This document summarizes key points from a training session on providing HCV testing and treatment to people who inject drugs (PWID). It notes that 10-26% of PWID globally have HCV antibodies. Treatment uptake for PWID is only 2-4% in high-income countries and nearly 0% in low-and middle-income countries, despite effective models of care existing. The document then reviews data on HCV prevalence among PWID populations in various countries, fibrosis levels among PWID living with HCV in Georgia and Vietnam, and low global coverage of harm reduction services for PWID. It presents a case study from Georgia demonstrating integrated HCV screening and treatment within a harm reduction program can achieve high treatment uptake, adherence and SVR rates
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Evolution and Revolution: Current Issues in HIV and HCV Co-infection
Chapter 1 – HIV-Hepatitis C Virus Co-infection: An evolving epidemic
Chapter 2 - Management of HIV infection in HIV/HCV co-infected patients
Chapter 3 - Management of HCV in co-infected patients
Chapter 4 - HCV Therapy: Direct acting antiviral agents in co-infected individuals
Chapter 5 - Drug interactions with directly acting antivirals for HCV: Overview & challenges in HIV/HCV Co-infection
Chapter 6 - Complicated cases
Chapter 7 - Future trials of Hepatitis C therapy in the HIV co-infected
Chapter 8 - HCV infection in marginalized populations
Chapter 9 - HIV/HCV Co-infection: Through the eyes of a co-infected hemophiliac
Risk factors of chronic liver disease amongst patients receiving care in a Ga...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Laura Bamford, MD, MSCE
Associate Professor of Medicine
Medical Director, Owen Clinic
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Edward Cachay, MD, MAS
Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Richard Garfein, PhD, MPH
Professor
Herbert Wertheim School of Public Health and Human Longevity Science
Adjunct Professor
Division of Infectious Disease and Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Evolution and Revolution: Current Issues in HIV and HCV Co-infection
Chapter 1 – HIV-Hepatitis C Virus Co-infection: An evolving epidemic
Chapter 2 - Management of HIV infection in HIV/HCV co-infected patients
Chapter 3 - Management of HCV in co-infected patients
Chapter 4 - HCV Therapy: Direct acting antiviral agents in co-infected individuals
Chapter 5 - Drug interactions with directly acting antivirals for HCV: Overview & challenges in HIV/HCV Co-infection
Chapter 6 - Complicated cases
Chapter 7 - Future trials of Hepatitis C therapy in the HIV co-infected
Chapter 8 - HCV infection in marginalized populations
Chapter 9 - HIV/HCV Co-infection: Through the eyes of a co-infected hemophiliac
Risk factors of chronic liver disease amongst patients receiving care in a Ga...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Laura Bamford, MD, MSCE
Associate Professor of Medicine
Medical Director, Owen Clinic
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Edward Cachay, MD, MAS
Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Richard Garfein, PhD, MPH
Professor
Herbert Wertheim School of Public Health and Human Longevity Science
Adjunct Professor
Division of Infectious Disease and Global Public Health
Department of Medicine
University of California, San Diego
Key Slides on ART for HIV : Evolving Concepts and Innovative Strategies.2020hivlifeinfo
Expert-authored slides on evolving ART concepts, including simplification to 2-drug therapy, ART safety during pregnancy, weight gain, and long-acting injectable ART.
File Size: 580 KB
Released: October 20, 2020
People living with HIV in 2018 now have normal life expectancy if receiving Anti-Retroviral Therapy (ART) and often require only one co-formulated pill every day to remain well. However there are still people living with HIV who are unaware of their diagnosis; who may present with a critical illness. Knowing who to test is essential. The population living with HIV are also ageing and often have comorbidities. It is vital that clinical conditions associated with HIV are recognised and for those receiving ART that significant drug-drug interactions are avoided. Pre Exposure prophylaxis (PREP) is widely used to prevent transmission and when to consider post exposure prophylaxis (PEP) should be understood. Although only one person has been cured of HIV ongoing research continues.
Hepatitis C treatment has been revolutionised with Direct Acting Antiretrovirals (DAAs) that are taken in an outpatient settings, however treatment rates in Australia are in decline. Patients living with Hepatitis C need to be identified to be treated. Those patients with established severe liver disease may remain at risk of decompensation and therefore it is considered vital to ensure linkage into adequate follow up. Drug interactions are important to recognise in patients completing DAAs and although Hepatitis C can be cured the management of any coinfections with blood borne viruses requires careful attention.
Treating Human Cancers with Medicinal Mushroom Preparations (Croatian Experie...Neven Jakopovic
This scientific presentation details the results of a 3 year human cohort study of 51 cases of colorectal adenocarcinoma and 105 cases of breast cancer, where medicinal mushroom extracts from Myko San company have been used in conjunction with the usual oncological therapy.
The regimen showed clear, dose-dependent benefits to including appropriate medicinal mushroom extracts for improved cancer status, survival and reduction of therapy side effects.
This work was presented by Dr. Ivan Jakopovic at the 4th International Medicinal Mushroom Conference in Ljubljana, Slovenia, in 2007.
Современное лечение ВИЧ: лечение ВИЧ у женщин.2017/Contemporary Management of...hivlifeinfo
In this downloadable slideset, Kathleen E. Squires, MD, and Program Director Joseph J. Eron, Jr., MD, review key data and optimal strategies in caring for HIV-infected women, including ART safety and efficacy in women, reproductive health management, ART and pregnancy, and preventing HIV infection in women.
Format: Microsoft PowerPoint (.ppt)
File size: 1.59 MB
Date posted: 4/25/2017
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
1. Dr. Niklas Luhmann (Médecins du Monde)
Training “Hepatitis C and HR for PWUD”,
9th
-13th
May 2016, Hanoi, Vietnam
Section 7: Providing HCV
testing and treatment to
people who inject drugs
2. » Reflect on the arguments usually used to refuse
PWID access to HCV testing and treatment
» Understand key elements related to HCV testing and
treatment for PWID
Learning objective of the session:
3. Context
* Nelson Lancet. 2011, **Harris Harm Reduction Journal. 2013
Prevalence of hepatitis C antibodies
in injecting drug users*
» 10 out of 16 million People Who Inject Drugs (PWID)
have HCV antibodies**
4. Context
» PWID-HCV+: 26% live in East/South-East Asia and
23.5% in Eastern Europe (Nelson, Lancet, 2011)
» Very high HCV co-infection rates among HIV infected
PWID (Platt L et al. Lancet infectious Disease 2016)
– The midpoint HCV co-infection prevalence in HIV+
PWID in 123 studies of PWID of 82.4% (IQR 55.2–84.5)
» Uptake to treatment :
– 2-4% of PWID in High Income Countries**
– Nearly 0% in Low and Middle Income Countries
– Although effective and acceptable models of care
exist
5. Anti-HCV prevalence in PWIDs
and general population
* Nelson Lancet. 2011
Country PWID Genreral Population
Brazil 39,5-69,6% 1,4%
Estonia 90% 5%
Germany 75% 0,75%
India 92% 1,5%
Indonesia 60-98% 3,9%
Mauritius 95% 2,1%
New Zealand 70% 0,3%
Pakistan 89% 5,9%
Thailand 90% 2,2%
Ukraine 70-90% 4%
United States 50-80% 1,8%
Vietnam 31-97,2% 0,4-1,7%
6. Anti-HCV prevalence in PWIDs
and general population
1) Hajarizadeh B, et al. Nature Rev Gastroenterol Hepatol 2013. 2) Grebely J and Dore GJ Antiviral Research 2014. In Press.
80% OF NEW INFECTIONS OCCUR AMONG
CURRENT PWID IN MANY COUNTRIES
PEOPLE LIVING WITH HCV
INFECTION
9. » 11 impossible evaluations with FS
» 177 FS evaluations
Cirrhosis:
» in people less than 40 years of age: 3.3% (n=3)
» in people 40 to 44 years of age: 13.3% (n=4)
» In people 45 or more years old: 23.3% (n=14)
Fibrosis stage among RNA + PWID in Tbilissi
Fibrosis level Result (%; n)
F0/F1 55.4% (n=98)
F2 15.8% (n=28)
F3 10.73% (n=19)
F4 11.82% (n=21)
10. » 104 Study participants
» mainly men (95.2%)
» median age of 35.8 years
» all under ART
» with 94.2% rate of undetectable HIV-RNA and a median CD4 cell
count of 504 (361–624) /mm3
» 69.2% reported past injection drug use
» 33% were still injecting drugs and 20.2% were receiving opiate
substitution treatment
» Current or past excessive alcohol consumption was
reported in 67.3% patients
» The prevalence of positive HBs antigen (HBsAg) was 12.6%
Fibrosis stage among RNA + PWID in Haiphong
11. » 89.4% had a positive HCV RNA
» Genotype distribution:
– genotypes 1: 68.8%
– genotype 6: 25.8%
– GT 5: 5.4%
– genotype 3b: 5.4%
» 41.3% had fibrosis F2 or more including
» 23.1% with extensive fibrosis (F3) and/or cirrhosis
(F4).
Fibrosis stage among RNA + PWID in Haiphong
12. » 55 (53,7%) patients came back to take their results
» 36 patients have been vaccinated for HBV (in 49 patients
positive HCV, who are support free prevention by HBV
vaccine)
» 12 (11,8%) patients showed levels of fibrosis
equivalent to level F3 – F4, who were considered to
be in need of urgent treatment
» Only 1 patient was successfully referred to HCV treatment.
Preliminary results after one month of intervention in Vietnam
14. Sub-optimal coverage of Harm Reduction services
Syringe and
needle
programs
OST
Global state of Harm Reduction, IHRA, 2015
15. » Knowledge from HIV field: Very limited prevention and
treatment access for PWID in general
Example East and South East Asia and Eastern Europe (Mathers B
et al . 2010, Lancet):
–Percentage of PWID accessing NSP:
• E/SE-Asia: 7% (6–9)
–Needles and syringes distributed per IDU per year:
• E/SE-Asia: 30 (7–68)
–Number of OST recipients per 100 PWID:
• E/SE-Asia 4 (2–8)
» The right of PWID to HIV prevention, care and treatment
has not been respected internationally and especially in
LMICS.
The reality of the response
16. National policies on HCV often omit to mention PWIDs
If not explicitly excluded!
Obstacles to treatment for PWIDs in LMICs
Georgia Ukraine Vietnam Russia Myanmar Indonesia
Existence of a national policy
plan for viral hepatitis or HCV?
Yes Yes Yes Yes No Yes
Prevention strategies for PWID
No No Yes No - Yes
Treatment inclusion of PWID
Yes No No No - No
(Luhmann et al. IJDP 2015)
17. HCV treatment possibilities for PWIDs
Country
National guideline
for the treatment of
HCV infection
PWID included in the
guideline
Active Drug Users Reimbursement of antiviral drugs
Belarus
Yes - -
State budget
Free treatment for persons < 18y
Bulgaria
Yes Yes, supplement, 2013
No
6 months abstinence period
National Health Insurance Fund,
All health insured
Czech Republic
Yes
Yes, separate
guideline, 2008
Yes
National Health Insurance Fund
All health insured
Hungary
Yes Yes, incorporated,1994
No
Abstinence period not specified
Health Insurance Funds
All health insured
Moldova
Yes
Yes, incorporated,
2008
Yes
Health Insurance Fund
300 pts planned per year
Poland
Yes Yes Yes
Health Insurance Funds
All health insured
Russian Federation
Yes
HIV-HCV
co-infected only, 2012
No
3-6 months abstinence period
Federal and local budgets
Only for HIV-HCV pts
Romania
Yes
Not mentioned, but not
prohibited
Yes
Health Insurance Fund
All health insured
Slovak Republic
Yes Yes
No
Abstinence period not specified
Health Insurance Fund
All health insured
Ukraine Yes No No State budget
Slide Courtesy of Marieta Simonova
19. PWID are difficult to reach, treatment uptake in PWID
is expected to be low
Prejudice 1
20. What we tried in Georgia
Non invasive screening within HR
21. What we tried in Georgia
Support during the diagnostic process
Escorting, mediation, tracking, help with paperwork
Done in a PWID friendly center!
22. What we tried in Georgia
No HIV coinfection
N %
Sociodemographics
Age (Mean
46.3; SD
7.4)
Less than 40 43 18.2%
40 to 50 109 46.2%
50+ 84 35.5%
Sex Men 234 99.2%
Education
Secondary 61 26.2%
Higher 172 73.8%
Employmen
t
Unemployed/disabled 151 64.8%
Employed 82 35.2%
Living
arrangemen
t
Unstable 25 10.7%
Hosted 133 57.1%
Own home 75 32.2%
Drug use
Age of first injection
Mean 18.5; sd
3.1
Injecting drug use in the last
month 112 48.1%
OST 58 24.9%
N %
HCV and liver disease
Liver
fibrosis
F3 89 37.7%
F3-F4 16 6.8%
F4 117 49.6%
F3 or more according to fib4 14 5.9%
Genotype
Genotype 1 40 17.0%
Genotype 2 61 26.0%
Genotype 3 124 52.8%
Mixed genotype 10 4.3%
Risk factors
of fibrosis
Heavy alcohol drinking (>7
drinks, >4 per weeks) 22 9.4%
Cannabis 109 46.8%
Obesity (157 data) 40 25.5%
HBV (235 data) 11 4.7%
Diabetes (217 data) 10 4.6%
Past treatment (231 data) 9 3.9%
Treatment
Sofosbuvir + Rbv + PegInter 12
w 100 42.4%
Sofosbuvir + Ribavirine 24 weeks 76 32.2%
Sofosbuvir + Ribavirine 12 weeks 30 12.7%
Sofosbuvir + Ribavirine 48 weeks 1 0.4%
Sofosbuvir + Ribavirine 20 weeks 29 12.3%
23. » Number of PWID screened at HR center: 554
» Number of PWID having started treatment (F3+): 239
Uptake and pre-treatment cascade (In a 6 month period)
What we achieved
24. » Organize targeted case finding
» Use one step screening and confirmation (point of care,
DBS)
» Integrate screening to harm reduction / OST services
» Use non invasive liver staging
» Implement peer support
» Fight against discrimination and criminalization
Conclusion: referral to treatment
80% of those ARN positive start a treatment are specific measures
are taken*.
* Hallinan Drug Alcohol Depend. 2007, Lindenburg Eur J Gastroenterol Hepatol. 2011, Grebely Eur J Gastroenterol Hepatol.
2010, Grebely Drug Alcohol Depend. 2010, Harris J Addict Med. 2010
** Grebely IJDP. 2015, Mravcik Patient preference and adherence. 2013
What is working**
25. Due to their instability and lack of adherence, PWID
may have bad treatment outcomes
Prejudice 2
26. What we tried in Georgia
Peer support intervention to enhanced retention in
treatment
Done in a PWID friendly center!
27. Adherence
»2 early stop (severe AE)
= 98.8% completed
treatment
»89.6% didn’t delay any medical
appointment
»82.1% did not missed any dose
What we achieved
Preliminary results on 171 patients expected to have completed treatment in end of
March 2016 (54 data for SVR12)
No missing dose p
Active drug use Yes
No
86.4%
78.9%
0.229
OST Yes
No
80.0%
82.8%
0.695
Peg Interferon Yes
No
77.8%
87.9%
0.104
SVR12 p
Genotype 1 (12)
2 (9)
3 (27)
Mixed (5)
83.3%
66.7%
96.3%
40%
0.009
Liver fibrosis F3, F3-F4 (24)
F4 (29)
91.7%
75.9%
0.127
Adherence Missed 1 dose or + (13)
Perfect intake (40)
61.5%
90.0%
0.018
Response rate
»100% at EOT
»83.0% SVR12
28.
29. » On-site multidisciplinary integrated care (OST, HIV, etc.)
» With access to harm reduction and social support
» Peer support to avoid lost to follow-up
Conclusion: treatment outcomes and adherence
Drug use at treatment initiation has limited impact on treatment
completion, adherence and SVR*.
What is working
30. Reinfection due to ongoing high-risk behaviors in
PWID negate the potential benefit of treatment
Prejudice 3
31. » During treatment:
– Peer-support within an HR organization
– Access to prevention
– Specific counselings on HCV reinfection
» Follow-up after treatment
– Individual conseling on HCV reinfection at HR center
– PCR testing at 6 and 12 months after SVR12
What we are trying in Georgia
33. Integrated prevention methods can lower the risk of HCV
infection of 50-80%*.
»HR intervention including NSP, OST
»Regular HCV testing
Conclusion: treatment outcomes and adherence
Drug use at treatment initiation has limited impact on treatment
completion, adherence and SVR*.
• * Aspinall IJDP. 2014; Nolan Addiction. 2014; Tsui,JAMA Internal Medicine. 2014, White Medical Journal of Australia. 2014
** Cunningham Nature Reviews. 2015, Grady Clin Infect Dis. 2013
What is working to reduce HCV transmission
34. Typical situation of middle income country – with not optimal
conditions:
»Strong criminalization
»No possibility to have an on-site treatment program
»Still peg Interferon and Ribavirin
»Limitation F3 +F4
But it was feasible and it works!
Summary case study
35. » System level
– exclusion of PWID in treatment guidelines and national plans
– treatment conducted in tertiary centers; not adapted care facilities for PWID
– lack of Harm Reduction platforms
» Provider level
– concerns about adherence issues
– concerns about reinfection
– concerns about side effects and drug-drug interactions during treatment
– reluctance to treat active drug users
» Criminalization of drug use
HCV treatment among PWID – main barriers
(Marieta Simonova, EASL 2016)
(Wolfe et al. IJDP 2015)
36. » “When caring for PWID, the central tenets of respect and non-
discrimination should be followed, and additional adherence
and psychological support given as required.”
» “Care should be given only with informed consent.”
» “Acceptability of services is a vital component of health care, and
peer interventions may help with reducing injecting
drug use and promoting safer injection practices.”
» “As a population with a high prevalence of HCV infection, all
PWID should be offered screening for HCV as an
integral component of a comprehensive package of
harm reduction interventions.”
» “Potential reinfection should not be an argument to
withhold treatment from PWID.”
WHO 2016 HCV treatment guidelines
37. This presentation was produced with the financial support of the French
development agency (AFD – Agence Franç aise de développement). The
ideas and opinions it contains are those of Médecins du Monde and do
not necessarily represent those of AFD.