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Hepatitis C a mong p eople w ho i nject d rugs (PWID) in India: High burden but limited access to care. Shruti H. Mehta, PhD MPH Professor, Johns Hopkins Bloomberg School of Public Health Department of Epidemiology Baltimore, MD. July 21, 2014.

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slide1

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 Health

Department of Epidemiology

Baltimore, MD

July 21, 2014

hepatitis c and injection drug use in india
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
Presentation outline & Data sources
  • Burden of HCV and liver disease among PWID in India
  • Access to care and treatment for HCV among PWID in India
  • 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)

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

Hepatitis C antibody prevalence

HCV/HIV co-infection prevalence

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

Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

slide5

Predominance of genotype 3 HCV infection but variability by region

New Delhi

Punjab

Uttar

Pradesh

Rajasthan

Manipur

Mizoram

West

Bengal

Subtype 1a

Subtype 1b

Subtype 3a

Tamil

Nadu

Subtype 3b

Subtype 6n

Solomon CROI 2013

high burden of liver fibrosis cirrhosis
High burden of liver fibrosis / cirrhosis

Chronic HCV

HIV/ HCV co-infection

Mehta EASL 2014; Solomon et al AIDS 2009

rapid hcv disease progression
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
The hepatitis C care continuum (aka CLIFF)n=5,777

Minimum Maximum

Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

variability by stage of drug use epidemic
Variability by stage of drug use epidemic…

Solomon IAS 2014 (POSTER LBPE13); Solomon EASL 2014

barriers to hcv diagnosis
Barriers to HCV+ diagnosis

14,450 persons

1,272 (9%)

EVER tested for HCV

13,178 (91%)

NEVER tested for HCV

  • 53% wanted to know their status
  • 25% were referred by a physician

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
  • 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 diagnosis
Facilitators of HCV+ diagnosis

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

ClinicalTrials.govIdentifier: NCT01686750

slide17

Acknowledgements

  • YRGCARE
    • Suniti Solomon
    • AK Srikrishnan
    • M Suresh Kumar
    • AK Ganesh
    • S Anand
    • P Balakrishnan
    • CK Vasudevan
    • Accounts
    • Data Team
    • Lab Team
  • Site staff & participants
  • 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