La dernière frontière : simplification et intégration des soins

Transcription

1 Jean-Michel Delile CEID, Bordeaux Vice-président de la Fédération Addiction ATHS Biarritz, 18/10/2017 Atelier «Simplifier pour éliminer l hépatite C» La dernière frontière : simplification et intégration des soins

2 Introduction Des traitements efficaces Des rapports d experts Une décision ministérielle La population-clef des UDI, TasP Comment avancer dorénavant pour éliminer l hépatite C? Dépistage/diagnostic Accès aux soins Traitement Prévention recontamination

3 Avec l aide de Pr Jason Grebely Pr John Dillon Pr Jeffrey Lazarus

4 Global Health Sector Strategy HCV targets at a glance Incidence targets 30% reduction in new HCV infections by % reduction in new HCV infections by 2030 Mortality targets 10% reduction in mortality by % reduction in mortality by 2030 Harm reduction Increase in sterile needle and syringes provided per PWID/year from 20 in 2015 to: 200 by by 2030 Testing targets 90% of people aware of HCV infection by 2030 Treatment targets 80% of people treated by 2030 Source: (Accessed

5 The global cascade of care for chronic HCV infection in 2015 Adapted by Macmillan Publishers Ltd, part of Springer Nature with permission, from Global HepatitisReport, 2017, World Health Organization,page 30, figure 8, Source: Lazarus JV. et al. Many European countries flying blind in their efforts to eliminate viral hepatitis. Nat. Rev. Gastroenterol. Hepatol,

6 Le traitement est efficace chez les usagers de drogues injecteurs Présents et passés

7 Defining populations of PWID Former PWID Current PWID Current PWUD PWID in OST

8 SVR12 (%) SVR12 among former/recent PWID % 89% 95% 88% 87% 82% 95% 90% 86% Hull Conway Bouscaillou Powis Norton Read Litwin Sulkowski Mazhnaya ) Norton B, et al. Int J Drug Pol ) Hull M, et al. INHSU ) Conway AASLD ) Bouscaillou EASL ) Powis J. Int J Drug Policy ) Read P. Int J Drug Policy 2017; 7) Litwin AL, et al. ILC 2017, Amsterdam, The Netherlands, April rd, 2017; 8) Sulkowski M, et al. ILC 2017, Amsterdam, The Netherlands, April rd, ) Mazhnaya Int J Drug Policy In Press 2017.

9 Response (%) Recent PWID The SIMPLIFY Study 74% injecting in past 30 days, 35% G1a, 58% G1, 9% cirrhosis, DAA-treatment naïve No virological failures, no viral relapse, 1 case of reinfection 96% /103 ETR 94% 97/103 SVR12 Grebely J, et al. INHSU 2017, New York, United States, September 6-8, 2017

10 Des moyens existent pour améliorer encore la compliance et l efficacité DOT Groupes Incentives Peer support

11 SVR12 (%) PREVAIL: Individual vs. DOT vs. group 85% genotype 1a, 27% cirrhosis, 11% treatment-experienced, 14% HIV 98% methadone, 65% with recent drug use in last 6 months % 98% 96% 46/51 50/51 46/48 Individual DOT Group 8 Litwin AL, et al. ILC 2017, Amsterdam, The Netherlands, April rd, 2017 (PS-130)

12 Initiating treatment (%) CHAMPS: HCV treatment uptake HCV genotype 1, 12% cirrhosis, 25% recent cocaine/heroin use P= % 24/36 76% 83% 41/54 45/54 Usual care (nurse) UC + incentives UC + peersupport 9 Sulkowski M, et al. ILC 2017, Amsterdam, The Netherlands, April rd, 2017 (SAT-228)

13 SVR12 (%) CHAMPS: Usual care vs. incentives vs. peer-support % 89% 90% 18/20 33/37 37/41 Usual care (nurse) UC + incentives UC + peersupport 10 Sulkowski M, et al. ILC 2017, Amsterdam, The Netherlands, April rd, 2017 (SAT-228)

14 Dépistage, diagnostic et accès aux soins sont donc les derniers obstacles à réduire

15 HCV care cascade among PWID Grebely J, Hajarizadeh B, and Dore GJ Nat Rev in Gastroenterology & Hepatology Iversen J, et al. Int J Drug Pol 2017.

16 Là-aussi nous disposons de modèles efficaces d intervention pour réduire cette cascade

17 What is a model of care? WHERE WHAT WHO HOW

18 Settings, services, and providers Settings Services Providers Drug andalcohol clinics Primary health care /GPs Sexual health NSP services Community healthcentres Prisons Specialists Primary care providers Drug and alcohol providers Nurses Peer supportworkers Others

19 Enhancing testing, linkage to care, and treatment in PWID Systematic review of interventions to enhance HCV testing, linkage to care or treatment among PWID 10,116 records 14 studies with comparative interventions included Interventions to enhance HCVtesting On-site testing with pre-test counselling and education Dried-blood spot testing Interventions to enhance linkage tocare Facilitated referral for HCV Interventions to enhance HCVtreatment Integrated care for HCV and drug use delivered by a multidisciplinary team (with or without non-invasive liver disease assessment) Bajis S, et al. International Journal of Drug Policy2017

20 We have plenty of interventions to enhance the cascade HCV testing Peer-delivered outreach HCV testing and counselling 1 Prison-based outreach testing and counselling 2 Patient referral contact tracing programme w ith monetary incentive for testing 3 Rapid HCV antibody testing at community pop-up/mobile clinics or low threshold settings 4-6 DBS testing 7,8 Integrated on-site testing, counselling and education 9,10 HCV linkage to care Patient navigation and facilitated referral for HCV evaluation Nurse-led pre-treatment assessment in prison w ith specialist support via telemedicine 14 Non-invasive liver disease assessment using transient elastography w ith facilitated referral to care 7,15-17 Integrated HCV care in drug & alcohol setting/primary care, including on-site HCV assessment w ith/w ithout peer support Community-based nurse-led HCV evaluation and liver disease assessment using transient elastography; and subsequent referral to specialist for treatment 24 HCV bridge counsellor employed to provide education, scheduling of specialist appointments, home visits to locate individuals, incentives and transportation 10 Multidisciplinary mobile clinic offering point of care testing, counselling and liver disease assessment using transient elastography 6 HCV treatment uptake Integrated HCV care in drug & alcohol setting/primary care, including on-site HCV assessment w ith/w ithout peer support 19,20,25 Integrated HCV care and drug use care in primary care, w ith/w ithout onsite treatment 22,23,26,27 Community-based nurse-led HCV evaluation, including ordering of blood tests and disease assessment using transient elastography; and subsequent referral to specialist for treatment 24 Patient navigation including motivational interview ing and treatment readiness counselling 13 1) Aitken CK, Drug and Alcohol Review 2002; 2) Skipper C, Gut 2003; 3) Brewer DD, Eurosurveillance 2009; 4) Conway B, J Hepatitis 2015; 5) Cosmaro ML, Infection 2011; 6) Remy AJ, U Euro Gastro J 2015; 7) O'Sullivan M, J Hepatology 2015; 8) Tait JM, J Hepatology 2013; 9) Pace CA, J Gen Int Med 2014; 10) Sena AC, Pub Health Rep 2016; 11) Trooskin SB, J Gen Int Med 2015; 12) Islam MM, J Sub Abuse Treat 2012; 13) Ford MM, Clin Inf Dis 2016; 14) Lloyd AR, Clin Inf Dis 2013; 15) Foucher J, J Viral Hep 2009; 16) Marshall A, Int J Drug Pol 2015; 17) Lambert JS, J Hepatology 2016; 18) Alavi M, Clin Infect Dis 2013; 19) Grebely J, Eur J Gastro Hep 2010; 20) Keats J, Int J Drug Pol 2015; 21) Martinez AD, J Viral Hep 2012; 22) Harris KA, J Addict Med 2010; 23) Malnick S, Israel J Psychiatry Rel Sci 2014; 24) Wade AJ, PLOS ONE 2015; 25) Newman AI, Can J Gastro 2013; 26) Seidenberg A, BMC Infect Dis 2013; 27) Woodrell C, J Addict Med2015; 28) Bajis S, et al. Int J of Drug Pol 2017.

21 Task shifting to community-based non-specialist providers Three hour education and training Overall SVR12 following sofosbuvir/ledipasvirwas 87.1% (CI, 71.8% to 94.7%) No difference by provider type: NPs, 90.4% (CI, 59.0% to 98.4%); PCPs, 87.6% (CI, 62.0% to 96.8%); and specialists, 84.8% (CI, 70.2% to 93.0%) Kattakuzhy S, et al. Ann Intern Med. 2017

22 Specialist restrictions for DAA prescription 94% (n=32) ofcountries required specialists to prescribe DAAtherapy 22 - NJ, Sept 2017 Source: Marshall, AD et al. Restrictions for reimbursement of interferon-free direct acting antiviral therapies for HCV infection in Europe. Poster presented at The International Liver Congress April Amsterdam,

23 Expanding prescriber base In countries without prescriber restrictions, such as Australia, general practitioners and non-specialists have greater access to reach patients in need of treatment 5-15% of individuals initiating DAAs had treatment prescribed by a GP Figure 5: Prescriber distribution in each month for individuals initiating DAA treatment during March to September 2016 in Australia Supervised medical officers included interns, temporary resident doctors, and nonvocationally registered doctors Source: Hajarizadeh B, Grebely J, Matthews GV, Martinello M, Dore GJ. The path towards hepatitis C elimination in Australia NJ,

24 Le risque de réinfection est-il un problème chez les injecteurs actuels?

25 What is the risk of HCV reinfection following therapy? Not calculated among people with recent injecting posttherapy

26 Simplification

27 SACC: Borgernær shared care Source: NJ,

28 conclusions

29 Merci