ARISTOTLE HCV-HIV: A fast-track intervention to seek-test-link-treat PWID in Athens, Greece

Transcription

1 IVHEM, 6-7 December 2018 ARISTOTLE HCV-HIV: A fast-track intervention to seek-test-link-treat PWID in Athens, Greece Vana Sypsa Department of Hygiene, Epidemiology and Medical Statistics Medical School, National and Kapodistrian University of Athens, Athens, Greece vsipsa@med.uoa.gr

2 Disclosures Gilead, Abbvie

3 People who inject drugs (PWID) in Athens, Greece High-risk drug users Injection in the last 30 days Greek Monitoring Centre for Drugs Annual report (2015 data)

4 High burden of HCV and HIV infection among PWID in Athens HIV outbreak in 2011 among PWID High HCV prevalence & incidence HCV prevalence in Athens (2015): 85% HIV prevalence ( ): 16.5% Prevalence among new injectors (injecting 2 years): 100% 80% 72,9% 60% 40% 20% 44,7% 0%

5 Harm reduction coverage and access to DAAs in Athens OST NSP Harm reduction coverage Increasing number of PWID on OST but waiting time of 6 months Access to DAAs A national treatment registry was set up approval for free DAAs granted through that registry July 2017: HIV-HCV coinfection or F2 and above September 2018: No restrictions However, small % of PWID accessing treatment with DAAs

6 Aim ARISTOTLE HCV-HIV To increase diagnosis and treatment for HCV and HIV infection among PWID in Athens Target population 3,000 PWID in Athens Injecting drug use in the past 12 months 18 years old Based on the design of ARISTOTLE implemented during the HIV outbreak ( ) Good practice in the health sector response to HIV in the WHO European Region & EMCDDA award for 2015 Sypsa et al, J Inf Dis, 2017, Hatzakis et al, Addiction 2015

7 ARISTOTLE HCV-HIV: A seek-test-link-treat intervention Seek Test Link &Treat Rapid identification of as many PWID as possible Interview, fibroscan, HCV, HIV & biochemical testing Linkage to HCV & HIV care with the help of a peer-navigator

8 Reaching the target population PWID hard-to-reach population Subgroups even more hard-to-reach: e.g. immigrants without documents Need to implement the intervention rapidly and to achieve high coverage in the screening of the target population In addition, a representative sample of the target population is desirable to estimate important parameters

9 Reaching the target population: Respondent-driven sampling (RDS) An initial number of recruits (seeds) from the target population receive coupons and are asked to draw from their existing injection networks to identify up to 3 potential recruits Chains of recruits are accrued Monetary incentives to: Participate Recruit others Linkage to care Heckathorn et al, Social Problems 1997 Study site: Located in the centre of Athens

10 PWID arrive at study site (recruited by peers) Informed consent process. Fibroscan, blood sample collection (anti-hcv, anti-hiv, biochemical testing, genotype if treatment criteria are met), interview Procedure At the end of the process: Payment of primary incentive 3 coupons are provided to recruit others A few days later: Collection of test results and counselling Payment of secondary incentives Patients with HCV-HIV coinfection: linked to infectious diseases specialists with the help of a peer-navigator. Patients with chronic hepatitis C without HIV: 1. They are entered to the national treatment registry of patients with chronic hepatitis C 2. They are linked to liver clinics with the help of a peer-navigator.

11 Steps to improve linkage to care 1. To obtain approval for DAAs, patient data have to be recorded to national treatment registry Social security number, genotype & fibroscan (cost not covered by the system), HCV RNA, biochemical testing etc Testing is performed in ARISTOTLE HCV-HIV in a single visit The program staff seeks actively social security numbers from participants (reminders through SMS etc) 2. A network of collaborating clinicians was set up they visit the study site to enter patients to the national HCV treatment registry 3. The peer-navigator accompanies patients to their first visit to liver or infectious diseases clinics.

12 Participants characteristics April-September 2018: participants Age, mean Gender Nationality Male Female Greek Other 39 years 83.7% 16.3% 86.3% 13.7% Currently homeless 29.2% Injecting drug use in the past 30 days 81.7% In OST program (now) 22.4%

13 Prevalence of HCV, HBV, HIV (first 1,088 participants) ΗΒsAg (+), N(%) 28 (2.6%) Anti-HIV(+), N(%) 180 (16.6%) Anti-HCV (+), N(%) 847 (78.1%)

14 Chronic hepatitis C (CHC) & eligible for DAAs: 412/1088 PWID (37.9%) CHC & HIV coinfection: % Anti-HCV(+): 847 CHC & Fibroscan 7.0kPa: 253 Anti-HCV(+) & fibroscan <7.0kPa: 377 Not eligible for treatment (until Sept. 2018)

15 HCV genotype 70 HCV monoinfection & 7.0 kpa HCV-HIV coinfection 60 60, ,3 42, , ,7 15,7 0 0,8 1, mixed

16 Cascade of HCV care at first participation to the program (first 1,088 participants) % % Anti-HCV(+) Already diagnosed 96 Treatment in the past (IFN-based) 20 Treatment now (DAAs) Self-reported

17 Steps towards linkage to HCV care: Preliminary results from ARISTOTLE HCV-HIV (first 1,088 participants during the period where DAAs where reimbursed for F2 stage and excluding coinfected patients who were referred to infectious diseases units) Chronic HCV & fibroscan 7.0 kpa Available social security number Entered to the national treatment registry

18 Overall: ARISTOTLE HCV-HIV combines features that facilitate screening and linkage: Chain-referral sampling to reach and screen for HCV a hard-to-reach population All testing (including fibrosis evaluation) is provided in a single visit to the study site Collaborating clinicians visit the study site and enter patients eligible for DAAs to the national HCV treatment registry to obtain treatment approval A peer-navigator accompanies patients to their first visit to liver or infectious diseases clinics.

19 Discussion Community-based peer-driven chain referral allowed to reach rapidly a large number of active PWID not linked to OST 2 out of 3 HCV-infected PWID are aware of their infection but, very low proportion reported treatment with DAAs In the presence of treatment restrictions, 4 out of 10 recruited PWID were eligible for DAAs; this would increase to approximately 7 out of 10 PWID if restrictions were removed.

20 Challenges and the future Challenges Ongoing efforts to identify/issue social security number for participants Linkage to OST, peers to support them throughout treatment etc. are needed to improve treatment outcome The program is ongoing We plan to initiate a second RDS sampling round in the following months to attract new as well as old participants We will initiate a similar program in another city in Greece (Thessaloniki)

21 Acknowledgements Supported by Gilead, Abbvie and the Hellenic Scientific Society for AIDS and STDs Research team: A. Hatzakis, G. Kalamitsis, G. Papatheodoridis, D. Paraskevis, G. Daikos, M. Phsichogiou and the network of collaborating hepatologists