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Uniting Voices
for HCV Elimination
4 July 2016
Royal Society of Medicine
London
MEETING REPORT
Working Document – October 6
2
3
TABLE OF CONTENTS
INTRODUCTION.............................................................................................
4
INTRODUCTION
Identifying and addressing key 2016 obstacles to the
elimination of hepatitis C as a public health concern
...
5
There is an urgent need for clear pathways to help individuals navigate
the clinical process so that those who test posi...
6
OPENING SPEECHES
Bryan Teixeira and Duncan Hamilton, meeting Chairs, officially opened
the meeting. Rachel Halford, The ...
7
were repeatedly cited as obstacles to hepatitis elimination as a public
health concern by health professionals and resea...
8
retention into care (30% of people living with HIV are on treatment and
undetectable).
Cascades can also be aspirational...
9
Key points:
 While deaths attributable to HIV in Western Europe have decreased
with the introduction of antiretroviral ...
10
3. Treatment access across Europe
Raquel Peck, World Hepatitis Alliance, London
Raquel Peck provided a snapshot of trea...
11
4. New Treatments for hepatitis C: Impact on morbidity and
mortality – What could possibly go wrong?
Helen Harris, Publ...
12
Projections for reducing HCV disease burden will not be met if
we fail to treat at least 70% of those with cirrhosis
Wi...
13
5. Current HCV research gaps and challenges
Graham Cooke, Imperial College, London
Graham Cooke explored the current ga...
14
6. Generics in the UK
Graham Cooke, Imperial College
There is increasing interest in access to generics for those who c...
15
Once people have been tested, we still need to ensure that they do
turn up for an assessment. Should we bring the asses...
16
shared across organisations and other stakeholders to help them
identify possible next steps in their programme plannin...
17
 Proposed activities: Development of simple patient information
leaflets and dissemination into the community. It shou...
18
Goal 2.1: Bring Hep C care into the community as an
alternative to hospital-based clinics
 Proposed activities: Develo...
19
3. South Asians Work-group
HCV infection rates in some South Asian countries, such as
Pakistan, have been shown to be a...
20
specialised travel agents, fact packs for mosques, oral
information sharing with Asian ladies).
 Potential partners: A...
21
the progress of prisons to date and research whether they are
using Fibroscans or Elf testing.
 Potential partners: NH...
22
However, this global recognition has not resulted in country action.
Despite the UK having signed up to the global heal...
23
opportunities to advance responses to HCV in the next 6 months and
beyond. These could be steps that simply complement ...
24
 Collaborate locally with potential partners who will be able to
engage and reach the populations most impacted by HCV...
25
PROGRAMME
Monday 4 July, 10.00 to 16.30
Morning
09.30 - 10.00 Registration
Royal Society of Medicine
10.00 - 10.20 Welc...
26
Afternoon
13.40 - 14.30 Key gaps and challenges and possible fixes across the HCV
treatment cascade in the next six mon...
27
PRESENTERS BIOGRAPHIES
Ben Collins
Ben is the convenor of ReShape, a London-based think tank to
reshape the response to...
28
Programme. The World Hepatitis Alliance is WHO’s official partner in
co-ordinating World Hepatitis Day each year.
Charl...
29
unit. She has 70 peer-reviewed publications and co-authored 4British
HIV Association Guidelines: ARV & Hepatitis, Malig...
30
committee and a member of the BHIVA executive committee. She is
the previous treasurer and current chair of the BASHH H...
31
ACKNOWLEDGMENTS
Thank you to all who have helped develop the Uniting Voices for HCV
Elimination initiative.
Thank you t...
32
Uniting Voices
for HCV elimination
4 July 2016, London
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Uniting Voices Meeting Report

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Uniting Voices Meeting Report

  1. 1. Uniting Voices for HCV Elimination 4 July 2016 Royal Society of Medicine London MEETING REPORT Working Document – October 6
  2. 2. 2
  3. 3. 3 TABLE OF CONTENTS INTRODUCTION..............................................................................................4 Identifying and addressing key 2016 obstacles to the elimination of hepatitis C as a public health concern ............................................................................................................4 OPENING SPEECHES....................................................................................6 THE HCV SITUATION NOW & IN THE NEXT SIX MONTHS.......................7 1.The UK HIV Treatment Cascade....................................................................................................7 2.Moving towards a UK HCV Treatment Cascade ....................................................................8 3.Treatment access across Europe................................................................................................10 4.New Treatments for hepatitis C: Impact on morbidity and mortality – What could possibly go wrong....................................................................................................................................11 5.Current HCV research gaps and challenges.........................................................................13 6.Generics in the UK..............................................................................................................................14 Comments on key opportunities and challenges across the HCV treatment cascade in the next 6 months. ..........................................................................................................14 KEY GAPS AND CHALLENGES AND POSSIBLE FIXES IN THE TREATMENT CASCADE INTHE NEXT SIX MONTHS...............................15 1.Co-infected workgroup......................................................................................................................16 2.People who use injecting drugs workgroup............................................................................17 3.South Asians Work-group ...............................................................................................................19 4.Prisoners..................................................................................................................................................20 CONCLUSIONS & ACTION PLAN FOR THE NEXT 6 MONTHS ..............21
  4. 4. 4 INTRODUCTION Identifying and addressing key 2016 obstacles to the elimination of hepatitis C as a public health concern Uniting Voices for HCV Elimination was a key stakeholder meeting that included clinicians, researchers, organisations, HCV patients and former patients, people sitting on government bodies and pharmaceutical representatives. The meeting aimed to serve as the starting point for strategic and ongoing collaboration to proactively address gaps in the HCV treatment cascade, in particular:  Awareness of HCV; awareness of curative treatment and related issues  Testing and diagnosis rates  Getting diagnosed individuals into treatment and care  Prevention of new infections and re-infection In 2015 there were an estimated 214,000 individuals chronically infected with hepatitis C in the UK. Deaths from hepatitis C related end stage liver disease have doubled over the last decade – the majority occurring in people under the age of 60 years1. Although more people with hepatitis C are now getting tested across the UK, awareness of hepatitis C infection is still relatively low and, as HCV can exist for years without symptoms, many people are not receiving the necessary care and treatment. As a result HCV is a leading cause of liver disease in the UK, with 15% of all liver transplants in England, carried out in patients with hepatitis C-related disease between 1996 and 20142. Furthermore, data from several countries has shown that even after being diagnosed, there are several stages at which people can disappear from the care continuum. Until recently, HCV therapy was based on a course of pegylated interferon and ribavirin. Side effects from this therapy are numerous and many patients either discontinued therapy or decided to wait until new treatments became available. Despite NICE recent approval of new, highly effective drugs for all patients, the majority of chronically infected people are still not being treated and uncertainty remains amongst patients and their doctors as to who is eligible for treatment. Patients who are either lost to care or just unwilling to undertake interferon-based therapy remain unaware of the recent changes and still need to be informed about these new treatment options.
  5. 5. 5 There is an urgent need for clear pathways to help individuals navigate the clinical process so that those who test positive do not fall through the net. Increasing awareness, diagnosing people, retaining them in care and ensuring access to care and treatment, including curative treatment, are all part of the care pathway or `treatment cascade` that ultimately determines who gets cured of hepatitis C. Following a series of face to face meetings with key stakeholders, the meeting was convened by ReShape and The Hepatitis C Trust to promote a coordinated approach and encourage HCV-impacted communities, organisations and individuals to take a more active role in supporting hep C patients, clinicians and researchers in their efforts. The meeting was based on a review of the hepatitis C treatment cascade, providing a snapshot of the present moment, allowing the participants to map out, immediately and clearly, areas of concern and develop ongoing coordination for follow-up actions. The full-day programme included panel discussions and presentations as well as a planning session focusing on developing solutions and follow-up community meetings in London, Birmingham and Manchester. This report is a summary of the meeting and of the key recommendations that will form the basis of a priority action plan for viral hepatitis to be implemented in the next 6 months. 1,2 Public Health England: Hepatitis C in the UK 2015 report
  6. 6. 6 OPENING SPEECHES Bryan Teixeira and Duncan Hamilton, meeting Chairs, officially opened the meeting. Rachel Halford, The Hepatitis C Trust Deputy CEO and Ben Collins, International HIV Partnerships (IHP) Director and ReShape Convenor, welcomed the participants and presented the concept behind the meeting. Rachel Halford welcomed the meeting participants, expressing her hope that this meeting would be the first of many events bringing people together to work towards hepatitis C elimination as a public health concern. She gave a brief overview of what had happened in the past year with regard to access to the new treatments, from the original approval by NICE, the set up of an operational delivery network (ODN) and the sequences put into place within ODNs to measure and hold the network to account. This sequence of events had eventually culminated in NHS England capping the number of people able to access the new drugs. The purpose of this meeting however was not to focus on treatment at this point but on the bigger picture. Rachel reminded the meeting that the World Health Organization has adopted the first ever global health sector strategy for viral hepatitis with a goal of eliminating hepatitis C as a public health threat by 2030. The UK government has signed up to this goal and, under the NHS constitution, patients have the right to drugs and treatments recommended by NICE, if doctors consider them as clinically appropriate for their patients. However, while securing patients’ access to all the drugs remains a priority for The Hepatitis C Trust and many other organisations, a successful HCV elimination programme will require more than just access to drugs. Other key areas need urgent attention, such as:  Prevention of new infections and re-infections  Diagnosis of people already infected  Linkage to care The elimination of hepatitis C by 2030, she told participants, could not be achieved by organisations working alone. All stakeholders needed to unify and work together to create a universal framework that would help mapping out the current situation, visualising where we are today, where we need to go and what is needed to get there. The aim of the meeting today is to start working towards the development of this framework. Ben Collins explained the background to the Uniting Voices meeting. ReShape is an independent think-tank which was set up to reinvigorate the community responses to HIV, hepatitis C, and related sexual and mental health concerns for best sexual health and well-being. During The Hepatitis C Trust conference last year, frustrations about drugs costs, lack of access to drugs and the general lack of community engagement
  7. 7. 7 were repeatedly cited as obstacles to hepatitis elimination as a public health concern by health professionals and researchers alike. Consequently, ReShape approached The Hepatitis C Trust to set up a ReShape’s lab to focus on these issues. ReShape’s labs are small working groups, set up to identify gaps, needs and possible responses. Their mission is to promote activities (either inside ReShape or externally), and act as vehicles for further action and evaluation. The HCV lab was set up in 2015, comprising patients living with HCV and activists. It became clear very early on that patients wanted their voices to be heard, they wanted to be united and they wanted to be SMART. The group also decided to be representative of all key populations and to move towards elimination together. Using the 4P analysis (position, problems, possibilities and proposal), the idea of hosting a stakeholders meeting to facilitate collaborative work towards the overall goal of elimination was developed. With this aim in mind, representatives of the HCV Lab carried on a series of face-to-face meetings with a diverse and representative range of clinicians, researchers, and organisations to shape the meeting agenda and draw up a list of participants. A series of outreach community meetings involving different key populations throughout the UK was planned for Birmingham, Manchester & London, as follow-ups to this meeting. THE HCV SITUATION NOW & IN THE NEXT SIX MONTHS 1. The UK HIV Treatment Cascade Laura Waters, Mortimer Market Centre, London Laura Waters gave an overview of treatment cascades, focussing specifically on the UK HIV Treatment cascade. Cascades are relatively new ways of looking at diseases, giving a broad overview of how well a given condition is managed. By looking at the overall picture rather than concentrating on people on treatment, as in clinical trials, they have emerged as a way to identify gaps in the continuum of care. A treatment cascade for an hypothetical condition works by first looking at the estimated number of people with the condition, then at how many are diagnosed, how many of those diagnosed are in care, how many are treated and how many are optimally treated. In the UK, the HIV treatment cascade shows us that out of an estimated 110 000 people with HIV, 83% are diagnosed, 75% of those diagnosed are on treatment and 70% of people on treatment are virally suppressed. In the US by contract, the HIV cascade shows that although most people with HIV are diagnosed, there is a big drop in
  8. 8. 8 retention into care (30% of people living with HIV are on treatment and undetectable). Cascades can also be aspirational and be the basis of public health targets and interventions. In 2014, UNAIDS 90-90-90 goals towards ending the AIDS epidemic by 2030 were set: 90% of all people living with HIV will know their status, 90% of people aware of their diagnosis will be on treatment and 90% of people on treatment will be virally suppressed by 2020. This means that overall 73% of all people with HIV globally should be undetectable on treatment. The estimates are that by achieving this by 2020, we could end the AIDS epidemic by 2030. The reality however is that globally only 32% of people of treatment are undetectable. Even though we are nowhere near achieving this target, there is already a call to add a 4th 90 goal to the HIV treatment cascade: 90% of people treated well are having a good quality of life. This adds a concept of well-being often missing from treatment cascades. 2. Moving towards a UK HCV Treatment Cascade Chloe Orkin, St Barts Hospital, London In her presentation, Chloe Orkin looked at HCV and HIV testing strategies in terms of similarities and differences.
  9. 9. 9 Key points:  While deaths attributable to HIV in Western Europe have decreased with the introduction of antiretroviral therapy in 1995, HCV mortality has been steadily increasing.  In terms of HCV care cascade, essentially we are looking at the great unknown. Estimates are that around 50% of people with HCV are being diagnosed, approximately 3% of people diagnosed are treated and 63% are achieving a sustained virological response.  Whether looking at the HIV or the HCV cascade, the first step of diagnosing 90% is not being reached: Screening. In HCV, testing is crucially important, as there is a cure available.  Unlike HCV, HIV testing is happening in many different places (Clinics, STI centres, saunas, prisons, prenatal clinic, GPs, DIY testing etc). Testing methods are tailored to the settings. In HIV, seroprevalence data underpins testing strategies. Testing in order to be acceptable and destigmatising has to be de-exceptionalised.  In the UK, HIV testing is universal in medical settings while HCV testing is targeted. This raises the question as to whether HCV cases are being missed. To answer some of this question, a roll out phase of a viral project testing for HCV in emergency departments is currently underway in Royal London Hospitals and so far the results indicate prevalence similar to the initial phase of the project: ≈3%, which is a lot higher than current estimates for the general population.  In HCV no anonymous seroprevalence work is done. At present, there is little willingness to discover the actual prevalence rate as it could have massive implications for costing.
  10. 10. 10 3. Treatment access across Europe Raquel Peck, World Hepatitis Alliance, London Raquel Peck provided a snapshot of treatment access across Europe, framed against the backdrop of the new sustainable development goals, including the elimination of hepatitis, to which 194 governments have committed by 2030, including the UK. This document carries time-bound goals: 90% of people must be diagnosed by 2030, and 80% must be treated. At present the UK only treats 3% of people diagnosed. In Europe, 28 EU countries account for nearly 70% of the total European population with an estimated 3.6 millions infections, of which about a third have been diagnosed, 133 000 treated and 97000 cured. The average age of people diagnosed is 54 years old, highlighting the need for rapid treatment. Out of these countries, 10 countries account for 85% of all infections and 6 countries account for 80% of treated patients (well out of the global 80% target needed for elimination). In France, from September 2016 hepatitis C treatment will be given to all people diagnosed (up to 230 000 people) and the government is currently looking at renegotiating prices. In Portugal, following great advocacy work from NGOs, the country is now committed to elimination. Interestingly, the government has agreed a deal whereby it only pays for people who are cured. In Germany, civil societies came up with an eco-hep model describing 2 scenarios: Maintaining treatment and screening rates at a cost of 13.2 billions by 2040 or maintaining treatment rates but targeting screening and prevention efforts at a cost of 14.2 billions. The results of this model showed that for a small difference in cost, the second scenario would have a huge impact on hepatitis rates. Germany is unofficially working towards elimination by 2028.
  11. 11. 11 4. New Treatments for hepatitis C: Impact on morbidity and mortality – What could possibly go wrong? Helen Harris, Public Health England, London Helen Harris spoke about the new treatments and their potential impact in terms of reducing morbidity and mortality. She also highlighted some of the difficulties that could arise on the road to elimination of hepatitis C as a serious public health threat. Although viral hepatitis had a global burden of 1,46 millions deaths in 2013, until recently, viral hepatitis has generated a lower level of attention than other diseases with lower disease burdens, like HIV and TB. To reach the new WHO target of elimination of hepatitis C as a major public health threat by 2030, diagnosis and treatment rates need to increase to drive down morbidity and mortality (by 10% by 2020 and 65% by 2030) while the number of new infections needs to decrease (by 30% by 2020 and 90% by 2030). New drugs have the potential to revolutionise HCV care; thanks to their shorter treatment durations and less side effects, they are easier to roll out in community settings. However, these new direct acting antivirals are very expensive. It is therefore essential to identify the consequences of focussing efforts on tackling severe liver disease vs reducing transmission via treatment as prevention. To figure this out two mathematical models were used:  A back-calculation model to estimate the impact of treatment of mild, moderate and compensated cirrhosis on new cases of HCV related end stage liver disease and hepatocellular carcinoma.  A dynamic model to determine the impact of the same treatment strategies on incidence and prevalence of chronic infection in people who use injecting drug, the main group at risk of infection in England. The results showed that dramatic reductions in HCV-related severe liver disease are possible when people with advanced disease are successfully treated, but this level of impact will not be sustained beyond 2020 if only people with cirrhotic liver disease were targeted. People with moderate stage disease also needed to be treated, and they needed to be tackled quickly. Diagnosis and retention in care therefore were key to this strategy. CONCLUSIONS: WHAT IS NEEDED FOR ELIMINATION  Active screening & strong prevention efforts  Switching to the new drugs & expanding treatment to everyone  Increasing eligibility to older patients to reduce liver related deaths  Stronger patient voice
  12. 12. 12 Projections for reducing HCV disease burden will not be met if we fail to treat at least 70% of those with cirrhosis With regards to treatment as prevention, in England the main route of transmission is through injecting drug use. Theoretically if we treat those individuals we should be able to reduce the prevalence within this group, and therefore the number of people getting infected. Using the same strategies of treating people at different stages of the disease, the modelling results showed that treating mild-stage PWIDs was required to make a substantial impact on transmission. Treatment as prevention, combined with other harm reduction measures have the potential to reduce the prevalence and incidence of HCV among PWIDs and need to be tested urgently. SUMMARY OF CURRENT CHALLENGES & NEEDS  Cost of new drugs  Need to restructure treatment services to facilitate rolling-out drugs to all  Need to raise awareness to increase testing  Need for improvement in prevention and harm reduction  Need to all work together as a group
  13. 13. 13 5. Current HCV research gaps and challenges Graham Cooke, Imperial College, London Graham Cooke explored the current gaps in research as it stands today, focussing in particular on what will be important in the next 5 years and what could be tested. Key points: We still need a vaccine. As we get through the patients pools and we start to think about elimination, evidence coming through from modelling studies support this. In terms of re-infection and recurrence, if we model out the risk of recurrence after successful treatment in people at risk, we see recurrence rates of around 5%, possibly higher for HIV co-infected people. Projection over time for MSMs co-infected with HIV shows that only by scaling up treatment, we can start seeing an impact on transmission, however it will need to be combined with other interventions in terms of risk reduction. We need to focus on how to prevent people from being reinfected. We will need better strategies for diagnosing people and will need to diagnose as many people as we can. We will also need to be smarter on how to use the new treatments. New drugs are in development and coming forward for licensing but we have not yet worked out how to use these treatments effectively without “over-treating” people. A recent case from Glasgow illustrates that some patients can be cured with much shorter treatment. This would also have an impact on costs. More data on resistance is needed. At present, resistance testing is not part of tailored therapies but as data emerges, this will probably change. So far, resistance does not appear to affect patients on longer treatment, however it is worth noting that resistance is not totally understood yet. New sequencing methods will give us more information both on resistance but also on transmission. To improve treatment rates, we will need to overcome the costs barriers. Making smarter use of the treatments we have and not over- treating patients will help reduce some of costs. At the same time, the imminent arrivals of newer and effective drugs will increase the competition between manufacturers. Flat pricing structures, increased level of activism from the community sector and increased access to generic treatments are other ways of achieving price reduction. Finally, HCV is a global challenge: Viral hepatitis is the 7th cause of mortality in the world in 2016. Hepatitis C has overtaken HIV, malaria and Tuberculosis as a cause of mortality.
  14. 14. 14 6. Generics in the UK Graham Cooke, Imperial College There is increasing interest in access to generics for those who cannot access treatment through the usual channels. Generics are the same compounds as original pharmaceutical products and are usually produced off patent or with some voluntary licence agreement. Patients can access generics online or through buyer’s clubs, such as fiXHepC and are entitled to import drugs for 3 months supply. The Redemption study is currently supporting over 400 patients worldwide taking generics versions of Sofosbuvir, Ledipasvir and Daclatasvir. Outcomes so far are broadly similar to patients receiving patented drugs with few side effects. Their use is fast becoming a day-to-day question for the clinics: are generics safe, will they work, will the clinic monitor the patients using them? Monitoring patients taking generic drugs not prescribed in the UK may be difficult to arrange and support varies between Trusts. They are also tensions between specialities. Issues around equity and using resources in clinics have been raised. Guidelines are currently being written and should hopefully be ready soon but it will be down to each Trust to negotiate issues related to monitoring. Comments on key opportunities and challenges across the HCV treatment cascade in the next 6 months. Charles Gore, Hepatitis C Trust Charles Gore summed up the morning discussion, and set the scene for the working groups in the afternoon session by highlighting some of the questions that would need answering if we were to respond to the HCV epidemic successfully. Key points: Elimination has to be our goal. The UK has signed up to it, and it is the global ambition. We should be able by 2030 to have a reduced mortality by 65%. Although cascades are a very useful way of looking at the management of hepatitis C, they do not always help us think about the details. For example, prevention does not feature in the treatment cascade but re-infection is potentially a critical issue in all key populations. Awareness of HCV and how we tackle stigma will be crucial to preventing re-infection. Questions remain on how to get the large amount of people who are undiagnosed to come for testing, as well as how often and where?
  15. 15. 15 Once people have been tested, we still need to ensure that they do turn up for an assessment. Should we bring the assessment to them instead? And how do we keep people engaged especially if we are not treating them? Run rates currently are creating barriers to treatment in the community, if not everyone can be treated, it is difficult to maintain interest and retain people into care. We also need to look at ways to support people, not just in term of linkage to care but also in terms of quality of life. Treatment must be more than just a medical intervention. People often need support to stop being a person with a chronic illness and they need help to move on. Re-infection is creating reluctance to treat and we need to know at which point and where this is occurring and we need to think about strategies to make sure it does not. Do we use cluster treating, do we use messages, and where, what kind and how? None of these questions and challenges can be addressed without community intervention and collaboration across the sector. KEY GAPS AND CHALLENGES AND POSSIBLE FIXES IN THE TREATMENT CASCADE IN THE NEXT SIX MONTHS The afternoon session was dedicated to exploring the current gaps and challenges across the treatment cascade. The participants were split into 4 groups, each focussing on a key population:  Co-infected  People who use injected drugs  South Asians  Prisoners Each group was asked to look at the overall picture and select 3 key topic areas, which they felt would be crucial to improve the HCV treatment cascade in the next 6 months, underscoring doable goals in each of these areas. Based on this initial assessment, they then went on to identify specific actions that could be taken by organisations, health professionals and individuals in order to reach the stated goals. These could be steps by individual organisations, actions across a network of organisations or actions to be taken by the affected communities. The ensuing worksheets were to provide the foundation of a framework around which all the key stakeholders could engage and strengthen the response to hepatitis in the next 6 months as well as improve the collaboration and coordination of activities across the sector. It is hoped that ideas generated from these workgroups will be
  16. 16. 16 shared across organisations and other stakeholders to help them identify possible next steps in their programme planning. In addition to shaping key opportunities and actions for the next 6 months, the group sessions also compiled a list of other gaps and challenges, which although not considered immediate priorities, will need to be revisited at a later date. 1. Co-infected workgroup People living with Hepatitis might also have co-infections such as HIV. Linkages between HIV and hepatitis services, as well as access to effective treatments for both infections, are needed to ensure the effective management of co-infection and to secure the health gains acquired through antiretroviral treatment. With decreased HIV-specific mortality, HCV has become a major problem in co-infected patients. Despite a long history of activism around HIV, there is still a lack of engagement from affected communities around hepatitis and a substantial amount of stigma and ignorance surrounding the virus. Public education and awareness activities will be key strategies for improving public understanding of viral hepatitis and constitute the first step on the road that will ultimately lead to an informed and active community. Goal 1.1: Build a community around hepatitis  Proposed activities: Development of safe spaces for discussions around hepatitis C and HIV (physical spaces but also virtual spaces). These could include movie nights, stigma confrontation events, peer support groups; social media pages. These safe spaces will provide a network of support and understanding in a “controlled” environment where people will feel comfortable enough to contribute to the discussion on HCV, HIV and related issues and support one another without feeling marginalised or stigmatised. Safe spaces can also help bridge gaps between the different communities and link potential allies in various social surroundings, thus opening up the possibility of stronger united communities.  Potential partners: GMFA, ReShape, Positively UK, Hepatitis Trust.  Needs: Spaces, network of people, promotion of events. Goal 1.2: Produce a consistent guide on HCV acquisition, treatment and rights relevant to all affected communities Due to rapid changes and the diversity of populations affected by HCV and HIV, it is currently difficult to find resources that are easy to read and with clear defined messages that would speak to all communities.
  17. 17. 17  Proposed activities: Development of simple patient information leaflets and dissemination into the community. It should include a call to action to increase participation and create empowerment: once you have read the leaflet, this is what you can do to participate.  Potential partners: BASHH, I-Base, HepC Trust, NAM etc.  Need: Development and distribution costs. Goal 1.3: Create a national prioritisation system for treatment There is currently no national prioritisation tool, only variable scores. A national prioritisation system would enhance decision- making and facilitate equitable access to treatment across the country. Health professionals treating patients also need guidance regarding the use of rapidly evolving regimens, including decision support tools.  Proposed activities: Development of a fair and equitable proposal for prioritised groups based on a point system. This will need to be transparent with justifications.  Potential partners: NAT with the help of the HepC Coalition and HepC Trust.  Needs: Agreed cooperation, a digital space to produce this tool, development of a parliamentary group to lobby for this. 2. People who use injecting drugs workgroup Limited knowledge about HCV, limited accessibility to testing locations, negative perceptions from healthcare staff about poor adherence and ongoing substance use, are all barriers to HCV testing and care for people who use injecting drugs. When planning interventions for people who use drugs, it is therefore important to ensure that services are low threshold, accessible, and responsive to the needs of people who use drugs. At the same time, community awareness needs to be improved by developing and mobilising community resources: outreach, face- to-face and peer-to-peer contacts through, for example, community cafés. Outreach helps to bring treatment and testing services to people and raises awareness about available health services. Outreach peer workers can also be a reliable source of harm reduction information and services, not only to people who use drugs and their families and friends, but also to agencies providing services to drug users to whom they can provide invaluable feedback . Outreach workers can be opinion-makers and raise awareness of HCV and drug use among communities.
  18. 18. 18 Goal 2.1: Bring Hep C care into the community as an alternative to hospital-based clinics  Proposed activities: Development of a community clinic - A community-based clinic staffed with key health professionals would fill both a therapeutic function and a diagnostic function. Additionally easy and friendly access to care would engage people to participate in a more productive dialogue about their care.  Potential partners: Hospital Trust, CCGs, drug services and other relevant services, services users/peers, commissioners.  Needs: Development of peer support to ensure treatment take- up and adherence and recruitment and training of “champions” in the local area to support the clinical team and their patients; Hospital buy-in of relevant staff; Mobile fibroscan for the clinic; Service level agreement agreed with commissioners; Development of pack for setting up a community clinic; Goal 2.2: Raise community awareness  Proposed activities: Development of a peer-to-peer model and of staff training; advertising campaign.  Potential partners: Commissioners, services providers, community groups, peer coordinators, champions.  Needs: Good information, support and training for peers, access to overall support and expenses. Staff training. Open doors policy for support services. Goal 2.3: Reach out to people who are not accessing drug services  Proposed activities: Outreach and testing campaigns in homeless hostels, pharmacies and needle exchanges; testing at point-of-care; staff member at testing point and peers training so they can do the test; “Talk and test” activities with peers giving the information then performing the test.  Potential partners: Needle exchanges; pharmacies; housing providers; local authorities; champion lead services.  Needs: Training for peers and pharmacists to perform the tests, funding for testing kits, development of pathways.
  19. 19. 19 3. South Asians Work-group HCV infection rates in some South Asian countries, such as Pakistan, have been shown to be as high as 5 to 7.5%. Medical care is very much injection-based and carries a high risk of HCV transmission. Furthermore, common cultural practices such as block circumcision, shaving rituals (at births, during Haji) are also high-risk activities. People of South Asian origin have been shown to be substantially at higher risk of HCV than the general UK population, particularly if they have visited high prevalence countries and have received medical or dental treatment or shared razors while abroad. At the same time, relatively low levels of awareness and stigma surrounding hepatitis C continue to pose obstacles to testing and care. Goal 3.1: Improve testing rates and retention in care by raising awareness of hepatitis C  Proposed activities: Awareness campaigns on local radio; development of “Asian Ladies” groups to talk to the community (Reading has been running very successfully such an initiative which could be rolled out in other cities), awareness campaign on BBC Urdu.  Potential partners: HepC Trust, local radios, existing Asian ladies groups, NHS services, local religious leaders.  Needs: Identify sites to send people for testing and care, collaboration with partners to be set up, identify existing training resources to train Asian Ladies. Goal 3.2: Distribution of emergency medical travel kits  Proposed activities: Distribution of medical travel kits, with set of colour-coordinated needles. These kits have already been produced, but need to be rolled out for under £10. To be easily accessible, they also need to be made available in a variety of settings related to the travel industry specialising in South Asia.  Potential partners: Hep C Trust, manufacturers of travel kits, pharmacies & travel industry for promotion and distribution.  Needs: Negotiations with travel kits manufacturers through the HepC Trust, contact with travel agents, travel clinics etc. Goal 3.3: Address Cultural differences  Proposed activities: Awareness campaigns and information dissemination on the risks of circumcision and shaving in culturally and linguistically appropriate ways (leaflets in
  20. 20. 20 specialised travel agents, fact packs for mosques, oral information sharing with Asian ladies).  Potential partners: Asian Ladies, Imams and council of mosques, travel agents.  Needs: Collaboration with councils of mosques, development and training of Asian ladies group. In addition, all 3 goals would require an in-depth look at the various stages involved in the process of travelling to determine where hepatitis C awareness could be promoted and information distributed: Airlines, travel clinics, travel agents, visa services etc. 4. Prisoners In October 2013 Public Health England (PHE), NHS England and the National Offender Management Service (NOMS) agreed to introduce an opt-out testing policy for hepatitis B, hepatitis C and HIV across the prison estate by 2017. Although some prisons, such as HMP Pentonvile, have implemented the policy, there are still issues that need to be addressed across the prison estate. There is, in particular, no clear picture as to which prisons are implementing the policy and which are not, highlighting the need for a tracking tool in order to map out prison regions and uptake of this policy. At the same time, prison staff lacks awareness of HCV and prisoners lack awareness of both HCV and opt-out testing. The development and training of HCV champions or Opt-out champions in each prison would provide ownership on ensuring the policy is fully implemented. Goal 4.1: Raise awareness amongst prisoners, health care staff and prison staff on HCV and Opt-out policy testing  Proposed activities: Training of staff: 1 or ½ day training delivered by voluntary organisations such as HCT who already have delivered some training. Education for prisoners utilising prison radio, poster and leaflet campaigns. Identification and training of HCV champions in each prison.  Potential partners: PHE/NOM’s, Hepatitis C Trust, NHS Health and Justice.  Needs: Training programmes for health and prison staff, involvement of voluntary organisations, leaflets/posters/DVD. Goal 4.2: Implementing the opt-out testing strategy across the prison estate  Proposed activities: Monitor the roll out and hold areas and specific prisons to account, using the regional format map-out
  21. 21. 21 the progress of prisons to date and research whether they are using Fibroscans or Elf testing.  Potential partners: NHS England Health and Justice, PHE, voluntary sector organisations.  Needs: Mapping of all regions for individual prison data regarding the implementation of opt-out policy & the use of Fibroscan or ELF, details of hospital links, ODN areas. Goal 4.3: Support in place for all prisoners testing positive, whether still in prison or released into the community  Proposed activities: Train peers in prison and local communities to work with patients, whether in prison or in local communities, and help expanding access to testing and treatment. Utilise trained Peers on patient councils to provide support to patients in prison ensuring their voices are heard in the local ODNs.  Potential partners: Community Rehabilitation Companies (CRC), prisoners who are engaged with services, patient council members, voluntary organisations.  Needs: Agreed working arrangements between voluntary organisations and prisons/CRC, access to prisons, promotion of peer-to-peer in prisons. CONCLUSIONS & ACTION PLAN FOR THE NEXT 6 MONTHS In May 2016, the 69th World Health Assembly (WHA), formally adopted the Global Health Sector Strategies for HIV, viral hepatitis and sexually transmitted infections (STIs). This was an important milestone, which fully aligned the three strategies with the attainment of the Sustainable development goals. The World Health Organization’s (WHO) global health sector strategy on hepatitis defines for the first time global targets of eliminating viral hepatitis as a major public threat by 2030, starting with a 30% reduction in incidence by 2020. The strategy defined a set of priority actions and interventions for countries to undertake, centred around services and medicines, which need to be covered in whole or in part by public funding to ensure access to services to all who need them. This national health improvement framework covers the entire cascade of care, from prevention and diagnosis to treatment and care.
  22. 22. 22 However, this global recognition has not resulted in country action. Despite the UK having signed up to the global health strategy, along with 193 other countries, access to the new treatments has been restricted to 10 011 patients per year by NHS England. Current mathematical models suggest that to reach the 2030 target of elimination of hepatitis C as a public health threat, many more patients will need to be treated. The lack of a national improvement framework is also contrary to the realisation of the hepatitis strategy goal. Public Health England 2015 report estimates that 214,000 individuals were chronically infected with hepatitis C in the UK, with a majority of infections occurring in marginalised groups. Deaths from hepatitis related end stage liver disease have doubled over the last decade. The new direct action antiviral regimens, with higher cure rates, shorter therapies and less side effects, have the potential to dramatically reduce morbidity and mortality. In this era of curative treatments, the social and human cost of hepatitis is clearly preventable and people should be receiving the full range of hepatitis services they need, as stated in the April 2016 WHO guidelines for the screening, care and treatment of persons with Chronic Hepatitis C infection. While the fight to secure access to treatment for all patients must continue in order to reach the 2030 target of elimination, community involvement and mobilisation throughout all stages of the care continuum are also essential elements to success. Raising awareness in the community, and among health-care workers and services providers, to reduce stigma and educate about the benefits of testing and prevention, remains key to hepatitis prevention and management. Furthermore, the community can play a key role, from the development of appropriate services, the support of HCV patients and of their care team, to providing feedback on the services provided. Success will only be achieved with the support of a broad mix of people united across the HCV sector. By working together on the development of an action plan and a set of achievable goals for the next 6 months, Uniting Voices is hoping to improve community engagement and collaboration and coordination of activities across the sector. The key desirable goals highlighted during the 4 afternoon workshops - co-infected, PWIDs, Prisons and South Asian populations - provided the foundation for the overall Uniting Voices action plan. They have been grouped under 3 key areas, spanning all 4 populations and covering all steps of the HCV treatment cascade: testing, diagnosis, treatment and care. A set of desirable goals is listed under each priority area. It is hoped that this action plan will be used as a foundation around which stakeholders and communities can identify actionable
  23. 23. 23 opportunities to advance responses to HCV in the next 6 months and beyond. These could be steps that simply complement existing activities or new activities. Stakeholders are encouraged to identify: specific actions they, or their organisation, could take to implement these goals, partners they could engage in collaboration and key and effective messages that would facilitate their realisation. Successful implementation of these goals will require sustained momentum and continued innovation. Regular meetings to monitor progress and strategise about overcoming obstacles, capitalise on new opportunities or emerging needs will be conducted. Action plan for the next 6 months 1. Priority area 1: Educate providers and communities  Develop simple but innovative and aspirational messages that can be use to unite voices around all activities, to gain media support and increase organisations and communities willingness to participate.  Conduct public education and awareness activities in communities affected by HCV through film nights, stigma workshops, webinars, radio broadcasts, social media and peer support in 3 cities across the UK (London, Birmingham and Manchester).  Publish a clear guide to hepatitis C that will speak to all groups, including a call to action to increase participation and engagement.  Train champions who can go out in the community to raise awareness (Prison champions, Asian Ladies group etc).  Involve health providers at all levels in the development and implementation of this work-plan to raise their awareness of opportunities for prevention, care and treatment, garner their feedbacks and help them share information with their patients. 2. Priority area 2: Support communities and providers in the prevention, care and treatment of viral hepatitis  Regular meetings with stakeholders to review the action plan and identifies regional activities, priorities, gaps and opportunities.  Seek new partnerships that might not be traditionally linked with hepatitis-related activities (travel industry, religious leaders, etc).
  24. 24. 24  Collaborate locally with potential partners who will be able to engage and reach the populations most impacted by HCV.  Advocate for the development of mobile clinics to bring the clinic to the communities.  Provide physicians with national tools to facilitate equitable access to treatment and develop guidance for physicians.  Identify gaps in provider training needs and materials. 3. Priority area 3: Build on existing strategies, tools, resources and services to create new opportunities  Build on relationships with key people and organisations, in and out of the HCV sector  Identify existing training resources to train champions, peers etc.  Keep pushing for things that do not happen but should: e.g. outreach is in the specification of the ODNs, including prison outreach, put pressure on ODNs to deliver on their contract.  Develop and/or adapt culturally and linguistically relevant tools and materials for populations at risk.  Initiate discussion with travel industry and medical kit manufacturers to promote and distribute an affordable travel kit
  25. 25. 25 PROGRAMME Monday 4 July, 10.00 to 16.30 Morning 09.30 - 10.00 Registration Royal Society of Medicine 10.00 - 10.20 Welcome Bryan Teixeira, Meeting Chair, Duncan Hamilton, Co-chair, ReShape Hep C lab Rachel Halford, Hepatitis C Trust Ben Collins, ReShape 10.20 - 12.10 The HCV Situation now and in the next six months 10.20 - 10.35 1. The UK HIV Treatment Cascade Laura Waters, Mortimer Market 10.35 - 10.45 2. Moving towards a UK HCV treatment Cascade Chloe Orkin, St Barts Hospital 10.45 - 10.50 Questions of clarification regarding the HCV treatment cascade 10.50 - 11.05 3. Treatment access across Europe Raquel Peck, World Hepatitis Alliance 11.05 - 11.30 4. New treatments for hepatitis C: Impact on morbidity and mortality – What could possibly go wrong? Helen Harris, Public Health England 11.30 - 11.50 Discussion/Questions 11.50 - 12.00 5. Current HCV research gaps and challenges Graham Cooke, Imperial College 12.00 - 12.10 6. Generics in the UK Stuart Flanagan, St Barts Hospital 12.10 – 12.30 Preparation for small groups brainstorming session Comments on key opportunities and challenges across the HCV treatment cascade in the next six months Charles Gore, Hepatitis C Trust 12.30 – 12.40 Guidance for small groups in the afternoon session Bryan Teixeira and Duncan Hamilton 12.40 – 13.40 LUNCH
  26. 26. 26 Afternoon 13.40 - 14.30 Key gaps and challenges and possible fixes across the HCV treatment cascade in the next six months - in small groups Small groups:  Co-infected  People who use injected drugs  South Asians  Prisoners 14.30 - 14.45 BREAK 14.45 - 16.10 Plans for the next six months 14.45 - 15.30 1. Report back from small groups’ leads and recorders  What are your group’s key gaps and challenges for the next 6 months and what can wait?  What are your proposed fixes for these key gaps and challenges 15.30 - 16.10 2. Open discussion  Consensus on key gaps and challenges to be addressed in the next 6 months 16.10 - 16.30 Closing Summary of action points Bryan Teixeira & Duncan Hamilton Closing Comments Charles Gore
  27. 27. 27 PRESENTERS BIOGRAPHIES Ben Collins Ben is the convenor of ReShape, a London-based think tank to reshape the response to HIV, HCV and related sexual and mental health concerns for best sexual health and wellbeing. Ben is the director of International HIV Partnerships (IHP) working with local partners across Europe and the Middle East, especially low HIV prevalence countries, for successful responses to HIV and HCV. He is a member of EATG, serves on the EACS education committee and the European Testing Week work group. Ben has been HIV+ since 1982 and undetectable since 1998. Graham Cooke Graham Cooke is a clinical academic based in Infectious Diseases at Imperial College. His practice and research is centred on HIV co- infection. He leads work on the global burden of viral hepatitis, the STOPHCV-1 trial (funded by MRC/NIHR) and point of care diagnostics development (http://www.imperial.ac.uk/people/g.cooke) Stuart Flanagan Dr Stuart Flanagan is an NIHR Clinical Research Fellow in Viral Hepatitis at Queen Mary's University of London while currently out of training as a Specialist Registrar in HIV/GU Medicine at Royal London Hospital. His research interests are BBV screening and Viral Hepatitis, and he was part of the Going Viral team, a study on BBV screening in Emergency Departments. Stuart is also an experienced medical broadcaster for the BBC, as resident doctor on BBC Radio 1's Surgery and CBBC's Newsround. He wrote and presented a BBC Radio 4 documentary on Antimicrobial resistance "The Path Of Least Resistance", available to listen to via iPlayer. Charles Gore Charles Gore was diagnosed with hepatitis C in 1995 and cirrhosis in 1998 and in 2000 he set up The Hepatitis C Trust together with 3 friends who also had hepatitis C. He has worked extensively with Government Departments, NICE and the National Health Service in the UK, championing the patient perspective. He was closely involved in the creation of the European Liver Patients Association and was elected its first President from 2004 to 2006. In 2007 he established the World Hepatitis Alliance, of which he is President, and was the driving force behind the WHO’s adoption of World Hepatitis Day and the creation of WHO’s Global Hepatitis
  28. 28. 28 Programme. The World Hepatitis Alliance is WHO’s official partner in co-ordinating World Hepatitis Day each year. Charles continues to work closely with WHO globally and regionally and with individual Member States as they look to develop national hepatitis strategies. Charles has sat on the WHO Guidelines Development Groups (GDG) for both hepatitis B and hepatitis C and treatment and is currently on the GDG for hepatitis B and C testing. He is also a member of the WHO Director-General’s Strategic and Technical Advisory Committee on Viral Hepatitis. Rachel Halford Rachel has over 20 years’ experience of working with people at high- risk of viral hepatitis, and liver disease generally – the homeless, prisoners, substance users and migrants. The past 12 years of which have been in senior management roles within the voluntary/ NGO sector. Passionate about equality and human rights, Rachel joined The Hepatitis C Trust in 2015 as deputy CEO, before this she was CEO of Women in Prison, a national UK campaigning organisation that provided support and advocacy for women affected by the criminal justice system. Diagnosed with Hepatitis C in 1998, Rachel completed Interferon treatment in 2007 clearing the disease. Duncan Hamilton Duncan Hamilton is a passionate young activist and aspiring psychology academic with strong interests in social well-being, equality, environmentalism and HIV/HCV. His involvement in HCV is an intimate one; only having been cured of the virus in 2015 through interferon based treatment. Being positive about his HIV+ status, he did not expect to find himself compelled to speak on stage about stigma and treatment inequality. Recently, Duncan's main projects are ReShape: HCV & LGBT+ Against Islamophobia. Helen Harris Helen is a Clinical Scientist and Research Associate within the Immunisation, Hepatitis & Blood Safety Department at Public Health England’s National Infection Service in London. Helen leads a programme of work on hepatitis C natural history and disease burden, co -coordinating the work of the national HCV register along with other national surveillance projects. Helen has published a number of papers in the field of hepatitis C natural history and disease burden. She also manages and edits the Hepatitis C in the UK report, which summaries current knowledge about hepatitis C and reports on the progress of UK Action Plans in tackling the infection. Chloe Orkin Dr Orkin is Consultant and Honorary Reader in HIV Medicine at the Royal London Hospital and runs an HIV & HIV/Hepatitis C research
  29. 29. 29 unit. She has 70 peer-reviewed publications and co-authored 4British HIV Association Guidelines: ARV & Hepatitis, Malignancy and Routine Monitoring. Dr Orkin is External Examiner to the Diploma in HIV Medicine. She is passionate about making HIV testing routine. Raquel Peck Raquel Peck is the CEO of the World Hepatitis Alliance (WHA), an international umbrella organisation of more than 230 hepatitis groups which she helped to establish in 2007 because viral hepatitis had been inexplicably neglected for so long. This persistent neglect means that there is an awful lot of catching up to do so she campaigns for a higher profile and priority for these diseases, ensuring the voices of patients are at the forefront of national and global health discussions. Before being appointed CEO, Raquel worked as the International Relations Director for the WHA and was part seconded to the World Health Organization (WHO) after the Global Hepatitis Programme was established to help the team in Geneva with their communications strategy. Previously to this she was employed as a Public Relations Coordinator for the only UK national charity dedicated to hepatitis C - The Hepatitis C Trust. Raquel's dedication to the fight against hepatitis contributed to the adoption of two WHO resolutions on hepatitis as well as the adoption of a robust Elimination Strategy for the diseases by 194 governments in 2016. She is committed to seeing a world where hepatitis is no longer a public health issue and will continue to campaign for the ultimate goal of eliminating the epidemic. Bryan Teixeira Bryan Teixeira has over 30 years’ experience leading on community- based sexual health and HIV programmes. More recently, he was the CEO of NAZ (London) for 11 years and also served for 3 years on the NGO Delegation at the UNAIDS Programme Coordinating Board (Geneva). He has extensive experience in high-level, multi- stakeholder meeting facilitation. Currently, Bryan works as a freelance consultant and is the Chair of the Policy Working Group of the European AIDS Treatment Group (EATG), Brussels. Laura Waters Laura Waters is a GU/HIV consultant and the HIV & hepatitis lead at the Mortimer Market Centre, London. She works predominantly in HIV and viral hepatitis outpatient services. Laura previously worked in clinical trials at Chelsea & Westminster and Brighton, gaining an MD on ART simplification and switch and is currently principle or chief investigator on several antiretroviral trials. She is chair of the BHIVA treatment guidelines, vice-chair of the BHIVA conferences sub-
  30. 30. 30 committee and a member of the BHIVA executive committee. She is the previous treasurer and current chair of the BASHH HIV SIG, a member of the 2015 PEP guidelines writing group and is chairing the forthcoming update of the BHIVA/BASHH/FSRH SRH guidelines for PLWH. She is on the HIV CRG including the Drugs subgroup and the CRG PrEP subcommittee. She has published and presented widely and is a regular columnist for Boyz magazine. ORGANISERS The Hepatitis C Trust The Hepatitis C Trust is the national UK charity for hepatitis C. It is a patient-led and patient-run organisation: most of its board, staff, and volunteers either have hepatitis C, or have had it and cleared it after treatment. The Trust firmly believes in patient-centred medicine and we are committed to ensuring that all our actions are for the benefit of patients, not for the benefit of other parties. We are also committed to the principle of continually increasing the employment opportunities at the Trust for people with hepatitis C, both as paid staff and as volunteers. The Trust’s ultimate goal is to close down because it is no longer needed and to do so as soon as possible. It’s no surprise then that we are whole-heartedly committed to the idea of eliminating hepatitis C in the UK by 2030. Our strategy is based around the three strategic pillars of better prevention, more diagnosis and treatment for all, and we have a range of projects and services to deliver this. ReShape ReShape is an independent London-based think tank formed to respond to the ongoing crisis in sexual health. ReShape seeks to promote personal happiness and social well-being by reinvigorating our community responses to HIV, hepatitis C, and related sexual and mental health concerns. ReShape works in small study groups, called labs, and in partnership with others, to focus on specific issues and projects of community/public health interest. The labs identify gaps, needs and possible responses, inform ReShape internal discussion, promote activities (either inside ReShape or externally), and act as vehicles for further action and evaluation. ReShape activities are borne out of the labs.
  31. 31. 31 ACKNOWLEDGMENTS Thank you to all who have helped develop the Uniting Voices for HCV Elimination initiative. Thank you to our hosts, Joanna Skoczylas, One Wimpole Street and the Royal Society of Medicine. Thank you to all the presenters, group leads and recorders and to Bryan Teixeira and Duncan Hamilton, today’s meeting chairs. Thank you to the Hepatitis C Trust, especially Charles Gore and Rachel Halford, for encouraging ReShape to join them on this effort. Thank you to the ReShape HCV Lab, mostly people living with or cured of HCV, who addressed the current HCV situation and its problems, weighed proposals and then made a plan to push for HCV elimination for all with greater community engagement that has resulted in this initiative. Thank you to the clinician / researchers who offered open support for ReShape to move forward on this initiative including Mark Nelson, Sanjay Bhagani and Babu Ranjababu. Thank you to Alison Rodger and Anna Maria Geretti who played a more important role than they might realise in developing this initiative, by expressing their own personal frustration with policies and prices that were keeping life saving drugs from their patients. Thank you to all of the people who advised us as we developed the initiative including Andrew Wilkinson, Hepatitis C Coalition; Andy Ustianowski, North Manchester General Hospital ; Peter Moss, Chair, NHS England Commissioning Advisory Group on Hepatitis C; Dee Cunniffe and Claire Foreman from London Joint Working Group on Substance Use and Hepatitis C; Chloe Orkin, Barts; Magdalena Harris, London School of Hygiene and Tropical Medicine; Yusef Azad and Susan Cole from NAT; Kam Gill, NHS England Health & Justice Commissioning Support Manager, North Midlands; Ahmed Elsharkawy, University Hospitals Birmingham; Sema Mandal, PHE; and Oliver Standing, Adfam. Thank you to representatives from Abbvie, BMS, Gilead, Janssen and MSD for their counsel, especially Bahar Turkoglu. Thank you to Gilead for financial support to launch this initiative. We welcome further support from a broader group of funders.
  32. 32. 32 Uniting Voices for HCV elimination 4 July 2016, London Organised by Supported by

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