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[Patricia Davidson] Good morning, everybody. I'm Patricia Davidson, Vice Chancellor of the ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp. Welcome today to our Luminaries session. Hepatitis C: a public health success story. My apologies, for people who tried to join, our previously scheduled session, but we had unanticipated, technical issues. But we're all good to go today. The Luminaries session at the ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp brings together researchers, industry experts, and thought leaders, for a session on a topical issue, particularly impacting on global challenges. And today, we are so excited to have, you know, an international panel who, experts in this in the field. But before I begin, I just wanted to provide an Acknowledgement of Country.

 

I would like to acknowledge, on behalf of the ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp, that country for Aboriginal people is an interconnected set of ancient and sophisticated relationships. The ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp spreads across many interrelated Aboriginal countries that are bound by this sacred landscape and intimate relationships with that landscape, since creation. From Sydney to the Southern Highlands to the South Coast, from fresh water to bitter water to salt, from city to urban to rural. The ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp acknowledges the custodianship of Aboriginal peoples of this place and space that is kept alive the relationships between all living things. The ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp acknowledges the devastating impact of colonisation on our campuses footprint and commit ourselves to truth telling, healing and education.

 

So today, you know, we are gathered here, to explore one of the most remarkable triumphs in the realm of public health as well as policy, the groundbreaking treatments in the management of Hepatitis C. But despite the scientific advancements and the innovation. Hepatitis C continues to be a global challenge. With over 50 million people around the world still with active Hepatitis C and more concerning, approximately 250,000 people a year die due to complications related to cirrhosis or cancer of the liver. So today is a great opportunity to not just delve into the successes, but also identify the challenges and the opportunities, particularly in collaborative, interdisciplinary practice.

 

So I'm so grateful to my colleagues who have joined us here today, for this webinar. Firstly, I'd like to welcome Nick Walsh, who's a physician in public health and addiction medicine. He holds a PhD in epidemiology from Monash ÁñÁ«ÊÓƵapp. And over the past two decades, he has participated in the development and implementation of global and regional W.H.O. strategy and guidelines towards the elimination of hepatitis. I hope he's here. But if he's. Oh, Josh, it's such a relief to see you. My colleague and friend, Doctor Josh Sharfstein, is the director of the Bloomberg American Health Initiative and vice dean for public health practice and community engagement, and professor of the practice in health policy and management at the Johns Hopkins Bloomberg School of Public Health. As a leader in public health, he's the author of the "Public Health Crisis Survival Guide Leadership and Management in Trying Times", and also the co-author of the book, "The Opioid Epidemic What Everyone Needs to Know". I've learned so much from Josh in his fearless advocacy and his ability to navigate complex, policy spaces. So, thank you, Josh, for joining us from the US today. Also, my colleague, David Currow, who is our Deputy Vice Chancellor for Research and Sustainable Futures at the ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp. As well, he's a physician, been very engaged in public health initiatives and particularly in cancer control. He was previously, the foundation chair of Cancer Australia and, before coming to the ÁñÁ«ÊÓƵapp of ÁñÁ«ÊÓƵapp, the Chief Cancer Officer and, Chief Executive Officer of the Cancer Institute in New South Wales, the state's cancer control agency. And last but not least, is, Scientia Professor Greg Dore, who is the head of the viral hepatitis clinical research program at the Kirby Institute at the ÁñÁ«ÊÓƵapp of New South Wales and an infectious disease physician at some Vincent's Hospital in Sydney, Australia. Under his leadership, there have been some really innovative models of care. In terms of addressing, not just viral hepatitis and HIV. And he's been a clear, avid advocate for improving clinical care and public health policy for the last 25 years.

 

So, colleagues, I see we have, you know, a stellar line up and, we will be taking, questions, within, the, the Q&A function and the chat. And our format today is going to be very conversational. And we wanting to try and draw out what are some of the factors that, impact on the success of treatment. And also to discuss how we really going to try and identify barriers. So, Nick, can we start with you and I'd like you to, particularly give a little bit of a background about viral hepatitis. Not everybody on this webinar will be a health professional. And I think it'd be great if you could also tell us why this is important and how it has come to be a great success of public health.

 

[Nick Walsh] Well, thanks very much. Patricia. And, you know, thank you for the opportunity to, to be part of this, this fantastic panel. So, look, just to start off with. Yeah, I mean, hepatitis C, it's a virus. And what's interesting about hepatitis C is it's one of the few, infectious diseases that crosses into the non-communicable diseases, arena. So it's one of the viruses that does cause cancer. It causes liver cancer. It's a flavivirus, similar to, Dengue, the West Nile virus. But, it does infect the liver cells, the hepatocytes and, and, a whole bunch of molecular mechanisms result in, liver cells dying, the liver, scarring. And over time, liver function being, reduced to the extent where, we reach a situation called cirrhosis, where we have insufficient liver function to maintain health. And at that point, some, a complicated, heterogenous oncogenic mechanisms ensue, which results in an increased risk of cancer as the years go by. So we have a virus, that causes liver cancer. And liver cancer is very difficult to treat.

 

About, 15 years ago, there was a revolution, in hepatitis C, and there were therapeutics, drugs developed, which cured about 98% of individuals. So now we have the opportunity to diagnose individuals with an infection, and then cure them before they get cancer, which is a difficult to treat cancer. So it's really a fantastic opportunity to really, have an impact on on all on health. We have about 50 million, as you mentioned, individuals living with hepatitis C around the world. It is transmitted blood to blood. And that's why it is ubiquitous. There was substantial transmission in the 20th century, particularly in, in Africa and, and some of the Eurasian countries through health systems. But also, in, in, in the West and in Australia, in the United States, through the sharing of injecting equipment to people, injecting drugs. It is a difficult to acquire, sexually, apart from, in the context of HIV infection, where it can be transmitted sexually.

 

So we're talking about a blood borne virus, one of the five hepatitis viruses that does cause cancer. That is, endemic. And now we have the opportunity to eliminate. Now, the countries of the world in 2014 did agree, for the first time. And this was re-emphasised through multiple, agreements at the global level, including Australia and the United States, to eliminate hepatitis, which was defined at the time at reducing new infections by about 80% and reducing deaths from hepatitis by about 65% by 2030. So, the countries of the world we're all on this journey towards that. Australia is one of the countries on the pathway towards elimination. And Greg Dore here in Australia has been instrumental in that. And as, sure, a lot more to say on that topic. But there have been other real success stories, around the world in Egypt, Mongolia, and a number of others.

 

[Patricia Davidson] Thanks so much, Nick. I think you know what is really interesting from a public health perspective, and I think we saw this in, in Covid is this intersection of the NCD and communicable disease worlds. And, you know, how we maybe have to think a little bit differently about our prevention, and health messaging, that we do. So, David, if I could turn to you, I think, Nick's alluded to this, but why is, treating hepatitis so important? It's hepatitis C in terms of cancer control.

 

[David Currow] Thanks, Trish, and thanks for the great introduction to the virus. That's a perfect platform for this. We need to bear in mind that, across the world, infections account for about 1 in 8 cancers. And here is, Nick has said we've got an opportunity to fundamentally change the future of, primary liver cancers. As we think about those, let's take some ballpark figures, 20 million new diagnoses of cancer per year across the globe and just under 10 million deaths. But we've got to remember that, about 1 in 12 of those deaths is related to liver cancer. Now, that's a huge, huge burden across our community. No, not all of those, deaths from liver cancer, due to, a virus. And indeed, it was sobering, quite literally, at a recent international meeting where, where France conceded that, 1 in 2 of their deaths, from liver cancer, are attributable to alcohol. But, that aside, we we can see the enormous burden that this generates, internationally. Of particular concern, however, is the fact that this disproportionately affects low and middle income countries. And so the burden in those countries where this is simply untreatable, and it's not very much more treatable, even in high income countries, but it is simply untreatable, in those settings. And, it really, needs to be considered in that context.

 

The other challenges that there are some strong associations with a couple of other cancers, beyond liver cancer. And, we need to bear in mind that the that is an emerging. Picture. As people look at larger and larger datasets. Males are disproportionately affected. So the ratio is 2 to 1. Male to female. And and so internationally it represents, the second most prevalent cause of death in males from cancer. We can change that and we can change that on a global scale. That, those treatments are available to us today, and we can change the future. Trying to treat this. Once someone has established, liver cancer, is really, as we've reflected, incredibly difficult. The opportunity to move right upstream and make a fundamental difference to the outcomes across the globe, is really exciting. So in summary, somewhere between, 2 in 10 and, 5 in 10 cancers of the liver, depending on where you live in the world and the other risk factors, related to hepatitis C, or B and, we have an opportunity to really change the future. But for that, we need to engage the whole of the health system, the whole of the social system, if we're really going to realise the the wonderful potential of, reducing this horrible burden on our communities.

 

[Patricia Davidson] Well, thanks so much, David. And that's a pretty powerful call to action. It's so reassuring that we can prevent all of this suffering, but the devil will be in the detail in implementation. Josh is a leading public health physician in the US. And we all know in the US, in the health system, we see the very best and the very worst of health care. And a lot of, this is related to policy financing, distribution and addressing disparities. Josh, I know that you are really, trying to drive a lot of reform in this area. We'd be great to hear on your, about the US perspective.

 

[Josh Sharfstein] Well, thank you so much. Trish, for having me. It's great to see you, as always. I would say that I appreciate the US being, lumped in with countries that are working on hepatitis C. There's a lot of work going on in hepatitis C, but the truth is, we're not making an enormous amount of progress in the United States. Just this week, I believe there's a paper published that estimates the number of people with chronic hepatitis C in the US is 4 million, which is up from the last estimated 2.4 million. That's the, middle estimate. That's going in the wrong direction, frankly. And, there's, a lot of concern that we're not only squandering the opportunity that countries like Australia are taking advantage of, but we're spending a lot of money for the privilege of squandering the opportunity that it by not being able to deliver effective treatment to people, and other services. The result is that we're spending a lot more money. So, there's a big effort.

 

The president has proposed it in his budget, to try to put the US on a better track. And that's an effort that, has a lot in common with the path that Australia has taken. And when I was visiting Australia, I got to see some of the technology that hopefully will be coming to the US soon and talk about some of the, policy, innovations that Australia really pioneered that made a big difference. And, we're hoping to bring some of that, to the United States, too. I will just add that it's true this point about non-communicable disease and hepatitis C, but it's not linked to to cancer alone. As you know, there's a lot of emerging evidence hepatitis C may be linked to chronic kidney disease, diabetes, even heart disease. And through the modelling that we've done on what a national program in the US was really serious about, making progress on hepatitis C, what it would accomplish over the next ten years that estimates.

 

I'm from a team at Harvard where, 20,000 fewer cases of, liver cancer, another 24,000 liver related deaths prevented, 49,000 fewer patients with diabetes and 25,000 fewer patients with chronic kidney disease within a decade. Those are pretty material. There's other, findings. And on top of that, there's evidence of heart disease. There is even some speculative evidence on conditions like Alzheimer's, which seems to be independent of the degree of liver damage. So it may be that the virus has some direct effect there, so that there's a lot of horrible things that hepatitis C virus does to your body. There's every reason to treat it. And in the United States, we really need to be in a much better policy, landing place in order to be able to take advantage of, the incredible innovations in science.

 

[Patricia Davidson] Well, thanks so much, Josh, and it's great to be able to have this collaboration across the world. So Greg, you have a unique perspective because in 1999, you established the, hepatitis service at St Vincent's. And and you've really led, this internationally recognised program in hepatitis C. Now, the great thing I would like about your work is the intersection with other issues, such as drug use and, and HIV. Be really interesting to hear your perspective, particularly from the grassroots clinical service delivery to the policy and for our listeners and particularly students today. What would be some of the key lessons that you would give to them?

 

[Greg Dore] Thanks very much, Patricia, and great to be part of the panel. It's interesting you sort of mentioned that the clinic that I started in 1999. I think one of the first lessons, was that when we had a clinic set up in the inner city of Sydney, to service the population that were very marginalised, to exclude people from treatment who were still injecting, which was the government sort of, eligibility criteria. That stage, made no sense to me whatsoever. And I really sort of advocated strongly and started to actually treat people who were injecting way back then in late 1999. And that sort of set the foundation, I think, to place hepatitis C in the context of human rights and equity of access to health care. And it was a long time, from 1999 until we had these revolutionary new treatments that, came through, for Australia in, in 2016 with the government subsidisation of the new direct acting antiviral therapies. But there was a lot of groundwork that was sort of done during the sort of ten and 15, 16 years that led to that sort of opportunity. And part of that groundwork was to get general practitioners involved in treatment, to get nurse practitioners involved in treatment. I led the first sort of GP pilot project with the old treatment, you know, theorem based therapy. And we'd also laid the foundation of a broader sort of, involvement of, primary care and nurse practitioners through HIV treatment that was, a clear sort of public health response at the Australian Institute. So I think sort of broadening the response, making it truly a public health response. I remember in 2015, there was a stakeholder meeting where the government brought together leading clinicians, academics, the drug companies and importantly, community organisations. Australia funds both drug user and hepatitis C community organisations to really grapple with the issue of these therapies. Were going to cost a lot of money. There's a lot of people that potentially needed to be treated. And how were we going to do that? And it was really the community voices that led the charge, so to speak, and advocated strongly that these therapies should be available for everyone, not just those that had very severe liver disease, which was sort of happening in many other countries around the world. And the government really drove a great sort of bargain with the companies to get that price down and to utilise what has been known as now the Netflix model, where they put a sort of annual cap on expenditure. And, so everyone sort of won from that those discussions. So patients won because there was broad access. The government won in terms of having security around their expenditure. And the drug companies still did pretty well, to be honest. So to start that sort of 2016 period with a broad base, not only specialist prescribing, but all registered medical practitioners prescribing, we've had a lot of nurse practitioners added to that sort of pool of prescribers since, to embed the treatment within public health services such as harm reduction services, where the the marginalised populations were sort of interfacing to start treatment programs in the prison setting, where we knew that a lot of the affected population would be sort of cycling through that setting. So to take a very broad public health approach rather than a narrow sort of clinical approach from the very start that this new, exciting era was the key.

 

[Patricia Davidson] Okay. Well, well, thanks, Greg. And I think there's a few things we can pick up on in the discussion, particularly how inherently political public health is both small P and big P. Nick, you've done a lot of work, in, the W.H.O.. And I think when I first, you know, met you, you were in DC, looking out to South America. What are some of the issues that we have to think about from a low and middle income country perspective? And not just, I guess, the challenges, but the opportunities. You know, some countries such as Egypt, you know, have really risen to the challenge. And I think we have some important lessons to learn, particularly from an integrated public health perspective from lower middle income countries.

 

[Nick Walsh] Yeah. Look, you know, thanks. Thanks, Patricia, for that, for that question. I did want to just recognise the work of Greg in Australia. I remember and I know this goes to the point I want to make, which is about the velocity of, efforts globally to address, hepatitis C. I remember, you know, more than two decades ago, asking, you know, who is that guy sitting up on stage talking about hepatitis C treatment? And, you know, the reply was, well, he's the guy that, he's the guy that talks about treatment. And he was really alone, at that stage. Yet now it's really part of the public health, curricula, addressing, hepatitis C and such a fashion. And so, you know, Greg's done an extraordinary amount here in Australia to drive that. So, look, it it is, being able to address, a disease and infection, in a public health manner. It takes strategy. And it has been a real, a journey which has been difficult when I first, became involved with hepatitis with the W.H.O. in the late 2000. The hepatitis program was sitting in, pandemic disease, in fact. It's since developed a global hepatitis program. And when I began in, in 2014 as a regional advisor on hepatitis in the West Pacific, covering, Korea, Japan, the Mekong, the Pacific Islands, Australia, New Zealand, a bunch of other countries. You know, we really didn't know where to start. And, but now we do, when I moved to Washington, D.C., working for the Pan American Health Organisation, you know, we really had, strategies across the Americas, particularly in South America, as you mentioned. One thing we did, for example, in South America, is get political agreement, in the Mercosur countries, in the, countries of the Andes, so that health ministers had agreed to the goal of the W.H.O. goal of elimination. So getting political backing is is critical. And then where do you go from there? So, obviously you need guidelines which are, aligned with the interventions you need. Access to testing, cheap testing. You need, fundamentally cheap, medications. And, and that's been a real problem for hepatitis because the price of medication has been so high in some countries, particularly in, say, South America.

 

If you look at the price of, of hepatitis C treatment in Pakistan and in some of the, this South Asian, subcontinental Asian countries, it is very cheap, $40, per cure, ostensibly. But then you have countries like Peru still paying thousands of dollars per cure. So that price of drugs is critical as well. At the end of the day, we found the most effective mechanism. And I know Greg, I was heavily involved in this in Australia, was, undertaking an investment case. I really speaking to the numbers. So understanding the epidemiology, projecting the epidemiology at the time and then looking at the economic impact of elimination policies to achieve savings in the health sector and a return on investment in the health sector over a relatively short period of time, maybe a decade, maybe a little bit longer. Because once you start speaking numbers and you start speaking to finance, then countries, can really that that they do tend to pay more attention. So we found the combination of health advocacy and speaking numbers through economic modelling to be very effective. We've done that in multiple countries. I was involved in, Mongolia, Vietnam, China, Brazil, Colombia, Peru. And it's been very effective. But at the end of the day, you do need to educate the, the health workforce and and of course, the community. Health literacy around hepatitis is also critical.

 

[Patricia Davidson] Thanks. Thanks so much, Nick and we might pick up on, you know, how we a little bit later, how we, interface with populations. But, David, if I could turn to you, and I guess another success story in Australia has been HPV and cervical cancer. How can we drive policy, or how can we set templates up for other nations to be able to say, have the same successes that we've had with HPV here in Australia and also, with hepatitis C treatment?

 

[David Currow] Thanks, Trish. Nick's just touched on the issue of, health literacy. And when we think about health literacy none of these, issues moves forward without controversy. And we've seen enormous controversy, around, rolling out, human papillomavirus vaccinations, right across the community. And we need to be aware that as we, go down these paths, there will be controversy. We need to be proactive about addressing, concerns, either founded or unfounded concerns, in this space. And so there's a lot we can learn from, the human papillomavirus program. The next thing to say is, and I don't want to look over the side fence to other cancers because we do that far too often. But we can learn a lot, from HPV. And, it is in the public consciousness of Australia now, whereas, as you pointed out in your introduction today, Trish, hep C and particularly the, the relationship to long term problems, cirrhosis, cancer, is really not at the forefront of people's minds. So there is an educative process that needs to, to take place if we're going to realise the same benefits that, we are realising with, with HPV, again, as, Josh has pointed out, we've got, two viruses that appear to have effects way beyond, their primary, organ of effect. And we've got two viruses where we have, either a vaccination or a treatment, that is effective, that is affordable and can change the future. But we still find, even in Australia, that there are times that, there are barriers to accessing that, that need to be broken down systematically and quickly. The long term consequences of not responding are overwhelming. And, you know, Nick and Greg have both, addressed the fact that, once you start to look at the economics of this, the pure economics of this, the case is absolutely compelling. But we, as always in public health, competing against, acute, treatment services. We still don't have an agreement nationally, on the proportion of money that should go to, to prevention and, and public health initiatives. And it's a live conversation that, I still think needs to be prosecuted if we're going to realise the full potential of, the advances that we're seeing.

 

[Patricia Davidson] Thanks David. Josh, if I could turn to you and, Greg brought up, some really good points in accessing populations. And I know in Baltimore you've done a lot of work in the prison system, particularly around addressing opioid abuse. My question to you is, you know, how how do we bring, policymakers and the broader community on this journey to address, populations that are largely invisible or society would like to make them invisible but are clear targets, because of their risk and often addictive factors, you know, these issues of, HIV, drug abuse, poverty, racism, they tend to hand impacts. So, Josh, I just thought you've been really successful in pushing through some of those stigmatised boundaries in the US. And if you could share some of your experience.

 

[Josh Sharfstein] Sure. Well, I would say that there's the direct and indirect argument. The direct argument is actually gonna get it gotten a little easier and some somewhat bipartisan in the United States. There was a little more political support for it. And it's kind of a story of redemption that people, can turn their lives around and that it's really important to help them. And that that led to criminal justice reform in the United States and a pretty different kind of conversation around criminal justice reform. Instead of kind of lock them up. It's led to, support for re-entry, that to get support across the political spectrum. It's led to an understanding, I think, of some of the harms of excessive incarceration. And part of that is that people are going to be coming out, and we want to give them the best possible chance to succeed. And so, you know, the discussion on hepatitis C is there are a lot of people that got hepatitis C through using opioids, for example, and many of them are in treatment. Many of them are doing everything they can to make their parents proud of them, to, you know, contribute to society, to get their kids back, their house back, their life back. And yet this disease threatens to pull them right back down. So that's sort of the, you know, redemption argument. And it is valid. I mean, it's actually valid. Hepatitis C can absolutely make it impossible for someone to be successful. And so that is an important direct argument to make that that we are, you know, a stronger country if we give people the chance to, to fix problems that have, you know, affected them and overcome them and be resilient. But then there are indirect arguments, obviously, the fact that it's an infectious disease and the more infectious disease out there, the more infectious disease out there.

 

So that means that people can get sick directly and indirectly. And then the money, you know, as more people get sick, we're paying for consequences. People with hepatitis, it's not a disease where people kind of wither away in their own corner, you know, hepatitis C, particularly if it's causing cancer or, cirrhosis causes enormous expenditures, hundreds of thousands of US dollars, you know, in the last years of life. And. The. It's just awful. You know, people bleed tremendously. They become antiepileptic. And when people show up in the E.R., we're all paying for that. You know, the cost is enormous. And so I think it's both the direct and indirect argument. It's not just that, like, you know, look, this isn't about people. It's about saving money. Even if you just want to, you know, look at it from a very, you know, specifically financial point of view, you should do it. I don't think that's the argument we make. I think we start with the direct argument that these are lives we're saving. These are people. These are people's mothers, brothers, children's aunts, uncles. And they're, you know, they deserve a chance. And so that, that that's really an important and I think that argument resonates and maybe more than it has, I think in my career, I think it resonates because of this general understanding that's happened in the United States about, overincarceration and some of the harms that that's caused. So I think that, we've got a lot of good arguments there. I don't know, you know, that there are obviously there's obviously still a lot of stigma. And it's if it were to cost a lot of money, then maybe we, you know, have a harder time. But if we can make the argument that it will save money and it's the right thing to do, I think that that's a strong place to be in.

 

[Patricia Davidson] Excellent. Thanks, Josh. So back to you, Greg. I know, initially you talked about some of your sort of foundation strategies. In terms of community based management. I just was I going to ask you to expand a little bit on that, particularly the role of community health workers, nurse practitioners, and, and how we make sure that people have access to treatment.

 

[Greg Dore] Thanks. It's interesting. I think you use the term invisible, and I can sort of see what you're getting at in terms of underserved or marginalised populations. But I actually think the populations that are affected by hepatitis C, are generally visible. There's some elements that are invisible. They're more likely to be in your standard suburban houses. But the visible components of the, say, population are people that are visible because they're attending drug treatment centres. They're visible because they're attending, they want fringe programs, invisible because unfortunately, they have higher incarceration rates, they're visible because they're sleeping in public spaces. So they are visible. We know where they are and they're interfacing with those public health systems and services. So what we needed to do was to, as I mentioned before, embed those prevention and treatment services where those people were. And that went to making sure that health care workers across those settings were involved. So clearly training up primary care practitioners, community health practitioners, nurse practitioners, people working in the prison setting, people working in drug treatment, harm reduction, in but employees, etc., and getting them involved. And the great thing about hepatitis C is how empowering it is. So it's amazing to be involved clinically in a disease, as a chronic disease that has a very easy diagnosis, even easier treatment, where almost 100% of people who commence on these therapies that people tolerate incredibly well are cured. I mean, it's quite remarkable.

 

So it's very empowering to get the broad healthcare workforce that is interfacing with these marginalised, affected populations, to get them involved in hep C, and you see that all the time. Then are people really being energised by that? So it's also important, I think, to empower the people that are affected by hepatitis C. And I just talked about sort of, trying to sort of bring them into the fold. And we're less in Australia, thinking about having to argue through a redemption lens. We're sort of more pragmatic, I think, in Australia in many respects. But what was really important was to make sure that the affected community could see the value of engagement in the hep C, sort of the prevention and treatment sort of journey. And you see that all the time with the individual sort of success stories and, and for them and a struggling with a lot of social and health issues for them to be able to sort of receive hep C treatment, be cured, that's incredibly individually empowering. So to, to harness this sort of innovation of hep C treatment has been quite remarkable. But the one thing I would sort of also state is we we can't stop innovating. Innovation is so crucial. So I think equity of access to service is really important. A human rights approach, but continued innovation, that's what we really tried to do in Australia. We've been innovating on the diagnostic front. We've got some great point of care. Testing programs are rolling out. We're continuing to innovate. On the therapeutic side, we've got a, four week treatment regimen we're going to roll out for evaluation very soon. It's only 8 to 12 weeks in terms of the main sort of regiments, but we really want to keep sort of pushing the envelope. We don't want to sort of, stand still in terms of that side of things as well. So sort of multi-pronged approach is really crucial.

 

[Patricia Davidson] So, Greg, can I just ask you a little bit more? So I've read your papers and, you know, different interventions. So one of the things that I've been really impressed with is your ability to address multiple problems, because I guess my experience of health care is we become more and more super specialised. In my world of cardiology, it's very specialised. But you seem to have been able to develop models of care that address addiction, HIV, hepatitis C and, and, you know, other mental health issues and social issues. What's the secret to that?

 

[Greg Dore] Like, this might sound, a bit not glib, but, simplistic. But there's no doubt in terms of the HIV response to hepatitis C response, some aspects of the drug use, response as well, that engagement and partnership with the affected community has been central. And we really sort of seen that and that I went back I said, I went back to that 2015 meeting where the sort of community really sort of led the voices trying to call for sort of broader sort of approach. We saw that absolutely in the HIV sort of response. We're starting to see it a bit more in the in the drug use sort of response as well in terms of the well involving drug user community organisations, and that's important in terms of understanding what the affected community really need, but what their sort of concerns are. And in working together in terms of changing policy, in developing sort of best practice, in terms of delivering care, rather than what has traditionally been a fairly sort of narrow, clinical sort of model. So I it, it seems straightforward and in some aspects of it are straightforward, but it does require strategic work. And Australia is just about to launch its sixth National Hepatitis C strategy. We launched our first back in 2000. And all those strategies been in partnership with the academics, clinicians, community organisations, and government. So really sort of crucial, sort of, bedrock foundation for everything we do around hepatitis C.

 

[Patricia Davidson] Yeah. So just as a question sort of coming in, do you think, there is any risks, in the infectious disease world with a perception that HIV, the battle is won and there's less focus and attention, coming through? Thanks for the question. That it's kind of over and it's it's going to impact, global health response, which we all know it's far from that. But there is some, some news. Nick or Greg, would you like to take that one?

 

[Nick Walsh] Greg's probably best placed.

 

[Greg Dore] I'm sure, Nick, you've got things to add, but what I would say is that. Look, this we've got these 2030 targets, both, HIV hep B, hep c, it's great to have those targets. So we're really sort of driving towards that and it's created a lot of momentum. But it's not as if we're going to sort of pull up stumps, so to speak, in 2030 and go home. Some of us might retire. But, I think what is happening is that the success stories are so crucial. We know that in clinical and public health sort of arenas that we do need these success stories, and we're doing really well in terms of controlling HIV and reducing morbidity, mortality. Same with hepatitis C, I don't think it's losing the attention because I think people see them as such important sort of models. But building upon in terms of what is sort of public health approaches, and you've only got to look at hepatitis C to think, okay, we've done such a good job there, but what about the broader issues around harms related to drug use? How can we sort of, you know, reduce, harm in many other sort of ways? How can we provide more non-judgemental, less stigmatised sort of care? We've had this sort of, empowerment through hepatitis C, but let's, let's leverage off that and let's sort of do better in lots of other sort of fronts, going forward. So, yeah, I, I think as the morbidity and mortality decline, we really need to sort of harness, to know how it got there and sort of broaden that approach.

 

[Patricia Davidson] Thanks, Craig. Nick.

 

[Nick Walsh] Yeah, maybe I can add, you know, we've had such success in hepatitis C, of course we have in HIV. But, and so when we do see success, it does have the appearance that, you know, we have won the battle. And and certainly the life expectancy of people living with HIV effectively treated is ostensibly, you know, similar to non HIV infected individuals. And so I think as public health individuals, I mean it's really important for us to keep emphasising that, at the end of the day, it's individuals, it's families that are suffering. And at that the battle is not won. And until we have reached the goals that we've agreed to, because every death, every person with cirrhosis, you know, are important. They have loved ones. And that's why we, we're here as clinicians and public health, you know, individuals. And, so at the, at the population level, it's easy to say, but at the individual level, I think, you know, we need to keep reminding, to advocate for the people that we're actually working for. I didn't want to bring just one example. You know, from the field, that I, for me, I think, does, resonate, it's the example of Mongolia. You know, I first went to Mongolia in 2014, and in between 2010 and 2014, they that treated out of 200,000 people living with hepatitis C, they treated 35 individuals, you know, through a combination of community based advocacy, local groups. It was clear that, you know, every family in the country, had someone with hepatitis C, if not cirrhosis of the liver cancer, the highest incidence of liver cancer in in the world, of course. And then with a 7% survival, if you had diagnosed liver cancer at five years.

 

So, you know, with community involvement and local, groups, a generic drug market as a consequence of, and in return on investment analysis, we worked with the US, CDC, the National Cancer Institute of NIH, to emphasise the public health importance to the parliament, not the government, but the parliament to adopt elimination as a goal. And today, Mongolia has diagnosed, around 95% of individuals living with hepatitis C, they've treated a third of the population living with hepatitis C, they've seen an absolute decrease in liver cancer, and they're on track for elimination. And so that's a tremendous public health success story. But what it does also mean it every single family has benefited individuals. Lives are being saved. And this can this can be repeated of course across the globe. It is being repeated in in some countries in Australia at the moment and parts of the United States populations in the United States that have adopted and are on track to achieve elimination. But, I just, wanted to bring that example because it does connect the individual, to the the public health goal that we're all trying to achieve.

 

[Patricia Davidson] Thanks, Nick. And and I think, as Greg said, success stories are critical because they show us the way. And, and I think about thinking about the individual as well as societal is critically important. So we're coming towards the end of our time together, which I think has been a great summary of the contemporary issues. Just before we end our time together, I just thought I would go around to the panel and, and just ask you, you know, what would be one of the key takeaways that you would, like to leave with listeners either, a challenge in the field, that we have to address or an opportunity that is low hanging fruit. Greg, can I start with you?

 

[Greg Dore] Yeah. Thanks, Trish. The one thing I haven't really talked too much about, and it's a, a bit of an elephant in the room, for the US, and I'm interested for Josh's comments is, is the importance of nailing fringe programs to the overall hep c control, endeavour, to Australia's be very, very, successful in rolling out broad access to the clean injecting equipment, except for one key city, and that's the prison setting. This is the last sort of remaining sort of component in terms of the real hep cresponse. We don't have any access to, any of the syringe programs in the prison setting. We're trying to advocate, to make that happen. It's very difficult to sort of treat your way out of a rising epidemic. So the US, as Josh mentioned, looks like they've got increasing overall prevalence and driven by increasing incidence among people who inject drugs without, effective high needle and syringe programs sort of access. It would be very, very difficult to turn that situation around. Look, I know there's been a lot of advocacy in the US to try and sort of to make that happen. There are sort of community and state based programs that are providing access, but but that you really do need this sort of broad national sort of approach, for harm reduction, because it's so pivotal. The prevention side is so pivotal to the overall endeavour to eliminate hep C as a public health threat.

 

[Patricia Davidson] Thanks. Thanks, Greg. Josh, I'll turn to you for sort of a closing statement and a response to Greg, if if you like.

 

[Greg Dore] Sure. Well, I would say that I really appreciate the discussion about the different countries. Because this is a national, you know, challenge, but a global mission. And the country's work is connected. It's connected in different ways. One of the ways is even the US really needing to follow the examples of other countries like Australia. And, we really appreciate the help that we've gotten from, Greg and others. Jason Grebely, even the harm reduction workers who showed us the point of care tasks that we're bringing to the United States now. This is, really important, you know, because, frankly, you know, this is a virus that moves across national borders. And the more countries that are doing a good job, the better it is for all of us. The U.S. generally, generally does treatment a lot better than prevention, just generally. I say that as someone who works in prevention and we don't even do treatment on hepatitis C, well, you know, so we're like, you know, if you take a lot of different problems, the U.S. might do treatment very expensively and often well, and then not do prevention very well.

 

That's sort of the classic US approach here. We don't do treatment very well, let alone prevention. I actually think that treatment, first of all, works to a large extent of prevention, but also, taking some steps on treatment will really, I think inspire people who are working in different areas to do more. And I do think that will be very helpful to the overall effort in this country. And, you know, we have the ability and certainly the resources to make a huge difference, to follow the path that Australia has blazed along with other countries and, make, hepatitis C a accessible and treatable illness and accessibly treatable illness. And, I think that can be, a launching pad for all kinds of other good work in treatment and prevention. So, I really want to thank you Trish for your work on all these different health issues, but really to everybody on the call and all the people in Australia who have really demonstrated that these viruses don't have to win, we're not stuck with them forever. That a coordinated action, good policies, smart financing, effective community programs make a huge difference. And, you know, I can tell you in all the discussions I have on hepatitis C in the United States and the efforts that I'm involved in, I don't think there's one of them that goes by where I'm not mentioning Australia. So I really appreciate it. And I really hope that, we can, make you all proud for, the projects that, we're hopefully going to see, taking place in this country and maybe, as we, you know, get going. There'll be a couple of things here or there that you'll find interesting, and can take back to Australia.

 

[Patricia Davidson] Well, I'll think I'll express post this recording to the Health Minister which is great. To, to see that, I think there are some enabling factors, particularly universal health care coverage, that, might make this, issue, a little bit easier. Nick, what would you like to leave with us?

 

[Nick Walsh] It's hard to know what to say after those closing remarks. But, one thing I would like to just mention, just on the needle syringe program is that, you know, we're all we're still getting new information. There's still innovations out there in prevention. One is that, the use of low dead space syringes, which are the syringes that we used to administer the Covid vaccine, results in a 75% reduction in  transmission among people who inject drugs, compared to, you know, the normal dead space syringes. And so, you know, that work was just published two years ago, so it was still making innovations and even in the prevention space. But at the end of the day, it is, as you mentioned, Trish, about implementation. And I think that, you know what, you know, we have to keep our eye on the ball where are the infections, who are the families, who are the people, suffering with this, find those individuals, test and treat. And we will be able to eliminate, hepatitis C as a public health problem in our society. And if we do that, you know, by 2030, that'll be two decades of effort resulting in the elimination of the virus that's been with us for millennia. So that's a real public health success story.

 

[Patricia Davidson] Thanks Nick and I must attribute the title of Public Health Success story tonight to Nick that came up in conversation. I think that's a great idea. David, can I leave you with the last words?

 

[David Currow] Thanks, Trish. Always delighted to have the last word. Thank you to my colleagues on the panel this morning. This evening for you, Josh. Fantastic conversation. Mindful of those directly from Nick. This is a great news story, and we need to get that out there far more into the public discourse to accelerate, the advances that have been made, the successes that have been achieved with mentioned stigma a couple of times. In today's conversation, stigma is still a very big part of this, particularly for some, groups within the community. And, as with so many public health initiatives, we need to be actively breaking down stigma if we're going to get the best possible outcomes. The thought with which I would like to leave you is that, we get this right globally. Give or take 250,000 people each year on New Year's Eve will be raising a glass, thanking us for what we have achieved. That's each and every year. That is an enormous opportunity for us all to work collaboratively globally and make a real difference.

 

[Patricia Davidson] Thanks, David. So, look, that brings us to the top of the hour. I just really wanted to thank our panellists. I think we've had a really, great conversation looking from prevention to treatment. But I think the key takeaways for me is the importance of data driven policy. The importance of community engagement and the importance of continuing to innovate and look for better ways. So again, thank you so much, everybody, for being with us. This recording will be made widely available. And again, I thank each and every one of you for the work that you do to make the world a better, safer and healthier place. Thank you.