Summary

Up to 83% of the expected number of patients with chronic hepatitis C have already been diagnosed by the proactive blood-borne virus testing carried out by community drug treatment services in Leeds. Once stabilised in drug treatment services, these patients are offered further investigations with a view to referral for antiviral therapy in the locally-commissioned Community Hepatitis C Service.

This beacon service provides a diagnostic, investigation, referral and treatment service for people living with hepatitis C who have traditionally found it difficult to access treatment programmes in conventional hospital-based clinical settings. This allows for continuity of care between prisons, hospital and the community drug treatment service.

Challenge

Patients were not being successfully recruited into treatment for hepatitis C from prisons or from the community drug treatment service in Leeds, despite significant numbers of diagnoses and referrals.

A community multidisciplinary team launched in January 2012, formalising the service in HMP Leeds and the Rapid Access Prescribing Service (RAPS). This allows continuity of care between prison and the community, and between primary and secondary care providers.

Opt-out blood borne virus screening for new prisoners was implemented on April 1, 2014. This could add to the burden of diagnosed hepatitis C infection, along with the challenge already posed by the 18-week referral to treatment compliance required by the current service level agreement.

Objectives

The main objective was to provide a high quality, GPSI prison-based Hepatitis C treatment service for up to 24 patients (or 16 patients with three on protease inhibitors), at any one time, at HMP Leeds and HMP Wealstun.

The project also aimed to provide clinically appropriate hepatitis C positive prisoners at the two prisons with early access to treatment and support.

Other objectives included providing a hepatitis C treatment that achieves SVR (Sustained Viral Response) rates comparable with published results according to genotype, and supplying service users with information and advice regarding hepatitis C.

Solution

The pilot service began in 2009. Public health representatives helped develop the business case and two registrars took the project on as part of their training (both are now consultants in public health medicine).

Local commissioners agreed that the service was necessary to address inequalities, to improve public health by reducing the pool of infection (it is estimated that one injecting drug user may infect up to twenty more) and to make service easier to access.

It is envisaged that the service might be expanded to treat up to 30 patients at a time as more specialist nurse posts are funded (specialist nurses are considered key to effective service delivery).

Service evaluations have shown consistently high treatment completion rates and non-inferior SVR rates against published data from specialist treatment centres.

Results

At the time of writing, 111 patients had completed their treatment, with 20 still in active treatment. A further 10 SVR tests were not yet due. Only seven patients were lost to follow up.

A total of 85.6 per cent of patients completed at least 70 per cent of their planned treatment, with all but six completing the entire course.

Five patients discontinued treatment because of adverse drug reactions, and six were released from prison during treatment. Of the latter, two continued treatment at RAPS, two at St James’ Hospital, and one at Bradford Royal Infirmary. The sixth was deported.

Learnings

Antiviral treatment for Hepatitis C can be delivered safely and effectively by primary care practitioners to a marginalised group of patients.

This model demonstrates that commissioners can create new services along the same lines. Specialist commissioning means a number of specialist centres across the UK hosting MDTs for their “spokes”.

Including prisons and community drug treatment services as spokes will mean treatment is more accessible for this marginalised group of patients. Increasing the rates of treatment will help reduce the prevalence of hepatitis C within a few years.

Evaluation

The project succeeded in meeting its objectives, as described in its service level agreement. All patients receive counselling including treatment options before they are discussed at MDT. They are then seen again to discuss the outcome of the team meeting before treatment begins. All patients are subsequently seen on a weekly basis by the nurse specialist and healthcare assistant and any problems are flagged up to the GPSI.

Such close monitoring and support has contributed to the high treatment completion rates the service has achieved.