L aderenza del trattamento e strategie

Transcription

1 L aderenza del trattamento e strategie di prevenzione per la reinfezione HIV/HCV coinfetto alla terapia Teresa Bini UO Malattie Infettive ASST Santi Paolo e Carlo Università di Milano

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11 PWID A preliminary modelling presented indicated that HCV treatment targeted at HIV infected PWDI in Andalusia would not achieve elimination among this population due to continued risk of HCV transmission from HIV-negative populations The burden of HCV is high among HIV-unifected PWID populations and HIV-infected PWID are likely to mix with HIV-unifected PWID populations Elimination among HIV-infected PWID is probably only achievable if combination HCV prevention effert are targeted both with HIV+ and HIV- PWID population

12 MSM One unifying characteristic is the relatively low rates of primary incidence among HIV+ MSM (1 to 2 per 100 person-years compared to PWID populations but high rates of reinfection ( 2 to 10 fold that of primary incidence) Among HIV+ MSM incidence of HCV over the past decade has remained relatively stable in the UK and Netherlands In the UK a modelling study indicated that scaled-up rates of DAA therapy ( from 46% to 80% treated within a year of diagnosis and from 7%/year to 20%/year thereafter) could reduce incidence among HIV+ MSM over 60% by 2030 but could not meet elimination targets Elimination target could be reached when all those diagnosed receive treatment within 1 year of diagnosis or if treatment scale-up is combined with a behaviour risk reduction

13 MSM HCV incidence among HIV+ MSM has increased over the past decade in Switzerland and Germany : - In Switzerland this has occurred with an increase in self-reported risk behaviour ( unprotected anal intercourse); elimination could not be achieved with HCV treatment alone and requires additional reduction in high-risk behaviour (behavioural interventions) - In Germany universal access for DAAs has been available since 2014 (>80% HIV+ MSM trated after their acute diagnosis); however the continued increase in HCV incidence among HIV+ MSM (0.33/100 person-years in 1996 to 1999 to 2.28/100 person-years in 2008to 2012) and high levels of reinfection (7 to 8 personyears)requires scale up of HCV treatment and reductions in high-risk behaviour

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15 Possible additional barriers

16 Possible additional barriers

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18 A recent Cochran sistematic review and meta-analysis found that OST is associated with 50% reduction in HCV incidence among PWID (RR 0.5,95%CI ) Weak evidence that exposure to any NPS is associated with a reduction in HCV incidence (RR 0.77,95%CI ) In combination OST and NSP can work synergically to reduce HCV incidence by 71% (RR 0.29, 95% )

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20 Case-control studies have identified numerous potential factors associated with HCV acquisition such as: Fisting Rectal trauma with bleeding Condomless receptive an al intercourse Group sex IDU A control study in NY among MSM found that «sex while on methamphetamine» was dependently associated with incidence HCV infection (OR 29) Two studies in Amsterdam found associations between HCV among MSM and consumption of cocaine, ecstasy, gamma hydroxbutyrate (GHB), ketamine,amphetamine or methamphetamine before or during sexual contact

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23 Project ECHO Personalized Cognitive Counseling (PCCC) to help participants identify and avoid risky sexual and drug using behaviors In a randomised sample of HIV-negative MSM who reported sex after substance use in the past 6 months the intervention reduceed the number of condomless AI events with nonprimary partenrs by 46% compared to the control group An intervention similar to Project ECHO could possibly be effective for HCV prevention due to associations found between sex-drug use and HCV infection

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25 When assessing suitability for HCV therapy PWID, people who are incarcerated, people with HIV/HCV coinfection and MSM had been considered «high risk» based on concerns regarding efficacy, toxicity, adherence, and particularly, the potential for reinfection

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29 The real-world efficacy of DAA therapy among people with HIV/HCV coinfection appears to be comparable to clinical trial efficacy High SVR12 (93%) was demonstrated among people with HIV/HCV coinfection and cirrhosis enrolled in the French National Agency for Research and viral Hepatitis (ANRS) CO13 HEPAVIH cohort

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