Summary

Built on a concept developed in rural Africa, the BBV Champions is a model to address the shortfall in detection on Hepatitis C in the UK – using local available resources to raise awareness, offer testing, provide provisional results and support service users into the treatment pathway.

It has had a significant impact in Reading, Berkshire, in increasing uptake of testing in two high prevalence communities: substance misusers and the local Pakistani population. BBV Champions provides an effective structure to identify significantly more people infected by HCV and to guide them into treatment services which will have an impact on future infection rates and a reduction in advanced liver disease associated with late diagnosis and limited monitoring. 

Challenge

The majority of people infected by HCV in the UK come from ‘hard to reach’ communities.  The main focus on  testing  is  around  people  who  use  drugs - and  while  the majority  of  new  infections  in  the  UK  are through this route, it does not reflect the profile of patients seen in viral hepatitis clinics requiring treatment. Many patients  are  diagnosed  only  after  presenting  to  their  GPs  with  deranged  liver  function  tests suggesting  that  harm  has  already  been  done  to  the  liver. National Treatment Agency (NTA) guidelines recommend that all service users engaged with substance misuse services be tested for HIV and HCV annually – but in Reading, with only one BBV nurse (relying on venous blood samples ELISA tested at the local hospital), this was an unattainable task.  

Objectives

There were various objectives, including to identify local communities likely to be affected by HCV, to explore and identify resources in the local community that might support a testing programme and to  develop  a  robust  structure  - from  sourcing  key  workers  to  clarifying  a  pathway  to  clinical treatment services, and to identify stakeholders and get them on board, offering training. It was also important to raise  awareness  of  HCV  in  a  constructive  and  enlightened  way,  avoiding  the  risk  of  stigmatising communities.

Solution

Unlike  some  other  testing  models  the  ‘BBV  Champions’  adopts  a  holistic approach  incorporating  awareness  and  education,  testing,  support  and  harm  minimisation.  It is sustainable and virtually cost neutral because most champions are already employed by their organisations as key  workers  or  volunteers. Substance misuse key workers were expert at engaging the service users and were positioned in agencies maximising opportunity for contact - what they lacked was knowledge of BBVs, testing and consent.

A training programme was written for these staff, and the first tranche of champions was trained in 2010. The initiative was successful in the substance misuse field, but to prove the value of the model it had to be repeated with another service user group. To this end, eight housewives (the ‘Asian ladies’) from the local Pakistani community were trained as champions for their own community using the same package (with some adaptation). 

Results

In the first year of the BBV Champions being rolled out in the substance misuse community there was a 150% increase in the uptake of HIV/HCV testing. All users found to have a reactive result have engaged with all services more closely following this event. There is a better level of staff retention in the agencies who have Champions trained and a cost saving to the agency in not having to pay for BBV training from external agencies. There are now more than 60 trained key workers in Berkshire, and testing for HCV in particular is being carried out in 6 substance misuse facilities as well as in squats, car parks and anywhere that the unroofed communities are likely to congregate.

The ‘Asian Ladies’ tested 300 people in the first 18 months with 8 service users testing reactive and subsequently being found to be PCR positive.  Of these 6 now have been treated and have achieved SVR. It is likely that none of these people would have been tested had it not been for this programme.

Learnings

The Champions model encourages individuals to take some responsibility for their health and supports them in doing so. No two centres working with this model will be the same, as it is intrinsically linked to the demographic of that geographical  area.  There  is  a  common  belief  that  the  majority  of  Pakistani  HCV  infection  is  in  first generation  Pakistanis, but  this  model  has  demonstrated  that  second,  third  and  fourth generation Pakistanis are also affected – and there is now dialogue with the Pakistani High Commission to explore collaborative work to raise awareness about the risk of infection. The fact that the model can be applied to different communities with significant positive impact, without relying on paying participants to take tests or relying on dry blood spot testing requiring follow-up appointments, demonstrates that it is robust, functional and effective.

Evaluation

Service  users  are  more  knowledgeable  and  this  is  demonstrated  by  better  engagement  with  treatment services, with more referrals coming through to treatment services. Service users who are more chaotic are entering treatment through the support of their community-based Champions.