Remarkable era of treating HIV/AIDS and hep C

 

Death sentence revoked

The last few decades have witnessed remarkable milestones in treating HIV/AIDS and hepatitis C.

Not so long ago, being informed you were HIV positive, or had contracted hepatitis C, meant your entire future was thrown into grave doubt – if you had a future at all.

Over the last 35 years, however, AIDS has gone from a virtual death sentence to a perfectly manageable condition. Indeed, my Uncle – Professor of Immunology, Anthony Pinching – reflected that “the HIV/AIDS model of research had become the standard bearer for other diseases”.

Meanwhile, Hepatitis C treatments have reached new highs, with thousands given renewed optimism and even a cure.

Now we hear exclusively from Jane Anderson – a uniquely-placed expert who has been involved in HIV/AIDS for 30 years – and Mykie Leong Chadwick, an award-winning hepatitis C Service Development Manager, from MSD.

 

Chance of a lifetime

Jane Anderson Director at the Centre for the Study of Sexual Health and HIV, and Chair of the National AIDS Trust

I have been privileged to work in one of the most interesting and fast moving areas of medicine; to have worked with some of the most inspiring and committed clinicians, patients and activists, and to have witnessed enormous progress during the course of my medical career.

I started work over 32 years ago as a newly qualified houseman at St. Mary’s Hospital Medical School, which saw the arrival of the very first patients with AIDS in the early 1980s. In those early days almost everyone died, there was a great deal of fear and an intense period of learning about AIDS and HIV.  

By the time I became a consultant at St Bartholomew’s Hospital in 1990, although medications were being developed they were often unpleasant to take and not particularly efficacious. It was the use of drugs in combination and – in 1995 – the introduction of the protease inhibitors, which made the difference. We began to see fewer deaths and better outcomes.

Working in East London with a very diverse population I became increasingly interested in the impact of HIV among migrant and ethnic minority communities, and the particular needs of women and families. This lead to the establishment of the Centre for the Study of Sexual Health and HIV, at Homerton Hospital in Hackney. I have also been privileged to Chair the British HIV Association and work with both Public Health England and NHS England and, in 2015, I became the Chair of the National AIDS Trust – our main policy and campaigning charity for HIV in the UK.

More people than ever before – about 105,000 – are living with HIV in England, as effective therapy increases longevity and new infections continue. For those diagnosed in time and who have lifelong access to antiretroviral medications, HIV has changed from a universally fatal infection into a manageable condition for the long-term, with clinical and virological outcomes that are world leading.

Virological suppression is key, both to avoiding HIV related ill-health and to prevention, as those with completely supressed viral activity are not infectious to other people. More people with HIV are now living into old age, often with added complications. Late and undiagnosed infection is a major challenge – more advanced infection being associated, not only with increased morbidity and mortality, but also with the risks of unwitting onward transmission.

Estimates suggest that about 17,000 people with HIV are as yet undiagnosed and at least a third of people newly diagnosed have advanced infection, making expanded HIV testing a crucial intervention.

Despite enormous clinical advances HIV continues to take a significant toll on people’s lives. For example, quality of life for people with HIV is below that of the general population, poor mental health is common and HIV-associated stigma and discrimination is unrelenting. Knowledge and awareness about HIV within the general population is dispiritingly low.

We now have the wherewithal to ensure long life for people with HIV but, as economic constraints deepen we must not allow the phenomenal progress of the past 30 years to stall. The next few years are crucial in ensuring that treatment evolves to effectively meet the changing needs of an increasing and ageing population. Measures that improve quality of life in particular, through reducing stigma and discrimination, need to be implemented.

Following the 2012 health reforms all three commissioning bodies have responsibility for some aspects of the prevention and care pathway. Ensuring a joined up approach that delivers seamless care to people is a challenge that must be overcome. Making sure new information is translated into action on the ground – for example, securing access to Pre-Exposure Prophylaxis for all those at high risk of acquiring HIV – must be a key priority.

 

Cure in the community

Mykie Leong Chadwick Service Development Manager, Hepatitis C, at MSD

For the 214,000 estimated people chronically infected with the hepatitis C virus (HCV) in the UK[1], there are more treatment options available than ever before.

Over the last decade, mortality – due to hepatitis C-related cirrhosis or liver cancer – in the UK had been increasing at an alarming rate; over twice as many people died of HCV-related illnesses in 2014 than in 2005[2]; but, in 2015, there was an 8% reduction in the number of deaths related to HCV compared with the previous year[2].

In recent years more people are becoming aware of their HCV status and seeking treatment. As HCV is usually asymptomatic, however, it can be a challenge to identify infected people – the number of people in England diagnosed was five times greater in 2015 than in 1996[2], but half of HCV patients are estimated to be undiagnosed[3].

Treatments available for HCV have improved dramatically in the last few years, with the introduction of direct-acting antiviral (DAA) treatments. Historically, treatment used to be 48 weeks long, involved injectable and oral dosing, and was effective in only 56% of patients[4]. DAA treatments can now be taken as a single pill per day, are well tolerated and have cure rates exceeding 90%[5].

The majority of HCV patients are from marginalised groups in society, including people who inject drugs[6], however, infection could occur through unprotected sex, infected blood transfusions – received before September 1991[7] – or sharing toothbrushes, razors and tattooing or body piercing equipment.

The HCV team at MSD has a vision – achieving a future free of hepatitis C; for patients and the NHS. We believe that each person in the UK living with chronic HCV infection deserves to be cured.

As treatment is only a part of the solution to eliminate HCV, we are also committed to collaborating with organisations to promote awareness and prevention, especially among the populations most at risk for chronic HCV.

Curing a patient of HCV is an amazing achievement, but it is also about developing holistic treatment strategies and reducing risk of re-infection that gets me up and ready to go every day.

 

References

1: Public Health England. Hepatitis C in the UK 2016 report. Available online (last accessed – April 2017): https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/565459/Hepatitis_C_in_the_UK_2016_report.pdf.

2: Public Health England. Hepatitis C in the UK 2017 report. Available online (last accessed – April 2017): http://hcvaction.org.uk/resource/hepatitis-c-england-2017-report

3: National Institute for Health and Care Excellence. Costing template: Implementing the NICE guidance on ledipasvir-sofosbuvir (TA363), daclatasvir (TA364) and ombitasvir-paritaprevir-ritonavir with dasabuvir (3D) or without dasabuvir (2D) for treating chronic hepatitis C (TA365)

4: National Institute for Health and Care Excellence.  Technology appraisal guidance [TA75]: Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C

5: World Health Organization, Hepatitis C, July 2015. Available online (last accessed – April 2017): http://www.who.int/mediacentre/factsheets/fs164/en/]

6: Public Health England, Hepatitis C in the UK 2015 report, 2015. Available online (last accessed – April 2017): https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pdf

7: NHS Choices, Hepatitis C – causes. Available online (last accessed – April 2017): http://www.nhs.uk/conditions/hepatitis-c/pages/causes.aspx/]