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Successful Cascade of Care and Cure HCV in 5382 Drugs Users : How Increase HCV Treatment by Outreach Care , Since Screening to Treatment Corresponding

Introduction: In France 33% of patients didn’t take care of hepatitis C because there were no diagnosed. Drug injection was main contamination route of hepatitis C virus (HCV) in France. French guidelines were to treat all inmates and drug users, even fibrosis level. Access of HCV screening, care and treatment in drugs users, prisoners and homeless was low in France. They were considered as difficult to treat populations. All these patients need specific support. Hepatitis Mobile Team (HMT) was created in July 2013 to increase screening care and treatment of hepatitis B and C patients. HMT was composed of hepatologist, nurses, social workers and health care worker. Objective: increase outreach screening care treatment access and cure of our target population. Patients and methods Target population was drugs users, prisoners, homeless, precarious people, migrants and psychiatric patients. We proposed part or all of our services to our 42 medical and social partners: HCV HBV screening by DBS (dried blood test); outside DBS and FIBROSCAN in converted van; Outreach open center; Drug users information and prevention, Free blood tests in primary care;, Staff training; Social screening and diagnosis; Mobile liver stiffness Fibroscan in site; Advanced on-site specialist consultation; Easy access to pre-treatment commission; Low cost mobile phones for patients; Individual psycho-educative intervention sessions; Collective educative workshops; Peer to peer educational program; Specific one day hospitalizations. All services were free for patients and for partners. Results: from 2013 July to 2018 December, we did 8382 DBS for 5382 people (3053 HCV DBS) and 2302 Fibroscan*. HCV new positive rate was 21.3%. Our HCV active file was 651patients included these 24.8% new patients screened by DBS; 98% realized HCV genotype, HCV viral load and FIBROSCAN. DAA treatment was proposed to 96%; 95% started treatment, 4% were lost follow up or refused treatment. After treatment, there was 7 relapse and 3 reinfections by drug injection and cured rate of 94%. Sociological evaluation showed that 4 program qualities for patients: free access, closeness (outside hospital), speed (of the results) and availability (of nurse and social workers). Conclusions: Specific follow-up of drugs users and other HCV high-risk patients including screening, early detection, diagnosis and treatment increase rate of treated and cured patients, with low rate of relapse and reinfections. Andre-Jean Remy, Hakim Bouchkira, Jeremy Hervet, Arnaud Happiette, Hugues Wenger Mobile Hepatitis Team, Perpignan Hospital, France DOI : 10.14302/issn.2574-4526.jddd-19-2770 Successful Cascade of Care and Cure HCV in 5382 Drugs Users: How Increase HCV Treatment by Outreach Care, Since Screening to Treatment Corresponding author: Andre-Jean Remy, Mobile Hepatitis Team, Perpignan Hospital, France, Tel: +33/468616137, Email: Andre.remy@ch-perpignan.fr


Introduction
In 2016, the World Health Organization (WHO) set an ambitious goal to eliminate hepatitis C as a major public health threat by 2030 [1]. Specific  From 2016 French guidelines [5] were to treat all inmates and drug users, even fibrosis level with direct antiviral agents (DAA). Success rate of DAA, one or tow pills per day for 8 or 12 weeks therapy, was 95 to 97%.
Before that, access of HCV screening, care and treatment in drugs users, prisoners and homeless was low in France. They were considered as difficult to treat populations. All these patients need support especially psycho-educative interventions. The Mobile Hepatitis Team (MHT was set up in 2013, following the publication of an scientific report on reducing risks of infection amongst drugs users in 2011 [1], which recommends screening all drug users for HCV and establishing multidisciplinary clinics with 'all-in-one' screening to treatment and providing medical and social care.

Objective and Methods
Our main objective was to increase outreach screening care treatment access and cure of our target population. Target  Epidemiology and prevention of HCV 1) PWID should be provided with appropriate access to OST and sterile drug injecting equipment as part of widespread comprehensive harm reduction programs (Class I, Level B).
(2) PWID should be offered HCV treatment, given they are at elevated risk of HCV transmission and successful treatment may yield transmission reduction benefits (Class IIa, Level C).

Natural history of HCV and effects of drugs on the liver
(1) PWID should be counselled to moderate alcohol intake, or abstain if evidence of advanced liver disease (Class I, Level A).
(2) Cessation of injecting is not required to limit HCV disease progression (Class IIa, Level C).

Testing of HCV infection
(1) An anti-HCV test is recommended for HCV testing among PWID, and if the result is positive, current infection should be confirmed by a sensitive RNA test (Class I, Level B).
(2) PWID who are anti-HCV negative should be routinely and voluntarily tested for HCV antibodies/RNA and if negative, every 12 months. Testing should also be offered following a high risk injecting episode (Class IIa, Level B).
(3) PWID who are anti-HCV antibody positive and HCV RNA negative (through spontaneous or treatment-induced clear-ance) should receive regular HCV RNA testing, every 12 months or following a high risk injecting episode (Class IIa, Level B).

Non-invasive liver fibrosis assessment
(1) Non-invasive assessments have a reduced risk and greater acceptance than liver biopsy, may enhance HCV screening and disease assessment among PWID, and should be offered, if available (Class I, Level B).

Pre-therapeutic assessment
(1) Pre-therapeutic education should include discussions of HCV transmission, risk factors for fibrosis progression, treatment, reinfection risk and harm reduction strategies (Class I, Level B).
(2) Pre-therapeutic assessment should include an evaluation of housing, education, cultural issues, social functioning and support, finances, nutrition and drug and alcohol use. PWID should be linked into social support services, and peer support if available (Class I, Level B).
(3) Models of HCV care integrated within addiction treatment and primary care health centers, as well as prisons, allow successful pre-therapeutic assessment (Class I, Level B).
(4) Peer-driven interventions delivered within OST settings may lead to higher rates of treatment initiation and should be offered, if available (Class IIa, Level C).
(5) Care coordination in conjunction with behavioural interven-tions can increase likelihood of PWIDs being evaluated and initiating treatment and should be offered, if available (Class I, Level B).

Indications for treatment
(1) PWID should receive HCV assessment, with treatment deci-sions based on an individualised evaluation of social, lifestyle, and clinical factors (Class I, Level B).
(2) Treatment is recommended for PWID with chronic HCV infection (Class I, Level A).

PEG-IFN and DAA-based treatment: treatment recommendations
(1) Evaluation of safety and efficacy of interferon-free DAA regimens is required in PWID (Class I, Level C).
(3) The decision to institute therapy in PWID should be based on the availability of agents locally and individual disease characteristics of infected persons. For regions without access to interferon-free DAA therapy, PWID with early liver disease should generally be advised to await access to interferon-free DAA regimens. For those with access to highly effective interferon-free DAA therapy, anyone with chronic HCV infection should be considered for therapy, taking into account social circumstances, adherence and medical and social co-morbidities (Class I, Level B).
(4) DAA therapy does not require specific methadone and buprenorphine dose adjustment, but monitoring for signs of opioid toxicity or withdrawal should be undertaken (Class I, Level B).

Impact of drug use on adherence and SVR
(1) Adherence assessments should consider missed doses and treatment discontinuation (Class I, Level B).
(2) PWID should be counselled on the importance of adherence in attaining an SVR (Class I, Level A).
(3) A history of IDU and recent drug use at treatment initiation are not associated with reduced SVR and decisions to treat should be made on a case-by-case basis (Class I, Level B).
(4) PWID with ongoing social issues, history of psychiatric disease and those with more frequent drug use during therapy are at risk of lower adherence and SVR and need to be monitored closely during therapy (Class I, LevelB).

Impact of mental health on adherence and SVR
(1) Pre-treatment assessment should include an evaluation of previous or current psychiatric illness, engagement with a drug and alcohol counselor or psychiatrist and discussions around potential treatment options (Class I, Level A).
(2) In cases of acute major and uncontrolled psychiatric disorders, a pre-treatment psychiatric assessment is recommended (Class IIa, Level C).
(3) In case of relevant psychiatric co-morbidities with an increased risk for interferon-associated psychiatric side effects interfer-on-free DAA therapy should be considered (Class IIb, Level C).

Treatment management
(1) HCV treatment for PWID should be considered on an individualized basis and delivered within a multidisciplinary team setting (Class I, Level A).
(2) Access to harm reduction programs, social work and social support services should be a component of HCV clinical management (Class I, Level A).
(3) Peer-based support should be evaluated as a means to improve HCV clinical management (Class I, Level B).

HCV treatment in prisons
(1) Screening and assessment for HCV should be offered to PWID in custody (Class IIa, Level C).
(2) Antiviral treatment for PWID in custody is feasible and clinically effective and should be offered to PWID in custody (Class IIa, Level B).

Reinfection following successful HCV treatment
(1) PWID should not be excluded from HCV treatment on the basis of perceived risk of reinfection (Class I, Level B).
(2) Harm reduction education and counselling should be provided for PWID in the context of HCV treatment to prevent HCV reinfection following successful treatment (Class I, Level B).
(3) Following SVR, monitoring for HCV reinfection through annual HCV RNA assessment should be undertaken on PWID with ongoing risk behaviour (Class I, Level B).

Treatment of acute HCV
(1) PWID with acute HCV symptoms should be monitored for 12-16 weeks (including HCV RNA levels) to allow potential spontaneous clearance (Class I, Level B).
(2) PEG-IFN mono-therapy for 24 weeks may be considered for PWID with acute HCV (Class I, Level B).
(3) Strategies to optimize adherence should be used in the setting of acute HCV, with consideration of directly observed PEG-IFN therapy (Class I, Level B).
(2) The accelerated HCV disease progression in HIV/HCV should be considered in treatment decision-making; HCV treatment should be prioritized in HIV/HCV patients regardless of fibrosis stage (Class I, Level B).
(3) HIV/HCV-coinfected PWID should be treated and retreated with the same DAA regimens as HCV-monoinfected persons, after recognizing and managing interactions with antiretrovi-ral medications (Class I, Level B).
(4) Early introduction of cART should be offered to all people with HIV infection (Class I, Level A).
(5) Potential drug-drug interactions between HIV, HCV and OST need to be considered. Consultation with a frequently updated database/prescribing information is indicated (Class I, Level A).

Management of hepatitis B virus (HBV) co-infection
(1) PWID should be vaccinated for hepatitis A virus and HBV (Class I, Level B).
(2) HBV DNA testing should be performed on all patients with evidence of chronic HBV infection (hepatitis B surface antigen positive) (Class I, Level A).
(3) PWID with active HBV/HCV co-infection should be treated according to guidelines for monoinfection (for both infections) (Class IIb, Level C).  (Figure 3). There was too many under diagnosed HCV patients, especially in homeless, prisoners and drugs users [9].