 Good afternoon, everyone. Thanks, Simone, for kind introduction. Today I'm going to present the high rates of hepatitis C co-infection and advanced chronic hepatitis among HIV cohorts and MSF programs in Myanmar. Firstly, I'd like to start with some epidemiological background. Globally, 131 million people suffer from chronic hepatitis C disease. In Myanmar, Department of Medical Research and the Ministry of Health conducted a national hepatitis survey in 2015. According to that survey, hepatitis C seroprevalence in general population is 2.65, but it's very high in people with injection drug users. It's 47%. For people living with HIV, it's 20%. As we have 14 states in Myanmar, there are some disparities between different states. Some states have high, very high prevalence. Some states have low prevalence according to the context backgrounds. But in Myanmar, most of the people are living or unaware of the infection and so the available prevalence data probably most not reflect the whole population. Currently, national hepatitis program has developed a guideline for diagnosis and treatment of hepatitis C. And they are planning to start the treatment very soon. So what MSF is doing in Myanmar? MSF OC has started working in Myanmar since 1992. They started HIV program in 2002 in three states, Yangon Shan and Kachin, with outpatient clinics not linked with MOH service. And from 2013, MSF has started screening for hepatitis B and hepatitis C in newly diagnosed HIV patient and also slowly started screening the old existing cohort, all the patients. Currently, we have 32,000 patients in Yangon Shan and Kachin. Objectives. The objective of this presentation is to describe the prevalence of chronic hep C infection among our cohort and to describe the prevalence genotype among Yangon cohort and also fibrosis staging among Yangon cohort. We analyzed data from two databases. The one is future database, which is for follow-up and treatment of HIV patients and also Habermool database, which is only for hepatitis patients. We got the data of prevalence data from future database, which we have started screening for all the HIV patients. And for further investigations of hepatitis C treatment, we got the data from Habermool database. So as I've already mentioned, we have started screening for all our patients since 2013. If using rapid diagnostic tests, if the screening test is positive, we should proceed to confirmatory testing using RNA viral load. And if the patient is confirmed as chronic HIV, we have to proceed with genotyping and fibrosis staging. And then we should start treatment and treatment monitoring using viral load. But in Shen and Kachin, we can only do screening at the moment. We have not proceeded to other confirmatory tests and investigations for treatment. But in Yangon project, we are doing the whole spectrum of investigations after treatment. So what do we found during screening? The results are somewhat interesting. In Yangon, the seroprevalence is only 7% among our HIV cohort. But in Shen and Kachin, it's alarmingly high. In Shen, it's 29%. In Kachin, it's 38%. The high prevalence of hepatitis C in Shen and Kachin is most probably due to the high number of injection drug users in that region. And we also found out that we have some patients who are co-infected with hepatitis B, a small number of patients. These patients have triple bottom of disease, HIV, hepatitis C, and hepatitis B. So relationship with people with injection drug use. In Yangon, 11% of our hepatitis C seropositive patients have history of injection drug use. But in Shen and Kachin, it's much higher. In Shen, it's 68%. In Kachin, it's 40%. So this clearly shows that the high prevalence in Shen and Kachin is related to high number of injection drug use in these regions. So as I've already mentioned, we are proceeding other investigations for treatment in Yangon project. For fibrosis staging, we are using two methods. One is fibroscan, which is a simple, non-invasive method using a fibroscan machine that measures the stiffness of labor. The results come out with kilopascals. If the result is more than 9.4 kilopascals, we say it's advanced cirrhosis, F3, F4. If less than 9.4 is only cirrhosis, F1 and F2. Interestingly, half of our patients are having advanced cirrhosis who need urgent treatment. And another method is APRI scoring, ASD platelet ratio index, which we choose to plot investigation, ASD, a liver enzyme, and platelet count. And we calculate using a formula. And we got an index value. If the index value is more than 1.5, it's advanced cirrhosis. If less than 1.5, it's early cirrhosis. But we can see that there are some discordance within fibroscan and APRI results. That might be probably due to the difference in sensitivity and specificity of fibroscan and APRI scoring. But since the fibroscan has higher sensitivity and specificity, we are relying mostly on fibroscan values. Regarding genotyping, in Yangon project, half of our patients are found to be genotype 3, which is assumed as most aggressive type. But in terms of fibrosis staging, all the genotypes have the same level of fibrosis, not very much difference. So we have very high hepatitis C seroprevalence and Shannon-Kachin that most probably is connected to the high prevalence of injection drug use. And the most common genotype among our cohort is genotype 3, which is assumed as most aggressive type. And half of our patients in Yangon cohort has advanced liver disease, F3 and F4, who need urgent treatment. And since the prevalence in Shannon-Kachin state are very high, we are estimating more patient who need urgent treatment, advanced liver disease in these areas. Limitations, this is not a limitation per se, but we still need to complete the serology test screening test for our whole cohort. We have covered almost over 70% at the moment. And the other point is the further investigations like confirmatory testing, genotyping, fibrosis staging for chronic HCV disease are done only in Yangon project, not in Shannon-Kachin. And the cause of investigations are still very high. And the treatment availability is still very much limited. The way forward is, as I've already mentioned, we are planning to complete the serology testing, screening testing for the whole cohort. We are hoping we can finish in early 2018. And to scale up further testing for chronic HCV disease, not only in Yangon project, but also in to start soon in Shannon-Kachin. And currently, we have planned to treat 200 patient in Yangon. It's a small number, but currently we have started treatments for our patient. So from our part, National Program needs to scale up the diagnosis and chronic HCV and also treatment. They have developed guidelines. They have planned to start a treatment, but there still is some urgent needs, urgent requirements, and also simple, reliable, affordable diagnostic tools still need to be developed. Still the diagnostic test, the treatment availability, everything is still much complicated and not simple yet. So thank you very much for your attention. Thank you very much for sharing this information. And as you can see, IV drug use and its correlation to as being a very high risk factor for hep C in these HIV quarts. And it's very encouraging to know that the treatments are also being initiated by the government. That will be an interesting thing to understand better. And I would like to ask the audience if you have any questions from this presentation or any others. Yes, please. Thank you. I am Dr. Dhan. My query is that the people who are HIV positive have hepatitis C. Is there any data about the prevalence of hepatitis B in that group? Because the risk factors are very similar. Yes, since we have started screening, also screening, but that is B in our cohort. Since 2013, we have, we also have data, but we haven't analyzed systematically yet. We have data. Any questions? Yes, please. Yeah. My name is Yogish. So we also have, like in our clinic, we have some patients from Myanmar. We have noticed genotype 3 and 6. I'm just curious, have you any, because even it's a Manipur is a triangle, a golden triangle for the IVDUs. So you have any differences among different clinics, the genotypes? So because you mentioned 25% of 6 and more on 3. So have you have any identified difference among them? And another question is, among our clinic patients, most of them don't know how they received the, infected with the hep C. So not with the, they are not IVDUs, but they don't know how infected. So you have any, because you are staying more on the Myanmar. So is there any prevalence more than IVDUs? More or less? Yes. The first question is, is there any genotype difference between clinics? In the cohorts. In the cohorts. Actually, we have started genotyping only in Yangon project. So we have two clinic in Yangon project and we see no difference. And the other point is in Yangon project, the patient from, the patient are not only from Yangon, but also from outside Yangon, the lower part of Myanmar. So I would like to say that there's no difference in genotyping. Yeah. So basically, you know, there's, there are other risk factors for acquiring hep C infection. And one of the most common, which we are sometimes very ignorant about is unsafe injection practices. And that's, you know, if you look at the, you know, the information is about 80% in India have said to have unsafe injection practices. So yes, please. I'm Dr. P.K. Bansal from District Hospital Marriott. With the collaboration of MSF, we started hep C prevalence and clinic and diagnosis in our setup. And most probably we'll be coming with the data very soon. Till date, I have a data till 90th May of, we started working from 25th of January this year. And by 90th of May of this year, we have more than 2,200 consultations out of which almost 8,750 patients, new patients, and more than 300 is already on treatment. We are providing all diagnosis, genotype, confirmatory test, rapid test and free treatment. And we are following up also. And all the cases what he asked about the hep C is B also. Certainly there are certain cases which have hepatitis B positive also in almost less than 1% HIV positive also. We are doing simultaneously those who have negative hepatitis B. We are doing hepatitis B immunization also in those cases. Thank you for this information. I think now we move on because of the limited time. And I will invite you to discuss further with him if you have any further questions.