 The aim of this presentation is to justify why people who use drugs should be included in programmatic hepatitis C treatment decisions and how this can be achieved in an equitable manner within the current context of limited treatment availability. MSF has been present in the Manipore State of India since 2004. Manipore shares a long border with Myanmar which has proven to be fairly porous to the transit of opiates. This has resulted in a high number of intravenous drug users within the northeastern states of India. MSF currently operates two HIV-ART centres under a public-private partnership with NACU. These are situated in Chirichandapur and Maure. We provide predominately care for HIV in addition to treatment for drug-resistant and drug-sensitive TB. More recently we have commenced treatment of hepatitis C in the context of HIV-Hepatitis C co-infection. Hepatitis C and the HIV epidemic in the northeastern states of Manipore or of India has been driven by the use of intravenous drugs. This has resulted in a very complex mix of interrelated competing co-morbidities within our cohort. Hepatitis C. If we look at the prevalence of hepatitis C within India, I beg your pardon, HIV has been the mainstay of treatment. In 2012 MSF systematically started screening for hepatitis C and we found co-infection rates with HIV and hepatitis C of approximately 30%. Within India the estimated prevalence of hepatitis C is 1 to 1.5%. The estimated prevalence of HIV is 0.26%, however in Manipore a high burden state of India the HIV prevalence is estimated at 1.22%. The morbidity which ties these two diseases together is substance use and in particular intravenous injecting drug use. A large study was conducted by Solomon Etel in 2015 across India. The HIV prevalence and hepatitis C prevalence was determined in just under 2,500 people within three sites of Manipore and as you can see by these prevalence figures here the injecting drug using community has a very high burden of the HIV and hepatitis C disease burden particularly when compared to the Indian prevalence listed above. In addition to these morbidities is an overlaid mental health illness. Sauciatric disease is significantly higher in people who inject drugs compared with the general population. In addition recent evidence is suggesting that hepatitis C has a direct impact on the central nervous system resulting in cognitive and psychiatric illness. Due to shared social determinants of health and immune deficiency caused by HIV and hepatitis C this population remains vulnerable to tuberculosis as well. Now when it was recognised that comprehensive treatment of HIV in this context must include treatment of hepatitis C the limited treatment availability instinctively led to the adoption of an exclusion mentality when determining who should be offered this treatment. That is the exclusion of patients who are more likely to have poor outcomes adverse events or more complicated treatment courses as a result of treating competing comorbidities. This complexity was made even more complex as a result of the fact that up until the beginning of 2016 Pegalated Interferium with its inherent adverse effects and complexity of treatment administration was the mainstay of hepatitis C treatment within the Indian context. Added to this there was a programmatic desire for a good performance resulting in the exclusion of patients with motorable comorbidities and initial prioritisation of patients with advanced liver disease. This provided another exclusion barrier for people who injected drugs as people who are actively injecting drugs by and large have less advanced fibrosis than past users as a result of the duration of hepatitis C infection. Concerns of reinfection, poor adherence and poor outcomes for hepatitis C treatment for people who inject drugs was also another factor which was considered. However, more recent studies have proven these factors to be unfounded with injecting drug-using groups being treated with hepatitis C having comparable results to non-drug using groups. Additionally, the rates of reinfection of injecting drug users following treatment of hepatitis C is approximately 2%. A model of hepatitis C care based on ethical and biological imperative necessitates a paradigm shift in the mentality from one of exclusion to one of inclusion. Such vulnerable groups including people who inject drugs can be equitably considered for inclusion in hepatitis C treatment initiatives. This requires a holistic, patient-centred approach focusing on individual priorities and not specific diseases. Ethical considerations of autonomy, benefits, non-malifference, justice and respect for persons has been largely ignored in these considerations but these are required such that therapy is considered for all groups who could be effectively and safely treated including the marginalised groups with high prevalence. This will provide an important opportunity for behavioural modification and uptake of harm reduction services. In addition, it's well noted that the highest burden of incident cases of hepatitis C is amongst the people who are injecting drugs. As such, there is a very strong public health argument for the inclusion of people who inject drugs into hepatitis C treatment considerations. That leads of course to the idea of treatment as prevention where modelling studies has revealed that treatment of a rather modest number of people injecting drugs for hepatitis C will result in a significant decrease prevalence over the next 15 years of hepatitis C. This is a diagrammatic representation of the model of care employed by MSF in the Manipur which we feel results in equitable access to the currently limited availability of hepatitis C treatment for all patients infected with hepatitis C within our cohort. There is basically three parts of this model. Initially, there's cohort entry which is through voluntary HIV testing and sputum screening in addition to referral in from harm reduction and other services. This is followed by a process of integration and individualised patient prioritisation that is the prioritisation of treatment needs. After this has occurred, the individual patient receives a specific individualised care depending on the treatment priority which is identified. This represents the five pillars of our care in the Manipur project. If we look more closely at the process of assessment and prioritisation, this consists of two components, a comprehensive medical assessment looking at HIV status and the adequacy of the HIV treatment being given, the HIV hepatitis C staging and severity and also an opportunity to screen for and diagnose opportunistic infections. The comprehensive psychosocial assessment looks at demographic, social support, mental health screening, substance use screening in addition to motivational barriers and adherence factors associated required for treatment. On the completion of these two comprehensive assessments, the medical team and the mental health team conduct a clinical case conference on a patient-by-patient basis to identify the patient's most pressing medical priority. Once this is identified, the patient enters one of our pillars of care to have the most pressing medical priority and intervention for that priority. Following completion of that intervention, the process is repeated such that another clinical case is reviewed, conducted. The medical and mental health team again reassess the patient and prioritise the remaining existing co-morbidities and medical treatment needs. Of the first 92 case conferences conducted on our HIV hepatitis C co-infected population, 11 of these patients were deemed to have an intervention for HIV as their most pressing medical priority. This was as a result of either adherence problems or the possibility of failure to first-line treatment. Of these 92 patients, one patient was identified as having opportunistic infection. Of the 92 patients, 54 patients were deemed to have hepatitis C as their most urgent medical treatment priority. That is to say that the HIV was well controlled and that there was either an absence of substance use disorder or psychiatric illness or, if present, these were well controlled and stable. Following the individual interventions for these medical priorities, a repeat case conference was conducted. Of the 11 patients who received an intervention to stabilise the HIV treatment, three patients were deemed suitable for consideration for hepatitis C treatment. The patient who had an opportunistic infection was treated and also deemed suitable. Of the 15 patients who required stabilisation of their substance use disorder following intervention including OST, nine of these patients were now deemed suitable for inclusion of treatment consideration for hepatitis C. That is, a substance use disorder was stabilised to the point where treatment could be affected safely and effectively. Of the eight patients with significant mental health disease, five of these patients, after thermotherapeutics and counselling, had their mental health stabilised and were also considered for inclusion into hepatitis C treatment. The average duration from the initial case review to prioritisation for hepatitis C treatment for all types of interventions was 7.5 months. If we look at those patients who were initially requiring assistance with substance use disorder, the duration of the intervention and reprioritisation was slightly higher than the average at 7.8. For those with a mental health intervention, it was 5.9. And for patients with HIV adherence issues or treatment failure, the mean duration of intervention required was 8 months. In conclusion, we feel that through a multi-disciplinary model to assess, prioritise and manage related comorbidities, the most vulnerable populations can be equitably included in treatment of hepatitis C. There is a requirement for programme management and treatment providers to understand, accept and adapt care models to issues of social function and stigmatisation specific to people who inject drugs that currently limit access to treatment, including the parallel provision of effective harm reduction services. And finally, there are sound ethical and scientific justifications for the creation of model of care delivery specifically tailored for the needs of people who inject drugs. I'd like to acknowledge our MSF advisers, Dr. McEul and Dr. Chris and MSF team in Manapur who do a terrific job. I'd also like to thank Dr. Thil Kinkal, who's contribution to your initial discussions were responsible for a reorientation from an exclusive to an inclusive mentality and I'd also like to acknowledge Dr. Julian Schieffer for his valuable contributions to the ethical considerations. Thank you.