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Pierre-Marie GIRARD, Hopital St Antoine & IMEA, Paris and ANRS Sénégal Site, for the UDSEN Study Group 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

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Injecting Drug Use and HIV, HCV infections in Dakar, Sénégal : From R esearch 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. - PowerPoint PPT Presentation

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Page 1: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Pierre-Marie GIRARD,Hopital St Antoine & IMEA, Paris and

ANRS Sénégal Site, for the UDSEN Study Group

Injecting Drug Use and HIV, HCV infections in Dakar, Sénégal :

From Research to Implementation, the UDSEN project

Page 2: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Starting point - ICASA 2008, Dakar

• A qualitative Rapid Assessment Study (2004-2005) confirmed Injectable Drugs Use

•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

Page 3: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Injection practices in Dakar, 2008

Page 4: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Pre UDSE

N

Outreach Program

UDSEN

Study

Post UDSEN Outreach and scaling up of

Clinical access

Opening of the first

Dedicated Setting in

West Africa

(« CEPIAD » in

DAKAR)

Operational

research: Cohort of IDU + HIV Test and

Treat feasibility

study

2008 2010 2011 2013 2014 2015

UDSEN = « Usagers de Drogues Injectables au Sénégal » = « IDU in Dakar area »

CEPIAD = « Centre de Prise en charge Integrée des Addictions à Dakar»

Page 5: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 6: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 7: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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.

Page 8: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 9: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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)

Page 10: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 11: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 12: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

UDSEN study : Main Results (1)

• Prevalences in the IDU population–HIV : 5.2% [IC95%(3.8-6.3)]–HBV (Hbs+ Ag) : 8.9% [IC95%(5.2-

11.1)]–HCV (HCV Ab) : 23.3% [IC95%

(21.2-25.2)]

Page 13: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

UDSEN study: Main results (2)HIV/HCV/HBV prevalence

Page 14: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 15: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 16: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 17: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Needles & Syringes Program

Nov-11

Dec-11Fe

b-12

Mar-12Apr-1

2Jun-12

Jul-12

Aug-12Oct-

12

Nov-12

Dec-12Fe

b-13

Mar-13Apr-1

3Jun-13

Jul-13

Aug-13Oct-

13

Nov-13

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

Quantité cu-mulée de seringues dis-tribuées

Quantité cumulée de seringues récupérées

Nom

bre

cum

ulé

de se

ringu

es

-«CRCF Cohort» 437 syr/PWID/year-Whole PWID of Dakar area 57s/PWID/an

Page 18: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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)

Page 19: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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

Page 20: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

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).

Page 21: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Demonstration in the streets of Dakar & Workshop, June 2014

Page 22: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Idrissa Ba, Annie Leprêtre, Abdalla Toufik, Papa Salif Sow, Maryvonne Maynart, Karine Lacombe, Coumba Toure Kane, Gilles Raguin,

Momar Gueye, Ibra Ndoye,

Page 23: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Thanks for yourattention

Page 24: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the

Lambdin et al CID, July 2014

Page 25: Pierre-Marie GIRARD, Hopital  St Antoine & IMEA, Paris and  ANRS Sénégal Site, for the
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