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  LIONS, DAD 2014  ROUX, CURR PHARM DES 2013

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 The role of general practitioners in access to HCV care  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  SALMON-CERON, BMC Health Serv Res. 2012

14 Positive impact of HCV treatment on adherence to ART  Objective: Relationship between HCV treatment initiation and ART adherence in HIV-HCV-coinfected individuals  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= %CI [ ])  Conclusions: Fear of reduced ART adherence should not be an argument to deny access to HCV treatment  ROUX, ANTIVIR THER 2014