André-Jean REMY (1,2), Hugues WENGER (1), Hakim BOUCKHIRA (1), Stéphane MONTABONE (1),

1. 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

2. EXPERT GROUP INSERM 2010 INFECTIOUS RISK REDUCTION AMONG DRUGS USERS (DU) Recommandations : • 1) Screening ALL drugusers for HIV and hepatitis B and C, and also screening againat 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

3. HEPATITIS MOBILE TEAM

4. 10 SERVICES « à la carte » 1. Screening / Point of Care Testing POCT (HIV HBV HCV) 2. Mobile liverstiffness Fibroscan* (indirect measurement of liverfibrosis) in site 3. Social screening and diagnosis (EPICES score) 4. Advanced on-site specialist consultation 5. Easyaccess to pre-treatment commissions (“RCP”) withhepatologists, 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: specialoutside POCT and FIBROSCAN* 4

5. 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

6. 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

7. 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

8. 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

9. PARTNERS ORGANIZATIONS • Asyleum medical unit • Jailhouse medical unit • Primary care access unit • TB unit • Addictology service • Gastroenterology service • Medical duty home Hospitalservices 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

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

11. Point Of Care Testing • POCT HCV / HIV / HBV • Alternative to blood test, but in case of positive test  a blood test confirmation isnecessary • Quick on digital puncture • Immediateresults • Free, renewal of HCV/ HIV status as soon as necessary • Reliable 3 monthsaftertakingHIV / HCV / HBV riskDo not detect the primary infection 11

12. 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

13. Fibroscan* 13

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

21. THANK YOU FOR YOUR ATTENTION! 21

22. Any questions ?