André-Jean REMY (1,2) (1) Hepatitis Mobile Team, Service of Gastroentrology, (2)Consultation Unit and Ambulatory Care, Hepatitis Reference Center, Perpignan Hospital, France INCIDENCE OF THE HEPATITIS C IN PRISON IN FRANCE RESULTS OF A STUDY BY POCT HEPATITIS MOBILE TEAM 1 1

800 km 200 km Barcelona 2

HCV in France (1)  Global incidence 2700/4400 new cases per year  HCV patients  unaware patients  waiting for treatment  cured patients 3

HCV in France (2)  Number of treated patients  2012   2013  6000  2014   2015 

French guidelines February / Treat all patients with liver fibrosis F2 F3 F4 and.. 2/ Treat all drugs users and inmates even if no liver fibrosis  100% of french DU / inmates have to be treated for HCV infection! 4 5

2016 HEPATITIS MOBILE TEAM  1 Hepatologist  1 Nurse coordinator  3 other nurses (2 for psycho educative intervention)  1 Secretary  2 Social workers  2 Health care workers  For a multidisciplinary approach 8 6

HEPATITIS MOBILE TEAM - 3 specific cars + 1 truck -3 Fibroscan - POCT/DBS HIV/HCV/HBV 9 7

Target population  Drugs users  Prisoners  Psychiatric patients  Homeless  Precarious people  Migrants 8

PARTNERS ORGANIZATIONS HEPATITIS MOBILE TEAM Associative sector Patients association Psychoeducative network Hepatitis network Hospital services Asyleum medical unit Jailhouse medical unit Primary care access unit Pharmacy TB unit Addictology service Gastroenterology service Medical duty home Psychiatric Hospital One Day hospital and Psychiatric Mobile Team Mao – psychiaitric diagnosis and orientation module Outside hospital Methadon centers Low threesold drug center Housing units Therapeutic Coordination Apartment Day reception and home association 10 9

PARTNERS ORGANIZATIONS HEPATITIS MOBILE TEAM Associative sector Patients association Psychoeducative network Hepatitis network Hospital services Asyleum medical unit Jailhouse medical unit Primary care access unit TB unit Addictology service Gastroenterology service Medical duty home Psychiatric Hospital One Day hospital and Psychiatric Mobile Team Mao – psychiaitric diagnosis and orientation module Outside hospital Methadon centers Low threesold drug center Housing units Therapeutic Coordination Apartment Day reception and home association people area 10

15 SERVICES « à la carte »  Early detection / Primary prevention 1. Screening / Point of Care Testing POCT (HIV HBV HCV) 2. Green thread: outside POCT/DBS (dried blood spot) and FIBROSCAN* with specific truck 3. Outreach open center 5 days/7 4. Drug users information and prevention actions 5. Staff training  Clinical management :Linkage to care and fibrosis assesment 6. Social screening and diagnosis (EPICES score) 7. Mobile liver stiffness Fibroscan* (indirect measurement of liver fibrosis) in site 8. Advanced on-site specialist consultation 9. Free access to hospital blood tests care 13 11

15 SERVICES « à la carte »  Access to treatment 10. Easy access to pre-treatment commission (“RCP”) with hepatologists, nurse, pharmacist, social worker, GP, psychiatric and/or addictologist Low cost mobile phones for patients  Follow up during and after treatment 12. Individual psychoeducative intervention sessions 13. Collective educative workshops 14. Peer to peer educational program 15. Specific one day hospitalizations 13 12

15 SERVICES « à la carte »  Hepatitis mobile team offers hotlines "all in one"  Each structure according to its needs could choose actions it wishes to include in its draft  For 1500 potential outpatients 14 13

244 HCV followed patients 14

1485 seen once 2056 DBS / 944 HCV DBS/ 414 Fibroscan HCV positive 244 (100%) FIBROSCAN + full blood tests done 202 patients in pretreatment commission(83 %) (61% of PTC cases) 146 HCV treatment decide (59%) / 56 only survey 121 started treatment(50%) 93 cured patients + 26 in treatment (49%) / only 2 stop treatment HMT linkage care 15

Introduction (1)  HCV rate is higher in the prisoners population than in the general’s one in France, between 5 and 7 % (INVS 2004, PREVACAR)  Prisoners accumulate risk factors before their confinement but the prison in itself represents a risk factor: syringes or straw share, home-made tattoos… 16

Introduction (2)  HCV incidence in prisons was not known  Screening of HCV is systematically proposed in the entrance to detention in France, recommended by the Methodological Guide of sanitary care is not still applied correctly  point of care testing (POCT) use could constitute an interesting alternative in classic serology  POCT was recommended in French HCV experts report in 2014 and in national guidelines in

Objective  use HCV POCT in prison  as a supplement to the classic serology  study the incidence of new HCV infections in prisoners 18

Methods (1)  HCV prevalence in our establishment is situated in national average around 7 %  HCV serology realized by venous way was proposed to all incomers in Perpignan detention center  average 1500 per year 19

Methods (2)  POCT was proposed to 3 types of prisoners:  1/refusal or impossibility of venous way  2/transfer of another penitentiary and previous negative serology  3/presence in detention 12-month- old superior and previous negative serology 20

Point Of Care Testing  POCT/DBS HCV / HIV / HBV  Alternative to blood test, but in case of positive test  blood test confirmation is necessary  Quick on digital puncture  Immediate results  Free, renewal of HCV status as soon as necessary 15 21

Methods (2)  In case of positivity  we did FIBROSCAN  And complementary blood tests 22

Mobile FIBROSCAN Liver stiffness = measurement of hepatic elasticity to detect liver fibrosis and liver cirrhosis diagnosis Uninvasive testing with rapid results, combined with DBS/POCT Performed by a nurse trained in the framework of a Memorandum of Cooperation (HSPT-Law Article 51) 16 23

Results (1)  333 HCV POCT was realized in 24 months  group 1 15 % (refusal)  group 2 27 % (transfer)  group 3 58 % (> 12 months detention) 24

Results (2)  2 serology were positive by POCT  2 inmates were imprisoned for more than 6 months  viral load was both positive  One patient had gone out in permission one week  One patient had never gone out of detention  Use of drugs was route of contamination in 2 cases 25

Results (3)  Calculated incidence in prison was 3/1000/year  potentially 470 new cases of HCV infection in France a year among the prison population  prisoners on May 1st, 2016 in France 26

Risk of HCV reinfection in IVDU and prisoners  Simmons and al, CID 2016: 62,  14 studies high-risk patients IVDU and prisoners  Risk rate = 22.3/1000 person years of follow up after HCV treatment 27

Discussion / conclusions  HCV POCT are useful in jailhouses because there are HCV high risk place  These route of contamination could be more than 10% of HCV new cases  So it was also necessary to give harm reduction tools for all prisoners like syringes share 28

THANK YOU FOR YOUR ATTENTION !!! 29

ANY QUESTIONS ? 30