Role of harm reduction in HCV prevention in France: from research to scale up

1. Role of harm reduction in HCV prevention in France: from research to scale up Bruno Spire & Patrizia Carrieri

2. How to reduce HCV incidence among people who use drugs? • Increasing access to effective treatment for opioïd dependence (e.g. methadone) • Diversifying harm reduction tools for safer drug consumption • Increasing access to HCV treatment as prevention

3. The ANRS Methaville trial (1) • Methadone included in the WHO list of essential medicines thanks to its effectiveness in • treating opioïd dependence • preventing HIV • improving adherence to ART • Limited access to methadone due to overdose risk during induction. • In France: buprenorphine initiated in primary care but not methadone • Many rural areas underserved because of lack of specialized centers

4. The ANRS Methaville trial (2) • Increasing access to methadone in France using primary care as an entry point => Evaluate the feasibility of methadone induction in primary care by a non-inferiority pragmatic trial • Primary outcome: % of patients abstinent from non-prescribed opioïds after 12 months • ROUX, BMC PUBLIC HEALTH 2012

5. The ANRS Methaville trial (3) • Non-inferiority of induction in primary care compared to specialized care on 12-month abstinence from non-prescribed opioîds • Significant lower engagement in care of patients randomized in specialized centers • Methadone duration significantly associated with an increase of abstinence from non-prescribed opioîd use difference between the proportion of patients abstinent from street-opioïds between both arms at M12

6. The ANRS Methaville trial: (4) • Less than half of the patients were adherent. Non-adherence was associated with cocaine use and perceiving methadone dose as inadequate • At M12, 68% of patients did not use non-prescribed opioïds. A good patient-provider relationship was the most important predictor • ROUX, CURR PHARM DES 2013 • LIONS, DAD 2014

7. How to reduce HCV incidence among people who use drugs? • Increasing access to effective treatment for opioïd dependence (e.g. methadone) • Diversifying harm reduction tools for safer drug consumption • Injection and other modes of consumption at risk of HCV transmission • Rising use of stimulants • Increasing access to HCV treatment as prevention

8. The ANRS AERLI study • Objective : to assess the effectiveness of community-based intervention of training and education to injection on HIV and other blood borne disease risk reduction in France. • Design : controlled clustered interventional study conducted in low-threshold services.

9. The ANRS AERLI study • Outcomes: HIV-HCV risk practices &complications at the injection site at M6-12 • Results : exciting! See you on ThAC0403

10. The crack pipe study • Crack is smoked through glass pipes that can lead to severe injuries which facilitate HCV transmission • Design : Before/ after intervention study • Intervention : distribution on Pyrex crack pipes on 350 crack users • Outcome : presence of face or hands injuries • Results : decrease from 90% at baseline to 30% after 18 months of intervention • JAUFFRET-ROUSTIDE, BEH 2010

11. The STIMAGO ANRS study • Background : • increased use of stimulants • no pharmacological treatment for stimulant dependence • dopaminergic agents as possible agonist substitution treatments • Objective : evaluating the efficacy of Methylphenidate on cocaine dependence. • Outcomes: self-reported abstinence from non prescribed stimulants use; craving score, urine toxicologies and MP plasma concentrations

12. How to reduce HCV incidence among people who use drugs? • Increasing access to effective treatment for opioïd dependence (e.g. methadone) • Diversifying harm reduction tools for safer drug consumption • Increasing access to HCV treatment as prevention

13. HEPAVIH The role of general practitioners in access to HCV care • SALMON-CERON, BMC Health Serv Res. 2012 • Objective: identifying the individual and structural correlates of access to HCV treatment • Design: 3-year follow-up of HEPAVIH ANRS-CO13 cohort of patients living with HIV and HCV. • Results: After a median follow-up of 12 months, 124 patients (21%) had started HCV treatment. Among structural factors, being followed-up by a general practitioner working in a hospital was associated with HCV treatment initiation • Conclusion: Possible role of primary care to scale-up HCV treatment

14. HEPAVIH Positive impact of HCV treatment on adherence to ART • Objective: Relationship between HCV treatment initiation and ART adherence in HIV-HCV-coinfectedindividuals • Design: comparing visits of patients when receiving HCV treatment with those of patient not yet receiving treatment • Results: Patients reported incomplete adherence to ART in 808 (68%) of the 1,190 visits. After multiple adjustment, initiation of HCV treatment was associated with improved ART adherence (OR= 2.6 95%CI[1.32-5.9]) • Conclusions: Fear of reduced ART adherence should not be an argument to deny access to HCV treatment • ROUX, ANTIVIR THER 2014