The study aims to assess the effectiveness of a model of hepatitis C screening and integrated care, targeting people who inject drugs (PWIDs) in Hai Phong, Vietnam. In a wider perspective, this model linked to mass screening through repeated Respondent Driven Sampling (RDS) surveys, to simplified treatment protocol, and to large community-based support to improve referral to care, retention in care, adherence to treatment and prevention of reinfection, may have the potential to eliminate HCV among PWIDs in this city.
Objectives : The primary objective of this study is to assess the effectiveness of a model of hepatitis C screening and integrated care targeting PWIDs in Hai Phong, Vietnam. This model will encompass all steps involved in achieving HCV cure among PWIDs: i) Mass detection of hepatitis C infection among PWIDs: in the community through a large community-based Respondent Driven Sampling survey (RDS); and in HIV out-patient clinics and methadone treatment centers where serological testing should have been made, but not HCV RNA to confirm hepatitis C infection. ii) a community-based support to improve referral to specific care for those with hepatitis C infection; iii) a HCV care system delivery integrated within the existing health system with a simplified treatment protocol taking into account PWIDs specificities such as frequent HIV co-infection and methadone treatment; iv) an optimized treatment adherence through a combination of health care therapeutic education and CBO support; v) an increase in harm reduction activities to encompass HCV risk transmission and to prevent HCV reinfection. Secondary objectives are: * to assess all steps of the hepatitis C cascade of care (Hepatitis C infection diagnosis; HCV care enrolment; HCV treatment initiation; HCV treatment success); * to assess the occurrence of adverse events (death, morbidity) and drug-related side-effects; * to evaluate adherence to HCV treatment; * to determine factors associated with treatment failure defined by a positive HCV RNA 12 weeks after the end of HCV treatment; * to estimate the reinfection rate at the end of the study and to identify risk factors of HCV reinfection; * to project the impact and cost-effectiveness of the implemented HCV treatment intervention. Study design : the effectiveness-implementation hybrid study type 1 design will simultaneously allow assessing the effectiveness of Direct-Acting Antivirals (DAA) care strategy among PWIDs in Vietnam, and the potential obstacles to widespread implementation. The strategy of care includes a large community-based mass screening, a simplified treatment protocol based on a combination of DAAs, taking into account co-morbidities (addiction, HIV), physician training and important support of Community Based Organizations (CBO's) for linkage to care after screening, treatment adherence and prevention of reinfection after cure. In addition, 2 others components are included in the study: * A modeling exercise to assess the impact of the intervention at the population level, * A cost-effectiveness analysis to further inform policy-makers. Patients will be followed for 48 weeks after initiating HCV treatment. The estimated enrolment is 1050 participants. Study population: people who currently inject drugs or who have recently started opioid substitution treatment. Implementation: The study is linked to the NIDA RO1 DA041978 / ANRS 12353 DRIVE project. Participant recruitment will take place through DRIVE RDS survey and DRIVE cohort follow-up visit in two community sites managed by peer-groups in Hai Phong. All participants with positive HCV serology will be screened for hepatitis C and positive HCV RNA will be proposed for DAA treatment in 3 hospital-based HCV clinics. All participants will attend 9 study visits, comprising of clinical examination, blood collection for side effects and viral load assessment, therapeutic education, questionnaires on alcohol use, on sexual, drug use and other behaviors focusing on HCV infection risks or HCV reinfection risks and on quality of life, and harm reduction activities with the support of CBOs.
All patients will receive sofosbuvir 400-mg and daclatasvir 60-mg (1 tablet each per day) during 12 weeks.
For HIV/HCV co-infected patients receiving efavirenz or nevirapine, daclatasvir dose will be increased to 90-mg per day.
In case of cirrhosis: * Ribavirin will be added to sofosbuvir/daclatasvir during the 12 weeks of treatment. The dose will be adapted to the patient weight although the vast majority of patients (weight \< 75 kg) will receive 500 mg x 2/day. * In case of ribavirin contra-indication or side effects leading to ribavirin discontinuation, sofosbuvir/daclatasvir will be used 24 weeks.
Hai Phong University of Medicine and Pharmacy
Haiphong, Vietnam
Viet Tiep Hospital
Haiphong, Vietnam
Proportion of all patients in success of the model of care
Proportion of patients with HCV RNA \< 15 IU/mL at the end of the study among patients who have signed the informed consent.
Time frame: Week 48
Proportion of patients with detectable HCV RNA
Proportion of patients with HCV RNA \> 15 IU/mL among those with positive HCV Ab
Time frame: Screening pre-inclusion
Proportion of patients enrolled in care
Proportion of patients with HCV RNA \> 15 IU/mL who attended the pre inclusion visit at HCV clinic among those with hepatitis C infection;
Time frame: Pre-inclusion visit
Proportion of patients initiating DAA treatment
Proportion of patients who initiate the treatment among patients enrolled in care and eligible for treatment
Time frame: Initiation treatment visit
Proportion of patients cured
Number of patients with HCV RNA \< 15 IU/mL among those initiating the treatment eligible
Time frame: Week 24
Rate of reinfection
Number of patients with HCV RNA ≥ 15 IU/mL at the end of the study among cured patients
Time frame: Week 48
Rate of mortality
Rate of deaths among all participants with hepatitis C infection
Time frame: Week 48
Frequency, type and time to grade 3 or 4 adverse clinical or biological events.
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Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
979
In case of cirrhose and of ribavirin contra-indication or side effects leading to ribavirin discontinuation, sofosbuvir/daclatasvir will be used 24 weeks.
All adverse events will be graded according to the ANRS adverse events grading table
Time frame: Week 48
Frequency, type and time to drug-related clinical or biological adverse reactions
All drug-related clinical or biological adverse reactions of grade 3 or 4 or leading to treatment interruption
Time frame: Week 48
Adherence assessment
Self-questionnaire on DAA drug intake and drug accountability for DAA
Time frame: Week 12
Factors associated with HCV treatment failure
Socio-demographic, co-infection, virological, adherence, behavioral, psychiatric disorders, intervention contact, recent incarceration, homelessness factors
Time frame: Week 24
Factors associated with HCV reinfection
Socio-demographic, co-infection, virological, adherence, behavioral, psychiatric disorders, intervention contact, recent incarceration, homelessness factors
Time frame: Week 48
Effect of the HCV treatment intervention
Estimation of the impact of the intervention on HCV infections and DALYs averted, QALYs saved, HCV incidence and prevalence as projected by the model under various scenarios
Time frame: Week 48
Incremental cost-effectiveness ratio (ICER)
Estimation of the mean ICER which will be compared against standard thresholds for intervention's being cost-effective in LMIC settings
Time frame: Week 48