Summary

This initiative has established an innovative delivery model for testing and treatment of Hepatitis C in a population receiving opioid replacement therapy (ORT) from their community pharmacy.  The greatest risk of acquiring HCV in the UK is through injecting drug use and the largest single infected group are the cohort prescribed ORT – but only small numbers of highly motivated patients from this cohort make it through current NHS pathways to be offered HCV anti-viral therapy.

Using focus groups, the team explored perceptions of using community pharmacy services to access testing and treatment, and set up a discreet choice experiment to identify the most valued attributes of a service. Patient outcomes are currently being assessed.

Challenge

In Tayside, approximately 40% of patients receiving ORT at the pharmacy are HCV positive.  Patients with a history of intravenous drug use or who are prescribed methadone should be offered HCV testing – but less than 10% of methadone users are ever tested, and of these fewer than 20% go onto treatment regimes that successfully clear the infection. However, new oral anti-HCV therapies have cure rates greater than 95%, minimal side effects and no need for complex monitoring – and should easily be delivered through novel pathways.

Community pharmacies can conveniently offer HCV testing on site and since pharmacists have almost daily contact with patients receiving ORT, they are in an excellent position to supervise anti-HCV therapy initiation, adherence, and persistence.

Objectives

To understand the experiences and perceptions of people receiving ORT from community pharmacies and gain an understanding of their preferences for testing and treatment service for HCV. To compare the uptake of dried blood spot testing (DBST) by patients receiving ORT though community pharmacies, with the uptake of testing provided by all current providers of testing in Tayside. To design and implement a treatment assessment protocol for pharmacist-led treatment of HCV for genotype 1 HCV and to train a cohort of community pharmacists to deliver this protocol with patients who have tested positive for this infection in their pharmacies. 

Solution

To identify the preferences of service users, a focus group series was undertaken with 41 people prescribed ORT and a pilot focus group and 6 further groups were recruited to investigate experiences across several variables: these included service users detained by the criminal justice system and perspectives of peer mentors. A discrete choice experiment (DCE) was used to elicit ORT users’ preference for HCV testing. An evaluation of dried blood spot testing (DBST) provided in 6 pharmacies in Dundee was used to estimate comparative uptake of DBST from all other providers of testing in Tayside. A further eight community pharmacies have been trained to assess patients diagnosed with genotype 1 HCV for treatment with oral antiviral drugs.

Results

Focus group participants described many instances of the prejudice that people felt towards them and could identify how behaviours of some of their group contributed to this. The DCE identified that ORT users preferred to be tested at their own pharmacy, followed by drug worker, GP and other pharmacy.  The most important attribute was whether they were treated with dignity and respect. In Dundee, 1,339 patients receive ORT: 561 had no record of testing for HCV. During the test period, 43 of 143 eligible patients from the 6 community pharmacies accepted a DBST. A total of 75 patients were tested for HCV outside of the pharmacies (30% Vs 13%). The OR for increased uptake of testing was 3.93 (95% CI 2.39 to 6.45, Z statistic = 5.41 p= <0.0001). The pharmacists will test approximately 600 patients using DBST in their pharmacies and will manage the treatment regimes of Genotype 1 positive patients and confirm SVR. Results gained so far from this work are extremely positive and indicate advantages to a pharmacist-led pathway.

Learnings

The ability to work across care boundaries and to harness the potential of the community pharmacy network is key. Engagement with and investment in this network has yielded very positive results, with the development of strong relationships and an aligning of perspectives that benefit the delivery of care to this patient group.

Evaluation

Progress with DBST in Tayside has enabled a large proportion of the population at risk to be tested for HCV. By the end of 2013, 2898 (perhaps 70%) of expected HCV antibody cases had been reported to Health Protection Scotland.  A further analysis of this data by HPS reports that in 2013, 52.9 per/100,000 of the population are recorded as being HCV positive in Tayside, compared to a rate of 35.8% per/100,000 in Scotland. Analysis of the cohort of 2064 people prescribed methadone in Tayside demonstrates that 1,266 (61%) have been tested for HCV.  A total of 798 (39%) have not been tested. This work demonstrates that a significant number of potential cases still remain to be tested and offered treatment. The pharmacist-led pathway provides access to these people, as well as to needle exchange users, where needle exchanges are based in pharmacies.