1. David Truong MD FRCPC Vancouver Infectious Disease Centre October 2017
DIAGNOSIS AND TREATMENT OF HEP C INFECTION: A TOOL OF ENGAGEMENT FOR PEOPLE WHO INJECT DRUGS (PWIDs) 2nd European Conference on Addiction and Dependences Lisbon, Portugal
David Truong MD FRCPC
Vancouver Infectious Disease Centre
October 2017
- Mention that the information being presented, particularly the results are the most recent data analysis, therefore it may be slightly different then what is in the program.

2. Disclosures
David Truong, MD, FRCPC, ABIM has disclosed that he has, directly or indirectly, received research grants, clinical trials support and/or travel support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Merck & ViiV.

3. Background: Canadian statistics
In 2011, an estimated 246,000 Canadians were living with chronic hepatitis C infection.
In 2014, there was an estimated 89,855 persons who injected drugs (PWIDs) in Canada.
Among the PWID population in Canada, an estimated 66% are antibody positive for hepatitis C.
CATIE: national stats from 2014
Across Canada, 0.7% is the rate among all Canadians.

4. Vancouver’s Downtown East Side (DTES)
In 2015, 12,500 PWIDs were identified in Vancouver.
In 2003, an estimated 8000 PWIDs were living in the DTES.
Hepatitis C prevalence is 88% in PWIDs of the DTES.
Many individuals remain undiagnosed or unengaged in care.
Community Pop-Up Clinics (CPCs) were developed to address this unmet need and to identify factors associated with engagement in care of this population.
Describe the DTES: Vancouver’s population is just over 600K. The DTES extends approximately over 15 square blocks.

5. Community Pop-Up Clinic (CPC)
Participants are recruited at CPCs held at several community centers in Vancouver’s DTES.
Soup kitchens
Shelters
Service centres
Supervised injection sites.
THE SALVATION ARMY
THE CARNEGIE HALL
UNION GOSPEL MISSION
THE DUGOUT
INSITE
EVELLYNE SALLER CENTRE
Team members
Physician
Nurse
Clinic staff (3)

6. Testing (oral swabs) OraQuick® Hep C point-of-care testing.
Results typically available in 20 minutes.
OraQuick Hep C Rapid (oral swab)
Comparable accuracy to serum EIA (enzyme immunoassay)
97% sensitivity, 98% specificity.
Public Health Implications of Rapid Hepatitis C Screening With an Oral Swab for Community-Based Organizations Serving High-Risk Populations (97.5%v matching between oral and serum EIA)

7. Pop-up clinic structure overview
Registration
Completion of Questionnaire
Hep C TESTING
Negative
$10 Gift Card
Positive
Standardized Brief Consultation
Overview of Hep C
Discussion and planning of additional testing
Discussion of treatment options
$10 Gift Card and Lunch Coupon
Appointment made at VIDC
Results Given Confidentially
Questionnaire aims to gather information on demographics, substance use, and housing situation.

8. Results: 2013-2017 CPC: Total patients tested (n = 3474)
Hepatitis C positive patients (n = 1119)
Through our pop-up clinic program, we have identified 1119 hepatitis C positive individuals

9. Patient approach: Four legged chair
Medical Needs
Hep C infection, HIV, renal disease
Psychiatric Needs
Depression, anxiety, psychosis
Addiction-Related Needs
Opiate substitution therapy, harm reduction, rehabilitation
Social Needs
NO MONEY, NO FOOD, NO HOME = NO HOPE.
So once a person is found to be positive for either hepatitis C or HIV, they receive an immediate, onsite consultation with a physician. We don’t simply approach the patient with a focus of their medical needs, rather we address 4 factors we have identified integral to their over well-being. Our approach, which we have coined the “four legged chair” involves addressing not only their medical needs, but also their psychiatric needs, addiction-related needs, and social needs.
We help them obtain government assistance, most importantly monetary assistance and housing.

10. Cascade of Hep C Care: 2013 - 2017 * *1095 self-identified PWIDs
Of the 1119 identified as hepatitis C positive, 329 are considered engaged in care (defined as attending their follow up appointment)
HCV+ include self identified and new diagnosis.

11. Linkage to Hep C Therapy (January 2016-present)
Patient Demographics
HCV Work-Up Completed (n)
187
Mean Age (years)
51.4
Male (%)
72%
Cocaine Use (%)
63%
Opiate Use (%)
70%
Other stimulant Use (%)
23%
Treatment Statistics
Initiated HCV Tx (n)
134
All-oral DAA Rx (n)
Completed HCV Rx (n)
126
Lost to follow-up 8
SVR-12 (=CURE)
92%
Recurrent Hep C viremia
0 (18 months mean f/u)
Demonstrating that we are successfully curing, but also having reduced rates of recurrent viremia

12. The Opioid Crisis: British Columbia, CANADA
2016
2017
We have also noticed a trend towards lower rates of opioid overdose among the patients who we have engaged into care through our CPC program.
In my province of British Columbia, we have an opioid crisis
In a duration of 16 months between January 2016 to April 2017, there has been over 1400 cases of opioid related deaths.
Each day in Vancouver, there are over 20 calls to paramedics for opioid related overdose.
Among the 119 patients we have engaged into care through our CPC program since 2016, we have had only 1 opioid-related death. This demonstrates that through engagement and retention into care, we can help change the opioid crisis.
Over 1400 opioid-related deaths in British Columbia from January 2016 to April 2017.
Among 119 patients engaged in care through CPCs since 2016, there have been 9 medically significant opioid overdoses and a single fatality.

13. Discussion
Community pop-up clinics (CPC) offer an effective way of engaging hepatitis C-infected PWIDs into long-term multidisciplinary health care.
Such engagement leads to successful initiation of Hep C therapy with SVR-12 (cure) rates comparable to those reported in clinical trials.
The CPC model may be an important strategy to consider in addressing the opioid crisis.

14. Discussion
Considering the patients receiving Hep C therapy within the current analysis, there have been no cases of recurrent viremia following achievement of SVR-12 (cure).
Since the inception of the Hep C treatment program at VIDC, the rate of post-SVR (cure) recurrent viremia (mean 5.5 PYFU) is 1.3/100 PYFU, a rate 60% lower than recently reported in the medical literature in a comparable population.
1.3/100 PYFU (person-years follow up) (95% CI, %)
In the medical literature, rate of recurrent viremia in PWIDS is 3.2/100 PYFU

15. Conclusions
Taken together, our data shows that the CPC model is a safe and effective approach to the diagnosis and treatment of Hep C infection among PWIDs and should be considered an essential component of micro-eradication strategies to achieve WHO-mandated goals for the control of Hep C infection as a public health concern by 2030.
This is a graph demonstrating the impact of reaching the targets
For hepatitis C, it involves treating 80% of people who have chronic hepatitis C by 2030.
The impact being a 90% reduction in new cases of hepatitis B and C, and 65% reduction in related deaths.
For Hep B, by 2030 vaccinate 90% of the population, and treating 80% of chronic hep B

16. Special Thanks Brian Conway: Principle investigator
Vancouver Infectious Disease Clinic staff
Arshia Alimohammadi
Amandeep Bassi
Julie Holeksa
Ivan Arlantico
Yashna Bhutani
Robyn Parsons
Deanna Woo
Anita Truong
May Hang