1. Simon Janes Antoine van Sint Fiet Giovanni Pintaldi
“The five pillars of care” An inclusive and equitable medical approach to hepatitis C care in people who inject drugs
Simon Janes
Antoine van Sint Fiet
Giovanni Pintaldi
MSF India, "The five pillars of care"

2. MSF India, "The five pillars of care"
Context
MSF present in Manipur state in the north-east of India, since 2004
Currently operates two ART centers under public private partnership with NACO, in Churachandpur and Moreh providing care for HIV, (DR)-Tuberculosis (TB), and Hepatitis C virus (HCV) infection
HIV and HCV epidemic in Manipur has been driven by the use of intra-venous drugs.
MSF India, "The five pillars of care"

3. Substance Use Disorder
Inter-related Morbidities
Estimate prevalence HCV infection in India: %1
Estimated prevalence of HIV infection in:
India (2015): 0.26%2
Manipur (2015): 1.22%2
Estimated prevalence's of HIV and HCV in people who inject drugs (PWID’s) in Manipur3:
HIV infection: % %
HCV infection: % %
HIV / HCV co-infection: 21.0 % %
Substance Use Disorder
Tuberculosis
Mental Health
Illness
HIV
Hepatitis C
Puri,et al. Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL); 2014.
National AIDS control Organisation: India HIV Estimations 2015, Technical Report.
Solomon, et al. Burden of hepatitis C virus disease and access to hepatitis C virus services in people who inject drugs in India: a cross-sectional study; 2014.

4. Barriers to HCV care for PWID’s
Barriers present at multiple levels of “HCV cascade of care”
Stigma and discrimination
Treatment domain of specialist hospital system
Absence of peer and adherence support
Separation of treatment from Harm reduction / oral substitution treatment services
Cost
MSF India, "The five pillars of care"

5. MSF India, "The five pillars of care"
Exclusion
Limited treatment with overwhelming demand
Complexity of treatment with interferon containing regimens
Programmatic desire for good performance resulting in exclusion of patients with multiple co-morbidities
Prioritisation of patients with advanced liver disease
Concerns of re-infection, poor adherence and poor outcomes in PWID’s
MSF India, "The five pillars of care"

6. MSF India, "The five pillars of care"
Inclusion
Holistic patient centered approach required, focusing on individualised priorities and not specific diseases
Ethical considerations of autonomy, beneficence, non-maleficence, justice and respect for persons have been largely ignored
Provides important opportunity for behavioral modification and uptake of harm reduction services
Highest burden of incident cases amongst PWID’s
Treatment as prevention
Improved care for related co-morbidities through increased awareness and development of expertise
MSF India, "The five pillars of care"

7. MSF India, "The five pillars of care"

8. Psychosocial assessment
ASSESSMENT AND PRIORITISATION
Medical assessment
Clinical assessment
Routine baseline blood
Screen for:
TB /Opportunistic infection
Review HIV care
HIV Viral Load
HCV Viral Load / Genotype
APRI: AST platelet ratio index
Fibroscan
Psychosocial assessment
Demographics
Social support and coping skills
Mental Health Status
Depression screening tool: PHQ9
ASSIST questionnaire
AUDIT Alcohol use tool
Motivation and barriers to treatment
Adherence factors
Clinical Case Review
ASSIST: Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
MSF India, "The five pillars of care"

9. INDIVIDUALISED CARE HIV TB / Opportunistic infection Hepatitis C
New patients: existing schedule for pre-treatment and on-going HIV counselling
Existing patients: Adherence counselling: second weekly
Clinical case review: 4/12
TB / Opportunistic infection
Counselling as required
Clinical Case review at completion of medical treatment of existing co-infection
Hepatitis C
Pre-treatment counselling
Adherence counselling:
1, 2, 4, 6, 8, 12, wks
Clinical case review at completion of HCV treatment
Substance Use Disorder
Counselling as required
OST referral for PWID’s as required
Regular counselling with OST
Repeat ASSIST / AUDIT
Clinical case review: 4/12
Mental Illness
Counselling as required
Sever illness: psychiatrist referral
Individualised counselling plan
Repeat PHQ9 at 3/12
Clinical case review: 4/12
Regular medical r/v
Adherence: Repeat VL at 3 /12 of counselling
Specific TB/OI treatment
Regular medical r/v
Regular medical r/v
Monitor HCV viral load
Test of cure at 12 wks
Routine medical care.
Care for complications of intravenous drug use
Psychiatrist review
Pharmacotherapy if required
MSF India, "The five pillars of care"

10. Morbidity identified as primary treatment priority
CLINICAL CASE REVIEWS 92
Morbidity identified as primary treatment priority
HIV 11 TB
Opportunistic
Infection 1
Hepatitis C 54
Substance
Use
Disorder 15
Mental Health illness 8
Repeated clinical case review of 31 patients: 18 re-prioritised for HCV treatment
RE-PRIORITISATION TO HCV TREATMENT FOLLOWING INITIAL INTERVENTION 3 1 9 5
MSF India, "The five pillars of care"

11. MSF India, "The five pillars of care"
Overall average duration from initial case review to prioritisation for HCV treatment for all types of intervention = 7.5 months
Average duration between initial clinical case review and prioritisation for HCV treatment for each initial priority:
Substance use disorder: months
Mental health illness: months
HIV adherence: months
TB / Opportunistic infection: 3.5 months
MSF India, "The five pillars of care"

12. MSF India, "The five pillars of care"
Conclusions
Through a multi-disciplinary model to assess, prioritise and manage related co-morbidities, the most vulnerable populations can be equitably included in treatment of Hepatitis C
There is a requirement for program managers and treatment providers to understand, accept and adapt care models to issues of social function and stigmatisation specific to PWID that currently limit access to treatment including the parallel provision of effective harm reduction services
There are sound ethical and scientific justifications for the creation of models of care delivery specifically tailored for the needs of PWID’s
MSF India, "The five pillars of care"

13. MSF India, "The five pillars of care"
Acknowledgements
We would like to thank the MSF specialist advisors
Dr Michiel Lekkerkerker and Dr Krzysztof Herboczek
We would like to thank the MSF team in Manipur for their unyielding dedication and hard work.
We would like to acknowledge Dr Till Kinkel whose contribution to initial discussions were responsible for a reorientation from an “exclusive” to “inclusive” mentality. We also acknowledge Dr Julian Sheather’s valuable contributions to the ethical considerations
MSF India, "The five pillars of care"

14. MSF India, "The five pillars of care"
Thank-you
MSF India, "The five pillars of care"