutes each Wednesday, from 5.30pm at 3 Hackney Road, Hackney, in the meeting room at the rear of Hepatitis SA.

Hepatitis C peer educators are available to provide treatment information and support to clients at the following services: DASSA Central Services Hepatitis C Treatment Clinic 91 Magill Rd, Stepney Tuesdays 9–12am

Calming th

DASSA Northern Service 22 Langford Dr, Elizabeth Monday fortnightly • Information and support in a co 10am–12pm friendly environment • Speak to others who have had t Upcoming dates: • Partners, family and friends welc Ring Lisa on 8362 8443 for details

Hutt Street Centre 258 Hutt St, Adelaide Now meeting at HACKNEY, E Wednesday weekly and PORT ADELAID 10am–12.30pm

For information, phone 836 WestCare Centre See over for dates 17 Millers Court (off Wright St), Adelaide Thursday weekly 10.30am–12.30pm

The program can assist with any problematic behaviours, including addiction to drugs, alcohol, cigarettes, gambling, food, shopping, internet and others. Focus is upon the addictive behaviour, not the substance itself.

For more information, call Lisa on 8362 8443, or visit smartrecoveryaustralia.com.

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