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?

g Increasing access to effective treatment for opioïd

dependence (e.g. methadone)

g Diversifying harm reduction tools for safer drug

consumption

g Increasing access to HCV treatment as prevention

3

The ANRS Methaville trial (1)

g Methadone included in the WHO list of essential medicines thanks to its

effectiveness in

treating opioïd dependence

preventing HIV

improving adherence to ART

g Limited access to methadone due to overdose risk during induction.

g In France: buprenorphine initiated in primary care but not methadone

g Many rural areas underserved because of lack of specialized centers

4

The ANRS Methaville trial (2)

g 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

g Primary outcome: % of patients abstinent from

non-prescribed opioïds after 12 months ROUX, BMC PUBLIC HEALTH 2012

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The ANRS Methaville trial (3)

g Non-inferiority of induction in primary

care compared to specialized care on 12-

month abstinence from non-prescribed

opioîds

g Significant lower engagement in care of

patients randomized in specialized

centers

g 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

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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

g 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?

g Increasing access to effective treatment for opioïd

dependence (e.g. methadone)

g Diversifying harm reduction tools for safer drug

consumption

Injection and other modes of consumption at risk of

HCV transmission

Rising use of stimulants

g Increasing access to HCV treatment as prevention

8

The ANRS AERLI study

g 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.

g Design : controlled clustered interventional study

conducted in low-threshold services.

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The ANRS AERLI study

g Outcomes: HIV-HCV risk practices &complications

at the injection site at M6-12

g Results : exciting! See you on ThAC0403

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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

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The STIMAGO ANRS study

g Background :

increased use of stimulants

no pharmacological treatment for stimulant dependence

dopaminergic agents as possible agonist substitution treatments

g Objective : evaluating the efficacy of Methylphenidate on

cocaine dependence.

g 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?

g Increasing access to effective treatment for opioïd

dependence (e.g. methadone)

g Diversifying harm reduction tools for safer drug

consumption

g Increasing access to HCV treatment as prevention

13

The role of general practitioners in access to HCV care

g Objective: identifying the individual and structural correlates of

access to HCV treatment

g Design: 3-year follow-up of HEPAVIH ANRS-CO13 cohort of patients

living with HIV and HCV.

g 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

g Conclusion: Possible role of primary care to scale-up HCV treatment

SALMON-CERON, BMC Health Serv Res. 2012

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Positive impact of HCV treatment on adherence to ART

g Objective: Relationship between HCV treatment initiation and ART

adherence in HIV-HCV-coinfected individuals

g Design: comparing visits of patients when receiving HCV treatment with

those of patient not yet receiving treatment

g 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])

g Conclusions: Fear of reduced ART adherence should not be an argument

to deny access to HCV treatment ROUX, ANTIVIR THER 2014