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Standing Committee on Health - 10/03/2015 - Hepatitis C in Australia

CARRUTHERS, Dr Susan, Research Fellow, National Drug Research Institute


CHAIR: Good morning, Dr Carruthers. How are you?

Dr Carruthers : I am well, thank you.

CHAIR: That is great. Do you, as a witness appearing before the committee, have any objection to being recorded by media during participation in this hearing?

Dr Carruthers : No.

CHAIR: These hearings are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter, and may even be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. I now would like to invite you to make a short opening statement to the committee.

Dr Carruthers : Firstly, thank you for the opportunity to present to this inquiry and to the Standing Committee on Health for organising the discussion. To give you some background into the National Drug Research Institute, we are housed at Curtin University and were established in 1985-86. We have two sister organisations that you may have spoken to. The first is the National Drug and Alcohol Research Centre in New South Wales and in South Australia there is the National Centre for Education and Training on Addiction.

The mission of NDRI—National Centre for short—is to conduct and disseminate policy and practice, relevant research that contributes to the primary prevention of harmful drug use and the reduction of drug-related harm. It is under this banner that NDRI has conducted research into the epidemiology of hep C amongst injecting drug users in Australia, and also the prevention of transmission of hep C within Australia. This has been happening for the last 20-odd years. I also need to inform the committee that I am also the past chairperson of Hepatitis WA; I was chair for 10 years. For a period of about six years I also chaired the viral hepatitis subcommittee run by the Sexual Health and Blood-borne Virus program.

I have been involved with hepatitis C for many years now. I have been listening to the other evidence, so I do not want to repeat anything that has already been said, but I do have three areas of major concern in which I have actually done hepatitis C research. The first is the need for further prevention initiatives to be established in adult prisons across Australia. This is nothing new. This is calling for the provision of clean needles and syringes in prisons. It is not just about the provision of needles and syringes, it is also about the provision of illicit drug treatments to reduce the demand for drugs. I have concerns about the ongoing use of illicit drugs in prisons and the difficulties that the corrective services have in stemming this flow of drugs going into the prisons.

The second area of concern is the need to provide greater access to treatment for all those infected with hepatitis C, and I have a particular interest in using the opportunities presented while people with hep C are actually in prisons.

The third is the major concern about the increase in hepatitis C prevalence and incidents amongst Aboriginal peoples in Australia, in particular in city areas, not necessarily in remote areas, and the need to work with Aboriginal corporations and organisations in providing specific education and prevention activities, and also in providing needles and syringes to a very vulnerable population.

Ms HALL: When you are talking about the prevalence of hep C in Aboriginal communities, looking particularly at non-remote areas—the area that you identified, and then you went on to say vulnerable populations—is there a correlation between Aboriginal people living in, say, a metropolitan area and those groups that are vulnerable that are living in metropolitan areas? Is there are similarity? Is there some sort of correlation between the non-Indigenous and the Indigenous or the non-Aboriginal and the Aboriginal people living in that metropolitan area? Is there some form of marginalisation that comes across in both groups?

Dr Carruthers : I think marginalisation amongst Aboriginal peoples is across the board, whereas, taking injecting drug users as a whole, once they become injecting drug users and go on then maybe to develop dependencies, they become unemployed and many of them become homeless. They go through and through the court system, and in and out of prison—they then become a very vulnerable population. I think, for me, many Aboriginal people in metropolitan areas, or across Australia, start off being vulnerable because of a lack of education leading to a lack of jobs. A lot of them are on benefits. Our young women tend to have their babies very early, so they start off vulnerable and become more vulnerable. Generally, with non-Indigenous injecting drug users, often—some of them may be vulnerable and lacking the education and have come from vulnerable backgrounds—they are just your everyday people who happen to get into injecting drug use and then go on to become vulnerable because of their drug use and their connections with the law and what have you.

Ms HALL: That is quite interesting. I know that you have had a lot of dealings with people living with hep C. What is your opinion on the lack of access to programs and treatments that are available to people—the waiting times; how that impacts on a person with hep C. Also, what is your opinion on the types of programs that are available—the centre-based programs compared to an outreach program such as a nurse-led program, or some other health professional leading that program. What are your thoughts on those?

Dr Carruthers : The population most at risk of hepatitis C is obviously injecting drug users, and it is usually within the first two or three years that injecting drug users become infected with hepatitis C. If your drug use career goes on beyond that, you tend to be very engaged with drug use and you may then find out that you have hepatitis C. You may have been asked to be tested or you take yourself off for testing. For many that are in the depths of injecting drug use and drug dependency, hepatitis C is an external issue. Their issue is about drug use, and I am talking about the smaller core of those people who inject drugs. They may well need treatment, but they are not interested in treatment.

There is a large population of people who used to inject drugs—and Mr Hackett referred to this—who dabbled in illicit drug use in their early years, became hepatitis C positive, were not diagnosed for many, many, many years and are now coming forward finding out they have got hep C and wanting treatment. I have spoken to many, many people, both in prison and out of prison, and the side effects associated with current treatments are a real turn-off. As we keep talking and there is more press about new drugs coming on board, shorter duration and fewer side effects, many of these people are actually living quite healthy lives. They are not suffering any of the signs and symptoms of hepatitis C. Some of them continue to monitor their health and their liver remains healthy. They will obviously put off treatment until such times as there are new treatments with shorter duration and less side effects. Some will need treatment now—those who have progressed to a certain level of fibrosis. While I understand that most would prefer to wait for the new treatments, there are many people who will go through the interferon-ribavirin pathway and put up with the side effects with good help.

I think we have a difficulty attracting people into treatment, and one of the major problems is the long waiting list. Sometimes it is up to six to nine months. The work-up should, I believe, be done through GPs, through primary healthcare. They can be doing all the tests that need to be done. They can do all the blood tests and the fibro scans for the liver to look at the health of the liver to see whether they need treatment and what level of damage there already is. This is not so much about shared care; it is about having GPs who are willing to be involved with hepatitis C treatment and then splitting off from there and going to the tertiary centres.

One of the things about the new drugs that I am hoping is that, with reduced side effects, especially with reduced psychological side effects, the PBS will, once they approve these drugs, actually enable GPs to go through the whole process. So there will be no need to go to tertiary centre unless you have advanced liver disease. There is always going to be a call for liver clinics. But let's, hopefully, be able to keep them for the more serious cases, and GPs, specially trained GPs, will actually handle the treatment of hep C. There will still have to be safeguards in place and probably additional services, but I really look forward to freeing up the liver clinics to deal with the very serious cases and having more going through primary care.

Mr WATTS: Just briefly, I wonder if you are in a positon to baseline us on the academic research about NSPs in a correctional context and any evidence from Australia and internationally that the committee is able to draw on?

Dr Carruthers : There is a large literature base on the introduction of needle and syringe programs across many European countries. I can provide you with a very good review that was conducted in 2003 and, if I remember rightly, has been updated, in which they evaluated the NSP programs across all countries and came to the conclusion that the various ways in which they operate worked well. There were no incidents of needles and syringes being used as weapons, either against other prisoners or against prison guards. There was no increase in injecting drug use or in drug use per se in prisons. Overall, they have evaluated very well. Unfortunately, this quite large body of evidence has tended to be ignored when we have been discussing the situation in Australia, and the one program that was to go ahead to be trialled in Alexander Maconochie was, of course, cancelled, which I think is a huge shame.

Mr WATTS: If you could provide that literature review to me, that would be useful.

Dr Carruthers : I shall.

CHAIR: In your research, what have you found is the cohort that tends to reinfect more, and are there many cases of reinfection?

Dr Carruthers : Do you mean after treatment?


Dr Carruthers : There are two scenarios. You become infected with hepatitis C, but your body automatically rejects it. So you never become chronically infected, although you still have antibodies. There is evidence to suggest that if you are one of that 25 per cent, your chances of being reinfected later are much less. Now, there is obviously a physiological biochemical reason for that, but I do not think the research has been done yet to find out why that is the case. There are also studies showing that reinfection rates after treatment tend to be lower as well, and I can, again, provide you with some literature on that. But they are not studies that have been done on a wide basis. So I think the jury is still out on it.

CHAIR: Just further to that, if you are going to provide us with some evidence, can you also look at what patients were on management plans and which ones were not and whether that had any effect on them reinfecting or not

Dr Carruthers : What do you mean by management plans?

CHAIR: I mean whether a particular clinic was doing follow up on the fact that they had been cured, and whether they continued to run a management plan with them or whether they did not.

Dr Carruthers : I can look for that. I am not sure that that is readily available, but I will look. Someone who has been through treatment and has a successful sustained viral response will stay in contact with a liver clinic for at least a year, if not two, for regular tests. Of course, a lot depends on whether those people were regular injectors to start off with or whether they have gone to treatment or stopped injecting. If people have stopped injecting, then the risk of reinfection is minimal.

Mr WYATT: I have a couple of questions. I noticed when I was asking Mr Farmer about devolving hepatitis C treatments to GPs, you were vigorously shaking your head indicating no.

Dr Carruthers : Sorry?

Mr WYATT: You were shaking your head earlier indicating we should not devolve everything to GPs like we did with sexually transmitted diseases. Were you disagreeing with what I was asking or were you saying that there is a better model?

Dr Carruthers : I do not recall disagreeing. I think devolving to GPs is a very important move, but it will, again, depend on the PBS rules, if the new drugs are approved. At the moment, they cannot be devolved, because of PBS rules.

Mr WYATT: Is that the fundamental reason: the PBS rules?

Dr Carruthers : Because the hepatitis C drugs are on the S100 list, the PBS demands that a person on hepatitis C drugs be attached to a tertiary liver clinic. That is specifically because with the interferon based treatments the side effects can be very severe, and the one that often causes the most concern is the association between interferon and depression. For many current injecting drug users, their mental health status is often fragile anyway, so adding interferon to that can sometimes make life very difficult and they will need to go on antidepressant medication. They need to be assessed by a psychiatrist before they can go on interferon, so, if there is any history of mental health issues, that is sometimes enough for a specialist to say, 'We cannot support you being on this treatment.'

The PBS is the one that says these drugs must be associated with a liver clinic. Once the initial prescription is done and everything is fine, GPs can take over the ongoing management of it, but it is only the liver clinic that can actually prescribe those drugs. And those drugs must be accessed through a tertiary hospital pharmacy. You cannot go down to your local pharmacy with a script and get them.

Mr WYATT: That then creates a tension for people in rural and regional areas.

Dr Carruthers : Absolutely.

Mr WYATT: If we go back to the question Ms Hall asked, that throws up very particular challenges for Aboriginal communities, where rates of hep C are reported to be much higher than anywhere else. That is something that we need to look at.

Dr Carruthers : Yes, absolutely.

Mr WYATT: How can testing, modes of prevention and treatment options be promoted to high-risk populations? I ask that in the light of your comment about—and you are the only one that I recall referring to this—the need to have treatment for illicit drug use and some thought being given to that. In your research, are there models that address hep C prevention and treatment but that are coupled with treatment for illicit drug use? I have only heard arguments and viewpoints being framed around the national strategy for hepatitis C, nothing else.

Dr Carruthers : If I understand your question correctly: drug treatment is a demand reduction strategy. So, if you want to reduce a person's use of drugs to improve their life—to prevent crime, to prevent homelessness and what have you—we need widespread drug treatment. In terms of heroin, that was obviously pharmacotherapy, so methadone and buprenorphine. We have in WA, in the metropolitan area, very well established central drug unit treatment. It is difficult to promote treatment to an injecting drug user whose drug use is out of control, because it is not on their agenda; they have many, many other issues. But if we can encourage people into treatment then we stabilise their lives and then they become eligible for treatment. It is no longer necessary to completely stop injecting drug use. That used to be another PBS rule, but now it is recognised that it needs to be very well controlled. Is that the sort of thing that you are after?

Mr WYATT: It is, because I want to ask you about ice becoming an epidemic in some areas. If you are on something like ice, then you are more likely to enter into risky behaviour that increases the capacity or the potential to contract hep C.

Dr Carruthers : Yes.

Mr WYATT: Have you done any research or work around that issue at all?

Dr Carruthers : No. There may have been some done by the National Drug and Alcohol Research Centre in New South Wales. They have delved into ice. Our institute has not and is only peripherally involved in that at the moment.

The only good thing about ice is that it is very effectively used by smoking and the need to move to an injecting drug use mode is much lower. With heroin, many people start off by either snorting it or smoking it, but the bioavailability of the active ingredients in heroin is inherently very low so it is not very long before you need to inject it to get the same effect. It is just far too expensive to keep smoking it. We just do not have the right sort of heroin. We have the salt of heroin here, rather than the base. If you are in a northern European country, the base is very well smoked and bioavailable. Ice does not need to be injected because it is very bioavailable by smoking. There are people who inject it, but at the moment we do not have very good figures on those people.

It is not just ice. The good old-fashioned methamphetamine and amphetamines—good old speed—is often injected; but with ice, certainly in WA, we do not have a very clear idea of who is injecting it. If you combine ice—whether it is injected or smoked—with high risk behaviours then you introduce a whole pile more of risk factors, one of which is violence. Hep C is spread by blood; and the level of violence we are seeing, not only with illicit drugs but with alcohol, is a real worry in terms of the spread of blood-borne viruses.

CHAIR: With regard to the new treatments, if they are listed on the PBS: what sort of education do you think GPs would need to undertake to help with the new programs and the new models for the new drugs?

Dr Carruthers : The basis of the existing education, whether it is online or run by universities—I know Edith Cowan University runs a lot of education, and it is a requirement for GPs to be involved in hepatitis C treatment— remains relevant and would not need to change. What would need to change is obviously the education around the particular drug and the dosage, whether it is by weight or by milligrams per kilo—those sorts of things would have to be refined specifically for the new drugs. But that is often the role of the drug companies themselves, to provide that education.

CHAIR: So it is no different to any other new drug being introduced.

Dr Carruthers : Not really, no. I would not see it as a problem.

CHAIR: Dr Carruthers, thank you for your time. We appreciate you taking the time out to come and see us. If you have been asked to provide additional information, could you do so by Tuesday 24 March. If the committee has any further questions I will send you them in writing through the secretariat. Keep up the good work.

Dr Carruthers : To whom do I send the—

CHAIR: To the secretariat. The committee will now suspend until 11:10 am.

Proceedings suspended from 10:53 to 11:09