HCV in PWID in Africa: A hidden epidemic

1. HCV in PWID in Africa: A hidden epidemic Niklas Luhmann Médecins du Monde 3rd International HIV/Viral HepatitisCo-infection Meeting HIV/Viral Hepatitis: ImprovingDiagnosis, Antiviral Therapy and Access

2. Conflict of interest 3rd International HIV/Viral HepatitisCo-infection Meeting I have no conflict of interest to declare

3. Part I: Drug use and healthrelatedharmsglobally

4. Drug use globally 3rd International HIV/Viral HepatitisCo-infection Meeting 27 million people (range: 15.7 million-39 million), or 0.6% of the adult population estimated to suffer from problem drug use The joint UNODC/WHO/UNAIDS/World Bank estimate for the number of people who inject drugs (PWID) worldwide is 12.19 million (range: 8.48-21.46 million) PWID are a very vulnerable and marginalized groups Source: UNODC, World drug report, 2015

5. Mortality in people who inject drugs 3rd International HIV/Viral HepatitisCo-infection Meeting • In a systematic review (Degenhardt et al. Addiction 2011) • the pooled CMR of 2.35 deaths per 100 PY provides evidence of the high mortality associated with injecting drug use • the pooled SMR of 14.68 shows that mortality is much higher in those who inject drugs than in the general population. • Drug overdose and AIDS-related mortality were by far the most common causes of death.

6. CHASE cohort Deans et al. CMAJ Open 2013

7. Health impact of problemdrug use: HIV Source: UNODC, World drug report, 2015 3rd International HIV/Viral HepatitisCo-infection Meeting • Accounting for an estimated 30 per cent of new HIV infections outsidesub-Saharan Africa • About 1.65 million (range: 0.92-4.42 million) PWID were estimated to be living with HIV worldwide in 2013 – corresponding to 13.5 per cent of PWID being HIV positive

8. (World Drug Report, UNODC, 2015)

9. Health impact of problemdruguse: HCV • HCV antibody mid-point prevalence worldwide 67.5% (Nelson, Lancet, 2011) • 8% of HCV + PWID livein SSA(Nelson, Lancet, 2011) • PWID-HCV+: 26% live in East/South-East Asia and 23.5% in Eastern Europe • In general drug user populations have rather low testing uptake and knowledge regarding viral hepatitis • Treatment uptake is very low (Grebely et al. Antiviral Research, 2014; Luhmann et al. IJDP 2015) 3rd International HIV/Viral HepatitisCo-infection Meeting

10. HCV global epidemiologyamong PWID Source: Nelson et al., Lancet, 2011

11. HCV/HIV Co-infection 3rd International HIV/Viral HepatitisCo-infection Meeting HIV/Viral Hepatitis • 10% of HIV-infected persons are co-infected with HCV in general population • The midpoint prevalence in 123 studies of HCV infection among HIV+ PWID was 82.4% (IQR 55.2–84.5) withlittleregional variation (Platt L et al. Lancet InfectiousDisease 2016)

12. Drug policy and health Source: Global Commission on Drug Policy 3rd International HIV/Viral HepatitisCo-infection Meeting • Repressivedruglaws force drugusers away from public health services and into hidden environments where HIV/HCV and overdose risk becomes markedly elevated. • The global “war on drugs” is driving the HIV/AIDS and hepatitis C pandemics among people who use drugs and partners and families • Mass incarceration of non-violent drug offenders also plays a major role in increasing HIV/HCV risk.

14. Part II: Drug use, HIV and HCV in Sub-Sharan Africa

15. Injecting Drug use in Africa 3rd International HIV/Viral HepatitisCo-infection Meeting (World Drug Report, UNODC, 2015)

16. Absolutenumbersof PWID in SSA 3rd International HIV/Viral HepatitisCo-infection Meeting (World Drug Report, UNODC, 2015)

17. HIV among PWID in SSA 3rd International HIV/Viral HepatitisCo-infection Meeting (World Drug Report, UNODC, 2015)

18. HCV prevalence data in SSA 3rd International HIV/Viral HepatitisCo-infection Meeting From Nelson et al. (Lancet, 2011) 4 countries with HCV prevalence data among PWID: • Kenya: 51.4% • Tanzania: 22,2% • Ghana: 40,1% • Mauritius 97.3% Fromlaterpartlypeer-reviewedworks and unpublishedstudies • Tanzania: 27,7% among PWID;267 PWID recruited from Temeke District, Dar-es-Salaam through snowball and targeted sampling(Bowring, Luhmann et al. IJDP, 2012) • South Africa (Pretoria): 24% HCV among PWID; 271 PWID, purposivesample, usingsnowballing of PWID from central Pretoria area (Vanessa Hecthter, Sediba Hope Medical Centre, Programatic report 2014) • Senegal (Dakar): 38,9% among PWID in UDSEN study, 23,3% amongoverall population of PWUD (Lepretre et al; JIAS, 2015)

20. Case example Kenya 2015 – MdM – Support Campaign Don’t Punish 2016 – MdM DIC – Peer Educators Training on HR 2016 – MdM DIC – HR kits packaging

21. Case example Kenya: epidemiological HCV data 3rd International HIV/Viral HepatitisCo-infection Meeting • High uncertainty about epidemiological HCV data • General population data in Kenia: • Systematic review by Riou et al. (JVH 2015): 2.8% antibody sero-prevalence • Reported HCV antibody prevalence for HIV infected persons: • The overall pooled sero-prevalence of HCV co-infection in HIV-infected individuals in Sub-Saharan Africa was 5.73% (Rao et al. Lancet InfDisease 2015) • Central Africa with 5.87% • Southeast Africa with 4·56% (Rao et al. Lancet InfDisease 2015) - FromMSF-B screening withinKibera HIV-Clinic (in Nairobi): 0,02 % amongapproximately 5000 VIH infected patients

22. HCV epidemiology among PWID 3rd International HIV/Viral HepatitisCo-infection Meeting Reported antibody prevalence for PWID in Kenia • Nelson et al. (Lancet, 2011): for PWID 51.4% • MdM-Kenya Antibody Testing for HCV campaign in Nairobi: • SAPTA campaign from March 2015 to April 2015 among 73 PWID : 14 clients with HCV AB positivity (18,4%), including 4 patients with HIV/HCV co-infection

23. HCV epidemiology among PWID Source: Rajiv Shah, Imperial College Londonand Maud Lemoine, Imperial College, London, unpublished, preliminary data 200 DUs were recruited at two rehabilitation centres in Mombasa (Reach Out Centre Trust and Muslim Education & Welfare Association drop-in centre) Local outreach workers were used to mobilise IDUs aged 18 and above and bring them to the centres where they underwent an interview, physical examination and blood sampling following provision of written consent.

24. HCV epidemiology among PWID 200 IDU recruited at two rehabilitation centres in Mombasa Source: Rajiv Shah, Imperial College Londonand Maud Lemoine, Imperial College, London, unpublished, preliminary data

25. Case example Kenya: good news 3rd International HIV/Viral HepatitisCo-infection Meeting MdMand MSF collaboration for treatment of HCV in HIV care and harm reduction services • MdMidentified 12 co-infected people who inject drugs for a phase 1 pilot HCV treatment program • Treatment provided in MSF HIV clinic for this phase 1 (UNITAID grant) • Treatment provided through Philips Pharma after submission of request-letter and individual and anonymous prescriptions (delay: 2 – 3 weeks)

26. Case example Kenya 3rd International HIV/Viral HepatitisCo-infection Meeting • Patient characteristics for treatment batch 1 : • 12 patients with HIV/HCV infection • Age 23 – 39 years • All male • APRI score: 6/12 with APRI below 0.5; 5 with APRI 0.5 – 1.5 and 1 patient with APRI 2.9 • Genotypes: 9/12 GT 1a and 3/12 GT 4 • All treatment naïve • 9 patients started on SOF400/LDV90 from 9th of May • Fibroscan status (n=9): 5 with FO, 2 with F2 and 2 with F3 • Follow up 4 weeks of treatment: 4 undetectable all other 5 patiens VL below 100 copies Source: unpublished program data, MSF-B

27. Case example Tanzania

28. Methadone Clinic • Set up in 2011 • Collaboration between the Ministry of Health and PEPFAR • First free access substance addiction clinic in Sub Saharan Africa • Also provides integrated medical care with free access to TB & HIV therapies • Now 4 satellite sites with > 2,000 registered clients

29. Study Population Demographics and liver fibrosis 143 patients included for study “The clinical characterization of patients with known Hepatitis C attending the substance addiction unit at the Muhimbili National Hospital, Dar es Salaam” Source: Zameer Mohamed, Imperial College Global HealthFellow/ Welcome Trust and Maud Lemoine, Imperial College, London, unpublished data

30. Study Population Demographics and liver fibrosis 143 patients included for study “The clinical characterization of patients with known Hepatitis C attending the substance addiction unit at the Muhimbili National Hospital, Dar es Salaam” Source: Zameer Mohamed, Imperial College Global HealthFellow/ Welcome Trust and Maud Lemoine, Imperial College, London, unpublished data

31. Part IV: HCV in PWUD in SSA: The response 3rd International HIV/Viral HepatitisCo-infection Meeting

32. The response: OST Source: Harm Reduction International, The global Sate of HR, online-tool 2015

33. The response: NSEP Source: Harm Reduction International, The global Sate of HR, online-tool 2015

34. The registration gap

35. Conclusion • Injecting drug use is prevalent in SSA especially in Eastern SSA • Many unknowns with regards to HCV epidemiology overall • Very limited data regarding HCV + HIV among PWID on the continent • HR programs available, but very low coverage and often only in pilot stage • Absence of public policies for viral hepatitis • Huge registration gap for DAAs - Inavailability of DAAs • Very expensive and centralized diagnostics platform

36. Conclusion • Verylittle data and evidence • Verylittleaccess to prevention and testing • Verylittleaccess to treatment

37. Acknowledgements 2nd International HIV/Viral Hepatitis Co-infection Meeting IAS Vancouver 2015 • Julie Bouscaillou (MdM, France) • Céline Grillon (MdM, France) • Chloé Forette (MdM, France) • Olivier Maguet (MdM, France) • ZinMar Han (MdM, France, Tanzania) • FrancoisBerdougo (MdM, France) • Karine Lacombe (St Antoine Hospital, France) • Maud Lemoine (Imperial College, London) • Zameer Mohamed (MuhimbilliUniversity, Dar es Salaam) • Karyn Kaplan (TAG, USA) • Tracy Swan (TAG, USA)