Transcript Diapositive 1 - AIDS 2014 - Programme-at-a

Injecting Drug Use and HIV, HCV
infections in Dakar, Sénégal :
From Research to Implementation,
the UDSEN project
Pierre-Marie GIRARD,
Hopital St Antoine & IMEA, Paris and
ANRS Sénégal Site, for the
UDSEN Study Group
Starting point - ICASA 2008, Dakar
• A qualitative Rapid Assessment Study
Injectable Drugs Use
(2004-2005) confirmed
•The legal and social context of drugs use was repressive.
•Very few care givers involved in IDU .
=>PWID/PWUD = hidden populations
•Poor experience of HCW on drug use (« drugs » mean only
Cannabis)
• Willingness of HIV experts and HCW to face this challenge
(CNLS/SMI Fann/Saint Antoine Hospital /ANRS/IMEA /ESTHER).
=> Implementation of an Operationnal research based on a
prevalence estimation of HIV/HCV/HBV by Respondent Driven
Sampling (RDS) method
Injection practices in Dakar, 2008
UDSEN = « Usagers de Drogues Injectables au Sénégal » = « IDU in Dakar area »
CEPIAD = « Centre de Prise en charge Integrée des Addictions à Dakar»
Post
UDSEN
Outreach
and
scaling
up of
Clinical
access
Pre
UDSEN
Outreach
Program
UDSEN
Study
2008
2010
2011 2013
Opening of
the first
Dedicated
Setting in
West Africa
(« CEPIAD »
in DAKAR)
Operational
research:
Cohort of
IDU + HIV
Test and
Treat
feasibility
study
2014
2015
UDSEN study: Objectives
• To provide objective data on:
– IDU prevalence and size of the population
– Practices
– HIV/HCV/HBV prevalence
• HCW and Social Workers training
• Advocacy for harm reduction programs
• Advocacy for access to HAART in IDU
Ethical Issues
• Security & confidentiality for participants :
– Setting of the survey in Clinical and Research center of
Centre Hospitalier de Fann
– Anonymous consent form
– Intensive training of HCW and staff members on addictions
issues and confidentiality
• Amount of incentive: the same as current amount for clinical
studies participation in the center
• Care access for all the recrutees :
– Prevention kits & counselling.
– Access to tests results and care
= 18-month duration for study preparation
UDSEN study (ANRS 12243): methods (1)
• Outreach program in the 4 previous months
• Settings: All 4 departments of Dakar area.
• Inclusion criteria: heroin and/or cocaine use in the
previous 3 months whatever the use patterns (=IDU).
• Size estimation by capture/recapture method :
– Capture : cardboard token distribution at W-1 RDS
survey
– Recapture : participation to the RDS survey.
UDSEN study (ANRS 12243): methods (2)
• Recruitment of IDUs for estimation of prevalence in
the population: Respondent Driven Sampling (RDS) :
8 seeds representative of the diversity of the
population.
• RDS, social and behavioral questionnaires.
• Biological assessment for HIV antibodies, HBV (HBs
Ag and HBc Ab) and HCV (DBS).
• Counselling and kit prevention
UDSEN study : Main Results
(April to July 2011)
• Size estimation of IDU in Dakar area:
1324
(IC95%: 1281-1367).
• RDS survey :
• 625 individuals were peer-recruited and 506 included.
• Non inclusion (N=119)
Main characteristics of the participants (1)
• predominantly male (n=434, 86 %)
• Median age: 43 year-old, women are younger (35 vs
44)
• Most of them (n=356, 70 %) were either single,
divorced or widowed and lived with their parents
(n=296, 59 %)
• History of incarceration reported by 62 %
• Median age of first heroin or cocaine or crack use: 27
year-old
• 28% (n=140) have injected drugs at least once in their
life
Main characteristics of the participants (2)
• Drugs use in the previous month: Heroïn 91 %,
Cannabis 64%, Cocaïne or Crack 63% , Alcohol 49%,
Benzodiazepin 30%.
– injection 14 %.
• 13 % syringe sharing
• Sharing: preparation water 27%, spoon 34%, cotton 27%.
– Smoking: 86% (sharing of oral implements 60%)
– Snorting: 49% (sharing of intra nasal implements 27% )
• At least one sexual intercourse for money or drug: 27%.
• Sexual contacts in the previous 12 months
– 80 %
– 46 % : multiple partners
– 65% : often or always unprotected sex
UDSEN study : Main Results (1)
• Prevalences in the IDU population
–HIV : 5.2% [IC95%(3.8-6.3)]
–HBV (Hbs+ Ag) : 8.9% [IC95%(5.211.1)]
–HCV (HCV Ab) : 23.3% [IC95%
(21.2-25.2)]
UDSEN study: Main results (2)
HIV/HCV/HBV prevalence
HIV:
•Injectors*vs Non-injectors: 9.4 % vs 2.5%
• Women vs Men: 13% vs 3%
HCV:
•Injectors vs Non-injectors: 39 % vs 18%
No statistic difference in gender
HBV: AgHBs + : 8.9%
*injection at least once lifely
Risk factors for HIV and HCV
• Risk factors for HIV
– Female sex (OR = 4.9, 95%CI: 1.6 – 15.6) p= 0.007
– Past or actual injection (OR = 4.3, 95%CI: 1.7 – 10.7) p= 0.04
– Age (OR per year) (OR =1.1, 95%CI:1.004 – 1.1) p= 0.03
• Risk factors for HCV
– Past or current injection (OR = 2.7, 95%CI: 1.7 – 4.3) p= 0.0001
– To be single, divorced or widowed (OR = 1.81, 95%CI: 1.08 –
3.04) p = 0.02
– Duration of relationship with study recruiter (OR per days) (OR =
1.001, 95CI: 1.0 – 1.002) p = 0.05
All results are generated through mutivariate analysis
OUTREACH ACTIVITIES
• Needle and Syringes programms (NSP) including
collection of used injections materials
• IEC with specific communications tools
• Feed back of the results of UDSEN study
• HIV testing and counselling
• Condoms programms
• Information, prevention and treatment of STI
• HAART access according to the Senegale
recommandations
Quantitative assessment of
Outreach Activities
Sept 2011-Dec 2013
• 8396 contacts/talks/services including 565
« new » IDU (ie post UDSEN)
• 419 IDU referred to clinics
• 18619 syringes given and 10785 used
syringes collected (58%),
• Distribution of 17564 condoms
Needles & Syringes Program
20000
18000
Nombre cumulé de seringues
16000
14000
12000
10000
-«CRCF Cohort»
437 syr/PWID/year
-Whole PWID of
Quantité
de
Dakar cumulée
area
seringues
distribuées
57s/PWID/an
8000
6000
4000
2000
0
Quantité
cumulée de
seringues
récupérées
Post UDSEN study: High Fatality rate
• 56 reported Deaths (05/2011 – 12/2013) :
• Mean age 43 yrs [ 25-60],
• 50 % injectors
• Causes of death: cardiac(2), accident(4), hepatitis
(6), renal failure (1), unknown (20),
overdose/toxic (6), neurologic(1), TB (2), HIV (4)
gastric (2), crime (1), surgery (1), cancer(1)
malaria(2), seizures (2), lung disease (1)
Health and Social Centre for Drug
Users
CEPIAD (Centre de Prise en
Charge Intégrée des
Addictions de Dakar)
• In Hôpital Universitaire
de Fann
• Under auspices of CNLS
• Connected with Clinical
Research Center
• Opening: end of 2014
• Financial supports:
GF/CNLS, Paris Municipality
, ESTER, ONUDC, MSAS,
CHNU Fann
Benefits of UDSEN study
•
IDU defined as a key population in the 2011-2015 national
program against HIV/AIDS.
• Leverage effect of the research on national and international
fundings (UNODC, Mairie de Paris, FEI, Japanese cooperation).
• July 2013: approval of the national multisectorial strategy
against HIV infection and other co-morbidities among IDU and
of its operational plan.
• 2014: Opening of the center of integrated care for addictions
with outreach, NSP and methadone programs in Fann Hospital
(Dakar).
Demonstration in the streets of Dakar & Workshop, June 2014
Idrissa Ba, Annie Leprêtre, Abdalla Toufik,
Papa Salif Sow, Maryvonne Maynart, Karine
Lacombe, Coumba Toure Kane, Gilles Raguin,
Momar Gueye, Ibra Ndoye,
Thanks for
your
attention
Lambdin et al CID, July 2014