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Welcome to the latest edition of the Hepatitis Scotland e-Bulletin.
This edition features some upcoming events across Scotland as well as looking at some of the recent topics and research relevant to viral hepatitis - including consideration of the implications of the Welfare Benefits Up-rating Bill on successfully meeting the outcomes of the Scottish Government's Sexual Health and Blood Borne Virus Framework.
The Hepatitis Scotland e-bulletin can be an opportunity to share news, views, knowledge and experience throughout our national and sector wide contact list. If you have a piece of research, an idea, article or event you would like to see featured or promoted in our bulletin, please e-mail firstname.lastname@example.org.
Wednesday 13 March, 2013 - Glasgow City Chambers, George Square, Glasgow G2 1DU
Joint international conference organised by Hepatitis Scotland and HIV Scotland, supported by HPS. Presentations from European, London and Scottish speakers and organisations.
• Examine current Scottish health and social responses to BBVs in minority ethnic communities.
• To build the capacity of workers and services in order to engage with and provide best-practice treatment and care to migrants and to prevent secondary disease in migrant communities.
BME Conference booking form.
Wednesday 30th January 2013
This conference is being organised by Terrence Higgins Trust Scotland on behalf of the Lanarkshire BBV Networks, NHS Lanarkshire and North and South Lanarkshire Councils. Outcomes include:
• Improving understanding of barriers and challenges to reducing stigma in the Lanarkshire area.
• An action plan to positively address barriers and challenges, finding solutions that work across all areas of policy and practise.
To register your interest in attending please e-mail email@example.com. You will be contacted with more information on how to register for the conference nearer the date.
View the flyer here.
Scotland's Hepatitis C Action Plan is highlighted as an international model of good practice in an Economist Magazine Intelligence Unit report, supported through an educational grant by Janssen, which investigates the health challenge posed by the hepatitis C virus (HCV), and how systemic innovation can minimise its impact.
Tuesday 5th February 2013
An expert seminar being run by Health Scotland. The seminar will:
• launch the final report from the national evaluation of a Hepatitis C peer education pilot project
• hear from the staff involved in the pilot project about their experience of implementing the pilot
• showcase the transferable learning from other peer to peer projects in Scotland
• promote peer to peer initiatives with people who inject drugs and former injectors as an approach to harm reduction and blood borne virus prevention in Scotland
• discuss how to improve or further support peer to peer initiatives among people who inject drugs and former injectors in Scotland.
Who should attend?
BBV executive and prevention leads, Viral Hepatitis clinical leads, Alcohol and Drug Partnership Chairs and Coordinators, staff who work in addiction and harm reduction services, voluntary sector service providers, and advocates for drug service users.
To register your place click here.
For more information contact
Senior Health Improvement Programme Officer
Tel: 0131 536 8760/07770 848478
The implications of the Welfare Benefits Up-rating Bill for many of those those affected by Hepatitis C.
If poverty/deprivation increases, as would seem to be suggested by the DWP Impact Assessment published on the same day as the parliamentary debate for the bill, then it follows that social problems such as problematic drug and alcohol use, and by implication criminal activity; as well as housing and homeless problems, will also increase.
The UK government has admitted that the poorest 2 deciles of the UK population will be the most negatively affected by the Welfare Benefits Up-Rating Bill. The Scottish Index of Multiple Deprivation Report, published in December 2012, highlighted that 49.1% of Glasgow’s data-zones were among the 20% most deprived areas of Scotland. 44.4% of Glasgow’s data-zones are among the 15% most health deprived data-zones in the UK.
As current Joseph Rowntree Foundation and Audit Scotland reports indicate, reduced income will lead to increased physical and mental health problems – which can lead to still more of harmful behaviours listed above in a cyclical fashion. Recent international research showed that the prevalence of hepatitis C amongst homeless populations ranged from 3.9% to 36.2% and HIV prevalence ranged from 0.3% to 21.1%. This correlation between deprivation and poor health was supported by an Audit Scotland report into health inequalities. Indeed and not unexpectedly given the previous citations; according to the latest Health Protection Scotland figures, 40% of hepatitis C cases in Scotland are to be found in Glasgow.
With around 90% of the prevalence of HCV in Scotland being related to injecting drug use recent statistics from Greece, also make for alarming reading. As part of its austerity program, Greece has agreed to keep public health spending below 6% of GDP (OECD Average 9%). It has also cut social programmes and welfare by 40%. Along with a huge upsurge in IV drug use and prostitution, there has been almost a 1500% increase in HIV transmissions. There is a high likelihood of an increase in incidence of HCV and other BBV transmissions.
In December the Joseph Rowntree Foundation published a report into inter-generational worklessness. Whilst the UK government has sought to portray the idea that there are many families who have developed a culture of worklessness down the generations, this was found to be an extremely rare occurrence. Where it did occur it was due to many factors such as poverty, poor schooling, family and housing instability, offending behaviours, and mental and physical health problems – in many cases brought on by the cumulative effect of these other adversities.
Intergenerational worklessness/unemployment may be rare at the moment, but will it be so rare when lone parents are to be the worst hit by the Welfare Benefits Up-rating Bill? The DWP impact assessment states ‘lone parents are the family type who are most likely to be affected and also have the highest average change, losing £5 per week.’ Increasing poverty of lone parents on benefits, especially where they are unemployed, is surely only likely to lead to their children being more susceptible to many of the issues and problems raised in our featured research pieces.
A US study published by the JAMA Network (American Medical Association) looked at risk factors for adolescent behavioural problems for infants brought up during a time of economic difficulty. It sought to measure the probability of engaging in substance use and delinquent behaviours. It found that even where there was a small increase in mean regional unemployment rates, this increased the odds of cannabis use, smoking, alcohol use, arrest, gang affiliation and both petty and major theft.
In 2011 the Scottish Government launched the Sexual Health and Blood Borne Virus Framework. 4 key outcomes were:
Given the choices being made by the UK government and looking at the evidence presented in this article (which only scrapes the surface of a huge body of evidence and research into the relationship between poverty, addiction, problem drug use, crime and health) there is the potential for a serious impact on the outcomes of the Sexual Health and Blood Borne Virus Framework for Scotland? Will not some of the decisions produce exactly the opposite of the desired outcomes?
Deprivation and problematic drug use are inextricably linked. A high proportion of Hepatitis C prevalence in Scotland is linked to injecting drug use. Poverty increases drug use increases BBV incidence increases prevalence increases incidence and so the cycle goes on. Physical health and indeed mental health are negatively affected by poverty and, aside from the strain of living with viral hepatitis and facing multiple stigmas around drug use, poverty, claiming benefits etc – treatment for hepatitis C can have serious mental health side effects.
The DWP Impact Assessment states that the reforms deliver on the commitment to deliver a ‘more sustainable welfare system’ and claims that ‘key vulnerable groups have been protected’. Under policy objectives it explains that ‘The primary objective of this legislation is to deliver savings to the government that contribute to efforts to bring down public spending on welfare.’ The question is, will the government save money in the long term, and if so at what human cost?
How do these short term savings in Welfare look when positioned alongside the social consequences and resultant financial obligations of the state to meet the potentially very serious problems of future generations. For those either with, or at risk of hepatitis C, there is a higher likelihood for increased incidence of transmissions, greater health inequalities and negative health effects from the illness and an overall much poorer quality of life. Leaving aside any discussions of morality the actual cost to the health system is likely to be far greater than the savings thus far indicated
Those affected by viral hepatitis are often very marginalized and stigmatized members of our society. Even if appropriately assessed as fit for work, they are highly unlikely to easily access employment. Their prospects of overcoming their illness, whether physically or mentally, can be significantly determined by financial hardship. Spending large amounts of public monies on healthcare in this area, as per current Scottish Government policy, then directly contradicting it by imposing benefits changes that are likely to disproportionately impact on people living with BBVs appears at odds with the professed policy goals of the UK Government.
The United States Food and Drug Administration has placed a boxed warning, commonly known as a black box label on Vertex Pharmaceutical's hepatitis C drug Telaprevir, warning that the drug has caused fatal skin rashes in some patients.
For serious skin reactions, including rash with systemic symptoms or a progressive severe rash, Telaprevir, peginterferon alfa, and ribavirin must be discontinued immediately. The telaprevir drug label already contains information on the risk of serious skin reactions.
The labelling follows the deaths of 2 Japanese patients who died after developing severe skin rashes and a 3rd woman who survived after stopping treatment. Mild to moderate skin rashes were known to be a side effect of Incivek/Telaprevir since it's approval last year. Full information here.
A recent systematic review has looked into whether it might be necessary and/or indeed to cost effective to offer non HIV positive MSM regular HCV screening. The review included 21 studies between January 2000 and May 2012 as well as 4 abstracts from International Conferences.
Incidence of HCV transmission in HIV positive MSM was found to be rising, bucking the trend of other high risk groups such as IDU's where incidence is falling. However, some reports of increased HCV incidence among non HIV positive MSM has prompted calls for universal HCV screening of MSM.
The review concluded that regular HCV screening of HIV positive MSM was indeed merited, due to a variety of factors which could increase the risk of HCV transmission. These included sexual practises that might lead to transmission through blood to blood contact, HCV having been found in the semen of co-infected men, concomitant sexually transmitted infections which may increase susceptibility or transmission rates, the practise of serosorting (choosing sexual partners who have the same HIV status),higher viral loads in those co-infected, and transmission networks. Phylogenetic studies have shown that HIV lineages are sustained in HIV positive MSM in Amsterdam, London, Paris and Rotterdam.
Many studies have suggested strong links between types of sexual practise such as fisting and transmission of HCV. However, other studies have found no link between sexual behaviour and HCV acquisition, largely put down to the inefficiency of sexual transmission of HCV.
The review acknowledged that differences in incidence rates between HIV positive and non HIV positive MSM may be attributable to a detection bias. HIV positive MSM receive regular health checks and in many cases are routinely screened for HCV. Given that acute HCV infection is often asymptomatic, non HIV positive MSM not regularly engaged with health services may not be diagnosed.
The review concludes that there is sufficient evidence to justify routine screening for HCV in HIV positive men. However, it remains unclear whether non HIV positive MSM should be routinely screened, as incidence is similar to that reported in the heterosexual population where screening is not recommended. It recommends formal cost effectiveness studies and the validation of factors under consideration - such as sexual behaviours - which are not often included in medical assessments.
A World Report published in this month’s Lancet Journal puts the spotlight on London.
The use of Crystal Meth in London’s gay scene is on the rise. The phenomenon of ‘chill outs’ – post club parties where MSM, lesbians, and male and female heterosexual groups of friends continue taking drugs, sometimes for days at a time – as well as sex parties where MSM congregate at homes for group sex, pose real risks for transmission of BBV’s – especially where injecting of drugs is involved.
As well as Crystal Meth use, ecstasy, cocaine, ketamine, GBL and more recently mephedrone are frequently used. With many users bingeing on these drugs, as well as alcohol, for days at a time without sleep it can result in indulgence of high risk sexual practises. The transmission risk of HIV and other STI’s is serious enough if people are engaging in unprotected sex – especially when under the influence of drugs or in groups – but there is another facet to this story.
The practise of injecting crystal meth and mephedrone in order to get a bigger high (a practise known as slamming) is also increasing. This usually takes place at sex parties or chill-outs where many people share equipment without sterilising it.
At London’s CODE Clinic, which treats MSM involved in the harder, higher risk sex scene connected with drug use, users of crystal meth, GBL and mephedrone represent 85% of their consultations. In 2011, 30% of mephedrone and crystal meth users visiting CODE were injecting these drugs. In 2012, this increased to 80%. Of these, 70% reported needle sharing. David Stuart, part of the team at CODE, says that using these hardcore drugs helps MSM deal with the shame and vulnerability issues many have about having gay sex.
Stuart’s team see 9000 people every year, but he fears this is just scratching the surface as there will be many more who are not engaged with any services. Not only that but 75% of those using crystal meth, GBL or mephedrone are HIV positive and of these, 60% report not taking their ARV’s while high – meaning that they become more infectious.
Owen Bowden-Jones, a consultant psychiatrist and co-founder of the Club Drug Clinic working alongside CODE, says ‘Injecting these drugs for some MSM seems to have become sexualised, which is very unusual. We are trying to understand why.” He goes on to say that people will sometimes say that they knew everyone they were sharing paraphernalia with was HIV positive, but that they never considered hepatitis C. “We have a mixture of people who are HIV and/or HCV positive and negative injecting and sharing needles, potentially creating a public health disaster.”
The Health Protection Agency says that estimated incidence of HCV infection in HIV positive MSM reduced significantly between 2008 and 2011. However, a recent Swiss Cohort Study of HIV positive MSM showed rates of HIV co-infection have increased 18 fold in the past 15 years.
Charles Gore, President of the World Hepatitis Alliance, believes the HPA figures may represent a substantial underestimate. He said, “High levels of stigma associated with hepatitis C exist within the MSM HIV positive community. This coupled with a lack of knowledge about the virus amongst this population, means that the number infected with hepatitis C may actually be much higher than is currently known.”
Emma Devitt, a consultant in infectious diseases and expert in HIV and HCV co-infection, says that increased risk of HCV transmission comes from a multitude of risk factors including party drugs and their means of use, HIV positive men relaxing safer sex practises in an era of ARV drugs and having undiagnosed STI’s which break down the mucosal barrier in the rectum making it easier to contract HIV sexually.
It is currently estimated that 8% of HIV positive men in the UK are co-infected with HCV.
Many issues raised in these studies highlight the importance of regular sexual health check ups for MSM who frequently change sexual partners in order to protect against increased susceptibility to blood borne viruses, particularly HIV. If you would like to find out more about sexual health check ups visit the Gay Men's Health Website www.gmh.org.uk.
A systemic review and meta-analyses published in an online edition of Clinical Infectious Diseases has found that treatment of addictions for drug users during hepatitis C therapy results in higher rates of HCV treatment completion. They achieved pooled SVR rates similar to those obtained in registration trials in the general population.
Hepatitis C infected people currently using drugs have largely been excluded from HCV care. Much of the time they are advised not to begin treatment until they have dealt with their addiction - both by clinical staff and support groups for fear that will struggle to cope with the side effects of treatment while either in rehabilitation or while still using.
This review and meta-analyses in fact shows a positive correlation between achieving SVR and involvement in multi-disciplinary support for addictions and hepatitis C treatment.
Hep C Vaccine to be tested in humans
Inovio Pharmaceuticals has announced that it plans to begin human testing of it's hepatitis C DNA vaccine by the end of this year.
Water, filters and water containers: HCV risk
A recent study published in the Journal of Infectious Diseases has shown that HCV can survive in bottled water for up to 3 weeks. Water containers also presented a risk because the container could remain contaminated with infectious particles of virus even after washing. Depending on what the container is made of, there may be a varied degree of risk if containers are refilled. HCV was also traceable in filter material, with 10% of the original amount of virus remaining for between 24 and 48 hours. (Login required for study)
New gene discovered that affects hepatitis C clearance rates
How hep C reprograms liver cells
Targeting hepatitis C treatment: The importance of interleukin (IL)-28
Update on Gilead Sciences all oral hepatitis C drug trials
Tolerability and Efficacy of anti-HBV Nucleos(t)ide Analogues in HBV-DNA-Positive Cirrhotic Patients With HBV/HCV Dual Infection
Long term antiviral hepatitis B treatment advocated
Treatment of HBeAg positive chronic hepatitis B: interferon or nucleoside analogues
A newly published conference abstract has suggested a link between drinking sweetened beverages, especially diet drinks, and depression - especially in older adults. It found that people who drink more than cans or cups a day of fizzy drinks, particularly diet fizzy drinks, were 30% more likely to suffer from depression.
Meanwhile, those who drank 4 or more cups of coffee a day were 10% less likely to develop depression than those who drank no coffee at all.