Summary
Diagnosing and referring patients with hepatitis C is not routine practice within the majority of drug or prison services. In 2004 a Hepatitis C Managed Care Network was formed in Tayside with the aim to increase referrals and access to the specialist hepatology service. The study evaluated the long-term outcomes of people who inject drugs who had recently been tested and diagnosed with hepatitis C.
This project demonstrated that people who inject drugs can have similar or even better treatment outcomes than non injectors. Many were younger, had low viral loads and less prevalence of fibrosis/cirrhosis, so while this group of patients may be difficult to reach they are easier to cure if there are effective pathways of care in place.
Challenge
Around 215,000 individuals in the UK are chronically infected with hepatitis C, more than 80 per cent of cases caused by injecting drug use.
Testing for hepatitis C and other BBV is not routine practice within the majority of drug or prison services. Testing this group is not considered cost effective because subsequent entry into treatment is poor. In 2004 a hepatitis C MCN was formed, to increase referrals and access to care and treatment. This was done by increasing staff education, redesigning services, changing the referral pathway and introducing nurse-led outreach clinics.
Once the new pathways had been established and shown to be effective, the priority was to increase the number of new HCV diagnosis, particularly in PWIDS.
Objectives
The aim was to evaluate the long-term outcomes of PWIDs recently diagnosed with hepatitis C. Data was collected on everybody testing antibody postive for HCV from 2009 to 2013 inclusive. Each individual was allocated to cohort A, those under the care of drug services, or cohort B, past injectors or those without a history of injecting drugs.
The objectives were to increase outreach clinics, establish treatment programmes within them, and provide medical input within outreach drug and prison services. The study aimed to compare the referrral and attendance rates of PWID with non injectors, measure adherance to treatment and completion rates, and compare SVR data. It hoped to encourage people into interferon treatment, and improve treatment rates among prisoners.
Solution
In 2009 an additional full time nurse specialist was hired. This allowed the team to support the implementation of BBV testing within drug services and to increase the number of outreach clinics. Previously patients were obliged to attend the main hospital for testing.
More nurse-led outreach clinics were established, mostly as weekly clinics; a portable fibroscan was bought and medical outreach clinics were set up in drug services and prisons. The team continued to provide education and awareness sessions and this provided a crucial link between primary and secondary care. Communication between health care professionals is key for all staff in contact with PWID, so the team has an open door policy and will accept referrals from any health care professional. Patients can also refer themselves back for treatment by telephone or e-mail.
Results
In cohort A, 96.7 per cent were referred and 82 per cent attended. Where follow up was required, 22.7 per cent continued with treatment and 21 per cent lost to follow up. In cohort B, 98.7 per cent were referred and 93.7 per cent attended. Forty-three per cent continued with treatment, with 6.7 per cent lost to follow up. The viral load was lower in Cohort A. PWID had less cirrhosis and a lower degree of fibrosis.
Forty-seven Cohort A patients are in treatment, with six awaiting PCR tests. Eleven completed treatment, tested negative, but were lost to follow up. In Cohort B, eleven are in treatment, three awaiting PCR and three lost to follow up.
Learnings
Since 2004 the team has worked to engage staff in contact with HCV patients. This project shows how successful partnership working can be.
HCV testing, care and treatment has been embedded into drug services. Members of the specialist team spend most of their working week in outreach clinics, improving communication and keeping hepatitis C.
This study has contributed to an increase in overall treatment numbers, which have continued to grow. The last treatment target of 100 (10 per cent of them prisoners) set by the Scottish Government, has been met. The latest data shows an overall SVR rate of 72 per cent in treatment naive patients and 73.6 per cent in treatment experienced patients.
Evaluation
This study demonstrated that PWIDs can have similar or even better treatment outcomes than non injectors. Many PWIDs had lower viral loads, were younger, had less prevalence of fibrosis/cirrhosis, so while this group of patients may be difficult to reach, they can be easier to cure.
This project also had a public health goal. Local audit on DBSTs carried out in needle exchange centres had shown that a significant number of attendees were continuing to inject despite the provision of methadone. Treating one person therefore had the potential to prevent infection.
The outcomes of this project also clearly show the benefits of a co-ordinated care network and what can be achieved if primary and secondary care work together.
