2015 NSW State Election: Priorities for Hepatitis B & C
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2015 NSW State Election:
Priorities for Hepatitis B & C
12015 NSW State Election:
Priorities for Hepatitis B & C
Of 210,000 Australians currently living with chronic hepatitis B, approximately 77,000 live in NSW.
More than 2,500 people were diagnosed with hepatitis B in NSW in 2014 alone.
Of 230,000 Australians currently living with chronic hepatitis C, approximately 90,000 live in NSW.
More than 3,500 people were diagnosed with hepatitis C in NSW last year.
More than two per cent of all people living in NSW – more than one person in every 50 –
live with viral hepatitis, which causes liver disease.
These viruses are killing a growing number of people each year, with an estimated 389 Australians
dying because of hepatitis B in 2013, and a further 630 people dying as a result of hepatitis C.
Viral hepatitis caused more deaths in Australia in 2013 than HIV/AIDS has done in any year
since that epidemic emerged more than 30 years ago.
The number of deaths from viral hepatitis is also expected to increase significantly in the future –
without access to new treatments and a significant increase in the number of people being treated,
there will be a 230% increase in liver-related deaths due to hepatitis C alone by 2030. Many more
people, including the family members and friends of those living with hepatitis B and C, are
indirectly affected by these epidemics.
Hepatitis B and C are also of high importance to specific communities and groups within NSW
which have higher prevalence of one or both of these diseases, including:
Aboriginal and Torres Strait Islander people
People from culturally and linguistically diverse backgrounds
People who inject drugs, including young people at risk of injecting and
People in or recently in custodial settings
This document sets out three key issues which should be addressed by all major political parties
contesting the 2015 NSW State Election. These issues have been chosen as policy areas which
have the highest potential to make a difference in combatting the hepatitis B and C epidemics.
They are:
1. Ensure NSW has appropriate models of care in place to support
increases in hepatitis C treatment numbers
2. Provide funding to implement key elements of the NSW Hepatitis
B Strategy 2014-2020, and
3. Introduce Needle & Syringe Programs (NSPs) in NSW Prisons.
21. Ensure NSW has appropriate models of care in place to
support increases in hepatitis C treatment numbers
The Liver Danger Zone Report Card, released by Hepatitis Australia on 28 July 2014 to coincide
with World Hepatitis Day, shows that, without significant increases in both the number of people
undergoing treatment for hepatitis C and the success rates for that treatment, the number of
deaths due to hepatitis C alone will rise by 230% by 2030.
Currently, fewer than 2%, and perhaps as few as 1%, of Australians living with hepatitis C access
treatment each year. This is much less than the goal set by signatories to the Auckland Statement
in 2012, which is that 5% of people living with hepatitis C are treated each year. This is the
minimum estimate of what is required to turn the corner of this epidemic in the Australian
community.
Reaching this target would obviously benefit a significant proportion of the 90,000 people in NSW
currently living with hepatitis C. For those people with minimal liver disease, being cured of their
hepatitis C will help prevent progression to serious liver disease, cirrhosis and liver cancer. For
those people who already have developed serious liver disease, being cured of hepatitis C
significantly reduces the chances of developing liver cancer and requiring liver transplant (although
people with cirrhosis will require lifetime monitoring for liver cancer even after successful
treatment).
Reaching this target is also cost-effective at both state and federal levels. While we acknowledge
the cost of hepatitis C treatment can be expensive, it is far more expensive for people to develop
serious liver disease, both in direct health costs (including increased hospital admissions and other
costs in the community) and in loss of employment and associated income. Without action, the
rising burden of liver disease in Australia due to hepatitis C will bring with it a rising price tag.
For most people, current hepatitis C treatment will involve at least 24 and sometimes up to 48
weeks of injections with interferon, a drug which brings with it a variety of potentially debilitating
side-effects, plus ribavirin tablets, which can cause anaemia and, for people with hepatitis C
genotype 1, a direct-acting anti-viral (telaprevir, boceprevir or simeprevir – with the latter being
included on the Pharmaceutical Benefits Scheme on 1 December 2014). Even after undergoing
almost six and sometimes 12 months of treatment, the cure rate is between 70 and at most 80%
for most people.
Fortunately, new, more effective treatments, which can be taken for shorter durations, with far
fewer side-effects and significantly higher cure rates (approaching 95% or more) have been
developed. Many of these treatments, including sofosbuvir, sofosbuvir/ledipasvir,
sofosbuvir/simeprevir, and daclatasvir, have already been approved in the US and/or European
Union.
It is highly likely that, within the next 12-24 months, these and other new treatments will be
approved in Australia, meaning that the vast majority of people living with hepatitis C should (PBS
funding and other regulation permitting) have access to all-oral treatments which can cure their
hepatitis in 8-12 weeks, with minimal side-effects and without interferon injections.
The Fourth National Hepatitis C Strategy 2014-2017 acknowledges the likelihood of new
treatments being approved and sets a target to “increase the number of people receiving antiviral
treatment by 50 per cent each year”. This would largely meet the Auckland Statement target of 5%
of people being treated each year over the course of the strategy.
3The NSW Hepatitis Strategy 2014-2020 also acknowledges the ‘new reality’ of hepatitis C
treatment in its targets:
“Increase the number of people accessing hepatitis C treatment in NSW by 100%* *: Over
the life of this Strategy, a range of new drugs may become available that will change
treatment and service delivery options. This target is subject to change accordingly.”
So, there will likely be a number of new, more effective treatments approved, and there is
Commonwealth and NSW Government commitment to increase treatment numbers. Why then is
ensuring appropriate models of care are in place a priority issue for people living with hepatitis C in
NSW?
Because current models of care will not be able to meet this level of demand. Many people
with hepatitis C are not able or willing to visit hospital liver clinics for treatment. New
models of care will need to be funded and implemented to ensure growing numbers of
people living with hepatitis C can access treatment in a broader range of settings.
The established system of liver clinics, which provide excellent care for those people accessing
them currently, will not be able to treat the number of people expected to come forward for
treatment, especially when these clinics will also be burdened with significant increases in the
number of patients with advanced liver disease and liver cancer caused by hepatitis C, hepatitis B
and other illnesses such as fatty liver disease. In fact, while overall cancer mortality decreased by
28% between 1987 and 2007, the mortality rate for liver cancer rose 70%, indicating the scale of
the challenge presented by liver disease in Australia.
It should also be recognised that, for some people and some priority populations (especially
groups disproportionately affected by hepatitis C, including people who inject drugs and Aboriginal
and Torres Strait Islander people), seeking treatment in liver clinics is not always realistic, nor
preferable.
This is for a number of reasons, including the stigma and discrimination which some people living
with hepatitis C have experienced with the healthcare system, the fact that some groups are
already accessing healthcare in particular settings (such as OST and alcohol and other drug
services) in which case it may be easier to deliver hepatitis C in those settings, and because other
barriers, including geographic barriers, may prevent people living with hepatitis C from accessing
treatment in liver clinics.
Treatment options can and should be provided, where possible, to the community in the
community.
Expanding treatment options to include more general practitioners, OST clinics, alcohol and other
drug services and in custodial settings will not only overcome barriers to access for priority
populations, but also ensure that a greater number of people living with hepatitis C can be treated
each year. Specific, funded programs will be needed to expand the number of GPs who are able to
prescribe new hepatitis C drugs, assuming that s100 restrictions remain in place in this area.
Hepatitis NSW acknowledges the work currently being done by the NSW Government’s Agency for
Clinical Innovation (ACI) in assessing existing models of care for hepatitis C treatment, as well as
developing new models of care for the coming years, particularly to meet increased treatment
numbers with the expected approval of new drugs.
4These new models of care include:
Adapting existing models to increase nurse ‘triage’, with greater involvement of nurses in
assessing the extent of liver disease, and ensuring patients are referred to the appropriate
services (liver clinics, general practitioners or other services) for treatment, as well as more
focus on monitoring liver health for those people for whom treatment is not currently a high
priority (which is equally important in reducing the growth in liver disease), and
A more substantive change, with the establishment of new co-ordinated teams or ‘referral
hubs’ of workers, including nurses, social workers and others, to take on a greater role in
testing, assessment and ongoing management of people living with hepatitis C. This model
would also see an increased focus on nurse involvement in hepatitis C treatment delivery in
the community, while still being supervised by specialists from liver clinics and/or s100
prescriber general practitioners.
Hepatitis NSW strongly believes that a combination of both models, including potentially a trial of
the latter (community referral hubs) in one or more locations, will be necessary to help ensure as
many people as possible can be treated for, and cured of, hepatitis C in coming years. We need as
many treatment options as possible to meet the needs of 90,000 plus people living with hepatitis C
in NSW, to avoid the growing burden of hepatitis C-related liver disease in coming decades.
We call on major political parties to commit to support the development
of, funding for and implementation of new models
of care to support increases in hepatitis C treatment numbers, including
the expansion of programs supporting GPs to become s100
prescribers.
52. Provide funding to implement key elements of the NSW
Hepatitis B Strategy 2014-2020
Of the 218,000 Australians estimated to be living with chronic hepatitis B, approximately 77,000
live in NSW – or approximately 1.11% of the state’s population.
The Australian Society for HIV Medicine & the Victorian Infectious Disease Reference Laboratory
have shown that, unlike hepatitis C which is more geographically dispersed, chronic hepatitis B is
more concentrated in certain areas, with Inner West Sydney (1.67% prevalence or 9,172 people),
South Western Sydney (1.61% prevalence or 13,513 people) and Western Sydney (1.56%
prevalence or 12,644) Medicare Local regions together accounting for almost 46% of the state-
wide population.
Other Medicare Local regions with higher than average prevalence of hepatitis B include Northern
Sydney, South Eastern Sydney, Eastern Sydney and Far West NSW (the only non-Sydney
metropolitan Medicare Local region with higher prevalence than the NSW average).
Chronic hepatitis B (HBV) in Australia is also over-represented among people who were born
overseas, who account for 61% of people living with HBV in NSW, compared to 31% from non-
Indigenous Australians born in Australia. In NSW, the predominant overseas countries of birth for
people living with chronic hepatitis B include China, Vietnam, Philippines, Italy and Fiji.
Approximately 8.3% of people living with hepatitis B in NSW are Aboriginal and/or Torres Strait
Islander people (who are estimated to be 2.9% of the overall population), meaning that Aboriginal
and Torres Strait Islander people are also a priority population for hepatitis B.
Issues surrounding hepatitis B have been receiving increased media and public attention in recent
years, across Australia and also in NSW. For example, in July 2014 the Commonwealth
Government released the Second National Hepatitis B Strategy 2014-2017.
In September 2014, the NSW Government released the historic first ever state strategy in
this area, the NSW Hepatitis B Strategy 2014-2020.
This announcement was widely welcomed, including by Hepatitis NSW, as an extremely important
document to help focus efforts on preventing, diagnosing and treating this epidemic in NSW.
However, neither the Commonwealth nor the NSW Government provided additional funding to
directly implement their respective strategies.
There are a range of areas, identified under both strategies, which will require additional monies in
order to make substantial progress. These include:
i) Provide funding for programs to raise awareness of hepatitis B, including the need
for testing and treatment, in high prevalence geographic regions and amongst
priority populations.
It is estimated that up to 45% of people living with chronic hepatitis B in Australia are unaware of
their status. This is a significant barrier both to preventing new transmissions within the
community, and a hindrance to increasing treatment rates (see below).
6We call on major political parties to support increased resourcing for
hepatitis B awareness initiatives, including programs prioritising people
from culturally and linguistically diverse backgrounds (especially those
born overseas) and Aboriginal and Torres Strait Islander people.
ii) Provide funding for programs which increase access to hepatitis B treatment,
including supporting general practitioner and nurse participation in management
and treatment.
The NSW Hepatitis B Strategy 2014-2020 sets a target to “[i]ncrease the number of people living
with hepatitis B receiving antiviral treatment (when clinically indicated) by 300%”. The Second
National Hepatitis B Strategy 2014-2017 also includes a similar target – to “increase to 15 per cent
the proportion of people living with chronic hepatitis B who are receiving antiviral treatment.”
Reaching these targets is essential to help prevent substantial future increases in the already high
burden of liver disease caused by hepatitis B – and to prevent the current annual number of
deaths (389 in 2013) caused by hepatitis B from climbing significantly higher.
However, these targets will not be achieved if treatment is confined solely, or even largely, to liver
clinics. In order to meet these targets, additional methods of delivering treatment, especially in
community settings and in health services which priority communities already access, is essential.
We call on major political parties to support funding for additional
programs which increase access to hepatitis B treatment, including by
general practitioners and in nurse-led models of care.
iii) Provide funding for community and non-government organisations to represent
people living with hepatitis B.
Unlike other blood borne viruses, there has traditionally been no non-government organisation
funded to primarily provide services to and advocate on behalf of people living with hepatitis B in
NSW: while there is the Multicultural HIV and Hepatitis Service (MHAHS), this is a small
government agency working across all of HIV, hepatitis C and B. There is no equivalent of ACON
in this area, while funding for Hepatitis NSW has traditionally been allocated for hepatitis C only.
We call on major political parties to support funding for hepatitis B non-
government organisations to more effectively represent the needs of
different priority populations to government.
73. Introduce Needle & Syringe Programs (NSPs) in NSW
Prisons
The needle & syringe program (NSP), introduced in NSW and across Australia in the 1980s,
initially in response to the HIV epidemic but later to prevent hepatitis C and other BBV
transmission, has been, undeniably, one of the most successful public health interventions of the
past 30 years.
The Return on Investment 2 study found that, between 2000 and 2009, NSPs prevented
32,000 new HIV infections, and 96,667 new hepatitis C infections.
It also found that, for every $1 invested in NSPs, more than four dollars were returned in
healthcare cost-savings in the short-term (10 years) in direct costs alone – with other indirect
savings, and greater returns over longer timeframes (including dramatically lowering the costs
associated with hepatitis C treatment), also anticipated. This research demonstrates that NSPs are
both life-saving and cost-effective, reducing the health and financial burden of hepatitis C for
decades to come.
However, NSPs are most effective in preventing hepatitis C transmission when they are easily
accessible – geographically, in time, via different methods (including primary and secondary NSPs
and vending machines) and, most importantly, by a wide range of priority population groups.
One such group, identified by the recently released NSW Hepatitis C Strategy 2014-2020, is
“people in or recently in custodial settings”. Preventing new hepatitis C transmissions amongst this
cohort is essential, given:
39% of NSW prison entrants in 2010 had a history of injecting drug use
24% of all NSW prison entrants, and 67% of prison entrants with a history of injecting
drug use, were hepatitis C antibody positive
Prior to entering prison, 75% of people who inject drugs (PWIDs) reported using sterile
injecting equipment each time they injected BUT
While in custody, 70% of PWIDs reported sharing injecting equipment, which is the most
common route of hepatitis C transmission in Australia
As a result, “[i]ncarceration itself is a risk factor for hepatitis C transmission due to high-risk
activities such as the sharing of non-sterile injecting activities” (Hepatitis Australia Consensus
Statement, 2011). Prisons have accurately been described as “powerhouses” (ibid) or “incubators”
for BBV transmission (Stories from the Other Side, 2013, p15).
Hepatitis NSW believes that it makes absolutely no sense to deny prisoners access to the most
effective means of hepatitis C prevention - sterile injecting equipment, for each injecting episode –
as part of a comprehensive harm minimisation approach.
The introduction of needle & syringe programs in prisons would, in the same way as it
operates in the wider community, help prevent a significant number of new hepatitis C and
other BBV transmissions in NSW.
Introducing NSPs in NSW prisons would be the single-most effective new initiative to
reduce hepatitis C transmissions.
8While no Australian state or territory has introduced a prison NSP to date, their effectiveness has
been comprehensively demonstrated by experience overseas. NSPs have been introduced in a
range of different jurisdictions over the past 10-15 years, including Switzerland, Germany and
Spain.
“Evaluation of NSP programs in custodial settings have shown that such programs:
Do not endanger staff or prisoner safety, and in fact, make these settings safer places to live
and work
Do not increase drug consumption, or injecting
Reduce risk behaviour and the transmission of the hepatitis C virus
Have other positive outcomes for the health of prisoners, including a drastic reduction in
overdoses reported in some prisons and increased referral to drug treatment programs
Have been effective in a wide range of custodial settings
Have successfully employed different methods of needle distribution to meet the needs of staff
and prisoners in a range of prisons
Have successfully complemented other custodial programs for preventing and treating drug
dependence” (from Hepatitis Australia Consensus Statement, 2011).
Overseas experience also refutes one of the major arguments which is commonly made against
prison NSPs in Australia – the claim by prison employee unions that the provision of sterile
injecting equipment will lead to an increased threat of syringes being used as weapons against
them.
As noted by the principal advisory body to the Prime Minister on alcohol and other drug policy, the
Australian National Council on Drugs, in October 2013: “[w]hile acknowledging the importance of
safety of prison staff, we note that there are no reports of this occurring in any prison in which
there is an NSP” (emphasis added).
It is highly likely the provision of sterile injecting equipment to prisoners will, over time, make prison
workers more safe, because there will be declining rates of hepatitis C and other BBVs amongst
prisoners, making any needle-stick injury, or even attack, far less likely to result in BBV
transmission.
The provision of sterile injecting equipment, via NSPs, would also be consistent with a range of
International Human Rights commitments, including the United Nations Basic Principles for the
Treatment of Prisoners, which “refers to the requirement that prisoners shall have access to the
health services in the country without discrimination on the grounds of their legal situation” (from
Hepatitis Australia Consensus Statement, 2011).
This principle – that prisoners have a right to expect an equivalent standard of health care to
general members of the community – is reinforced by the Standard Guidelines for Corrections in
Australia:
“2.31 Every prisoner is to have access to evidence-based health services provided by a
competent, registered health professional who will provide a standard of health services
comparable to that of the general community.”
There are few public health services with as much evidence supporting their effectiveness as the
needle & syringe program. Prisoners have the right to the same access to this vital health service
as they would enjoy in the community.
9This is essential not just to protect their own health, but also to help protect the health of other
people in their life, who would potentially be exposed to hepatitis C and other BBV transmission
upon the prisoner’s re-entry to the community – transmissions which could be significantly reduced
if a prison NSP was introduced.
Finally, we note that some political parties and candidates may be tempted to cite the ACT
Government’s 2012 election commitment to introduce an NSP at the Alexander Maconochie
Centre as a reason to delay introducing a similar scheme in NSW, ostensibly to monitor the results
of the ACT Government’s ‘trial’ before deciding whether to implement a similar scheme in NSW.
There are two strong arguments against such a proposition:
i) As at publication (January 2015), while there have been a number of public announcements,
the ACT has not yet implemented their prison NSP, and there is no guarantee that they will do
so prior to their next election, and
ii) There is no need to wait for the results of this ‘trial’ before deciding whether to introduce NSPs
in NSW prisons. The evidence is clear, both from the effectiveness of NSPs in the wider
community, and of prisons NSPs from overseas, demonstrating that such a move is essential
to help prevent further hepatitis C and BBV transmissions among this priority population.
We call on major political parties to support the introduction of NSPs in
NSW prisons as a matter of priority to help reduce hepatitis C and other
BBV transmission.
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