29 September 2021
Name: Scientia Professor Greg Dore
Location: Sydney, Australia
Organisation: St Vincents Hospital, The Kirby Institute
Specialisms: HCV, HIV, epidemiology
In our latest Meet the Members article we spoke with Scientia Professor Greg Dore about how HCV treatment has changed lives, why we need to build trust around drug dependency management, and discuss the best methods to show reluctant healthcare workers the life-changing value of treating people who use drugs.
TELL US A BIT ABOUT YOUR BACKGROUND
I trained at St Vincent’s Hospital in Sydney, Australia and during my residency there spent some time in Malawi at a mission hospital. At that time, I wasn’t sure what I wanted to specialise in, but when I got back knew it was infectious diseases. I was the HIV registrar in 1993, completed my training in infectious diseases, then in 1995 embarked on an academic career at Kirby Institute, UNSW Sydney, including completion of my PhD in HIV and AIDS epidemiology.
I eventually ended up moving into HCV clinical and academic work as I saw a clear gap and opportunity – people working in HIV are comfortable with social diversity and are generally public health-oriented. I felt like that was missing at the time in HCV. I started to see people clinically and then set up St Vincent’s hepatitis C clinical service in 1999.
On the academic side, I started to build a hepatitis program at the Kirby Institute, starting out initially with surveillance and monitoring, some epidemiology and then moved into treatment studies. My work in hepatitis C has transitioned from local, to national, then to international research.
My current work is a mix of clinical and academic – I do one day per week in the hospital (currently including COVID work) and am a Professor and Program Head for the Viral Hepatitis Clinical program at the Kirby Institute.
HOW HAVE THINGS CHANGED DURING YOUR TIME WORKING WITH PEOPLE WHO USE DRUGS?
When I first started out, the cure rate for HCV with just Interferon was just 10%, then it rose to 40% with the addition of Ribavirin. And – at that stage, in Australia at least – government-funded treatment required people to have 12 months abstinence from drugs.
I thought that was clearly discriminatory; we ignored those guidelines and ended up being one of the first groups internationally to treat people who were currently injecting. I’ve always had a health and human rights approach and believe that people shouldn’t be precluded from having access to treatment, just because they’re injecting. It just didn’t seem to make any sense at all.
In the last decade, that’s changed a lot though. And when it comes to the health of people who use drugs, hepatitis C is a bit of a standout. We can improve so many people’s lives now and reduce the risk of serious liver disease. That’s a huge step forward.
There have been other advances, albeit less than revolutionary. Drug dependency management has improved a bit – we’ve now got a bit more choice. But we’re still stuck with generally rigid systems for delivery and monitoring.
WHAT CAN BE DONE TO IMPROVE THE HEALTH OF PEOPLE WHO USE DRUGS?
We need flexible systems to allow improved drug dependency management. In years to come, we will look back and be amazed that we expected people to come to methadone clinics every day to pick up their dose. We don’t give people much trust.
There’s also challenges around mental health and infections from injections. I’d like to see better access to mental health services and better options (such as supervised injecting sites) to treat harms from injecting.
Then there’s the whole issue of stigma and discrimination. There’s still enormous stigma from the broader community, including that people who inject drugs are not to be trusted, and this clearly impacts health and wellbeing. There’s also still that lack of trust from healthcare providers when it comes to caring for people who use drugs.
HOW CAN THIS LACK OF TRUST TOWARDS PEOPLE WHO USE DRUGS BE IMPROVED?
I do understand some people’s concerns, but we need to be less risk-averse and more trusting. Can we ensure no diversion if we gave a week of methadone? The answer is no. But we shouldn’t require 100% non-diversion to open up such programmes?
I’d really like to see a more trusting delivery of drug dependency management in the future. There are some prescribers and dispensers that are pretty flexible at the moment but they’re the small minority. The question is, how do you translate that to a much larger population?
A key issue is building that understanding amongst healthcare professionals that many people with dependency will have a varying pattern of drug use throughout their life.
If people go through periods where they are using more, it doesn’t concern me so much, but it seems to concern a lot of healthcare professionals. It’s just about having a more understanding approach when you interact with people that use drugs. Build up a trusting relationship with them, and don’t be judgemental.
WHAT’S STOOD OUT THE MOST DURING YOUR CAREER?
I think what’s been interesting is being able to convince conservative, traditional clinicians who have been involved in Hep C treatment for a long time, the value and importance of treating people that inject.
To move them away from ‘what’s the point of treating someone who uses drugs because they’ve got other issues/might get re-infected/probably won’t finish their treatment’ to a framework of ‘these results are really positive and we can cure all these people and lower re-infection’.
I’m glad to have contributed to that transition in a meaningful way and play a part in changing people’s mindsets – to show that people who use drugs want to be treated and can be.
HOW DO YOU PERSUADE A HEALTHCARE WORKER WHO IS RELUCTANT TO TREAT SOMEONE WHO IS CURRENTLY INJECTING?
Some people need solid evidence, and there are lots of trials that have been pivotal to demonstrate high adherence, high cure rates, etc. This can really help to shift people’s thinking.
For other people, it’s about opening their eyes to opportunities. When it comes to HCV – here’s this revolutionary treatment that cures pretty much everyone.
There’s an empowerment that comes with being able to prescribe a therapy that can absolutely change people’s lives. So why would you hold that back? There are no downsides.
LAST BUT NOT LEAST…WHAT DO YOU GET FROM THE INHSU NETWORK? WHY SHOULD SOMEONE JOIN?
INHSU offers diversity, enthusiasm, and commitment. But I think it’s the diversity that is the real key. INHSU isn’t a narrow, conservative network – it’s a very diverse group of people who share common goals and come at it from a broad range of backgrounds and disciplines.