Integrated Care for the Use of Direct-acting Antivirals in Patients With Chronic Hepatitis C and Substance Use Disorder.

OBJECTIVES: Since little is currently known about predictors of response to direct-acting antiviral agents (DAAs) in people who inject drugs, we undertook an analysis of patients attending a hepatitis clinic with addiction services (outpatient clinics and inpatient services) to examine the outcomes associated with the treatment of difficult-to-manage patients with substance use. Our experience was based on integrated care. METHOD: A retrospective analysis was undertaken of 50 patients with hepatitis C virus (HCV) and a history of addiction who received treatment with DAAs, according to European guidelines. These regimens were sofosbuvir/ledipasvir for 8 weeks (n = 3), sofosbuvir/ledipasvir ±â€Šribavirin for 12 weeks (n = 19), sofosbuvir/daclatasvir for 12 weeks (n = 20), sofosbuvir/simeprevir (n = 1), or sofosbuvir/daclatasvir for 24 weeks (n = 7). Characteristics of patients who did versus did not achieve a sustained virologic response (SVR) 12 weeks after treatment were compared by univariate analysis. RESULTS: Forty-two patients (84%) were male; mean age was 46.2 ±â€Š7.3 years. Genotypes were 1 (n = 21), 2 (n = 4), 3 (n = 18), 4 (n = 6), or 6 (n = 1). Most patients were treatment-naïve (n = 38). Five patients had coinfection with human immunodeficiency virus (n = 4) or hepatitis B (n = 1), 28 (56%) had evidence of cirrhosis on FibroScan (>12.5 kPa), and 34 (68%) were receiving opioid substitution therapy. Psychiatric disease, illicit drug use, unemployment, and homelessness/precarious housing were common. Forty-five patients (90%) achieved SVR, 2 were lost to follow-up, and 3 had treatment relapse. CONCLUSIONS: SVR was not significantly associated with sociodemographic or virological characteristics, treatment, social environment, alcohol/drug use, and adherence. Although adherence was slightly worse than in "usual" patients, it did not affect the SVR rate. In these difficult-to-manage patients with HCV and substance use disorder, the real-world SVR rate (90%) was similar to that in nonaddicted populations.

[Equity and planning: a critical analysis of a third generation regional healthcare management program]. / Equité et planification: analyse critique d'un schéma régional d'organisation sanitaire de troisième génération "perinatalité".

The third generation of the regional healthcare organization plan (Sros III) proposes to develop the organisation of healthcare and its management according to evolution of its activities and the populations concerned. At the time of a strategic analysis of SROS III (what we refer to as its perinatal period), the question is whether promoters can move from an approach based on accessibility (egalitarian equity) to a needs-based approach (differential equity), which although more complicated in to apply and implement, was found be much better adapted to healthcare users. The research is derived from an analysis of documents from November 2004 to November 2006. A university public hospital developed the data which supported a proposal to shift from level I to level II. This proposition was retained in the territory's medical plan authorized by the regional health authorities. Health professionals and the architects of the healthcare plan have the capacity to new organizations responsible for taking into account the activities and healthcare needs of the population in order to initiate and establish differential equity.