HEPATITIS MOBILE TEAM News Tools of screening viral hepatitis in real life: the french model of care André-Jean REMY (1,2), Hugues WENGER (1), Hakim BOUCKHIRA (1), Stéphane MONTABONE (1), Agnès SENEZERGUES (2) (1) Hepatitis Mobile Team, Service of Gastroentrology, (2)Consultation Unit and Ambulatory Care, Perpignan Hospital, France Andre.remy@ch-perpignan.fr 1

INFECTIOUS RISK REDUCTION AMONG DRUGS USERS (DU) EXPERT GROUP INSERM 2010 INFECTIOUS RISK REDUCTION AMONG DRUGS USERS (DU) Recommandations : 1) Screening ALL drug users for HIV and hepatitis B and C, and also screening again at least once a year 2) Evaluating impact of advanced hepatology and infectious diseases consultations : in high and low levels methadon centers (CSAPA/CAARUD) and inmates medical unit (UCSA) and other potential places 3) Being close to DU in high and low levels methadon centers (CSAPA / CAARUD) because it appears an improvement factor for viral hepatitis diagnostic and treatment 4) Promoting access for DU to psycho-educative intervention programs outside of hospital 5) Establishing multidisciplinary outreach centers "all in one" screening to treatment, including vaccination against HBV, provide medical care and also social care 2

HEPATITIS MOBILE TEAM

10 SERVICES « à la carte » 1. Screening / Point of Care Testing POCT (HIV HBV HCV) 2. Mobile liver stiffness Fibroscan* (indirect measurement of liver fibrosis) in site 3. Social screening and diagnosis (EPICES score) 4. Advanced on-site specialist consultation 5. Easy access to pre-treatment commissions (“RCP”) with hepatologists, nurse, pharmacist, social worker, GP, psychiatric and/or addictologist.. 6. Individual psycho-educative intervention sessions 7. Collective educative workshops 8. Staff training 9. Drug users information and prevention 10. Green thread: special outside POCT and FIBROSCAN* 4

Introduction Hepatitis B and C screening was usually done by serology in laboratories or medical centers If serology was positive, viral load and genotype was determined patient saw hepatologist if viral load was also positive

Introduction (2) Liver fibrosis was measured after first medical consultation All steps took 3 to 6 months Drug injection was main contamination route of hepatitis C virus (HCV) in France and western Europe since 1990 highest european screening rate in France  still 33% of patients didn’t take care of hepatitis C

Methods (1) Hepatitis mobile team proposed new model of screening high risk patients for hepatitis C or B All team members (nurses and social worker) came together in outreach centers, jailhouses, drug services centers and all structures which care drugs users, homeless or other precarious patients

Methods (2) triple screening in same time: social screening with specific score of 11 questions called EPICES POCT for HCV HBV and HIV liver fibrosis screening by FIBROSCAN* With this results, patient could do his/her biology quickly and see hepatologist in 2 or 3 weeks only  

PARTNERS ORGANIZATIONS Asyleum medical unit Jailhouse medical unit Primary care access unit TB unit Addictology service Gastroenterology service Medical duty home Hospital services 500 000 people area One Day hospital and Psychiatric Mobile Team Mao – psychiaitric diagnosis and orientation module Psychiatric Hospital HEPATITIS MOBILE TEAM Associative sector Methadon centers Low threesold drug center Housing units Therapeutic Coordination Apartment Day reception and home association Outside hospital Patients association Psychoeducative network Hepatitis network 9

Workplaces of HMT Drug centers Jailhouse Day reception home unit Primary care acess unit Specific converted truck 10

Point Of Care Testing POCT HCV / HIV / HBV Alternative to blood test, but in case of positive test  a blood test confirmation is necessary Quick on digital puncture Immediate results Free, renewal of HCV/ HIV status as soon as necessary Reliable 3 months after taking HIV / HCV / HBV risk Do not detect the primary infection 11

Results (1) 1101 POCT were done in 24 months 12% were positive for HCV 22% were positive for already known patients  who returned to medical care by this pathway 7% positive for HBV 1 POCT was positive for HIV  

Fibroscan* 13

Results (2) 393 FIBROSCAN* were done medium rate of 7.8 Kpa fibrosis level F2 68% for HCV 3% for HBV 29% for alcoholic liver disease  

Results (3) All patients were evaluated with specific social score EPICES (since september 2014) 11 questions yes/no Maximal score 100 > 45.8 = precarious patients 90% of our patients were precarious… 98 patients in 9 months 311 interviews Average 3 per patient Maximum 15 interviews for one! 15

Results (4) 190 patients were followed by nurses and social worker 134 patients were addressed to on site hepatologist consultations  112 came at least once 45% of patients were treated by DAA only 3% were lost sight  

Patients’ words Free access Closeness (outside hopital) Speed (of the results) Availibility (of nurse and social workers)

Possible by specific trained nurses A new clinical patient pathway? Free services for outpatients with or without social insurance Screening (POCT / FIBROSCAN*) Diagnosis (biology) Treatment (RCP) HCV cure New referral pathways Possible by specific trained nurses 18

Conclusion a new model of care based on site triple screening (serology, liver fibrosis, social diagnosis) and follow up increased number of patients diagnosed, treated and cured

We need to provide services that meet the needs of high risk groups 20

THANK YOU FOR YOUR ATTENTION! 21

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