BSG CSSC Service Development Prize 2023 joint 3rd place submission by Dr Matthew Foxton

Liver disease in persons experiencing homelessness (PEH) is the third commonest cause of death after accidents and suicide. The borough of Westminster has one of the largest homeless populations in Europe.  In 2011, we were approached by Westminster Public health team to provide a community liver service to persons experiencing homelessness, concentrating particularly on treating chronic HCV infection. Prior to that, PEH with HCV infection were referred in to secondary care for assessment and treatment.

In 2012, we started a clinic within the South Westminster Centre, on a monthly basis, to screen and treat patients with hepatitis C. Over the next five years, we had limited success, with poor attendance rates (~10%) and poor cascade of care with regards to hepatitis C, with less than five patients being treated with pegylated interferon over that time.

Following a conversation with the GP lead, providing primary care services to PEH, we initiated a weekly clinic within the GP practice. This coincided with the new availability of direct acting anti-viral (DAA) therapy. The GP practice has been providing holistic care to PEH, including opiate substitution therapy, for 35 years.

Since 2017, we have been able to provide screening for blood-borne viruses, elastography services and same day treatment for hepatitis C. This was funded, in part, by a successful bid to the Gilead fellowship. Initially we struggled with blood sampling for HCV RNA testing, as we did not have access to dry blood spot testing, but were able to negotiate with the viral laboratory to enable the use of paediatric blood bottles meaning that we could use finger prick testing to acquire 150 microlitre samples. More recently, CW+ (the hospital charity) has funded a Cepheid machine for near-patient HCV RNA testing.

The final obstacle to overcome was prescribing. NHS England mandated that all the DAAs should be prescribed from out-patient pharmacies to ensure VAT savings. However, these could only be issued on a named patient basis and could not be returned to the pharmacy. This represented a high financial risk, due to the risk of non-attendance. By negotiating with NHSE, for this patient group,   and accepting the increased initial cost of paying VAT,  we used over-labelled drugs from our in-patient pharmacy, enabling initiation of DAA on the same day using pan-genotypic regimens.

During the COVID pandemic, the specialist nurses helping to deliver this initiative were seconded to the ITU. However, our list of known HCV patients was shared with the ODN team enabling them to treat patients who had been housed temporarily as a consequence of the pandemic.

Since the initiation of the clinic, we have identified 1136 patients within the practice who have been screened for hepatitis C, with 589 patients being HCV antibody positive. Of these, 545 have undergone HCV RNA testing, of whom 432 (79.2%) were RNA positive. Three hundred and fifty three (81.7%) have undergone treatment of which 162 were treated within the GP surgery. The remainder were treated within the community, secondary care or prison by other providers. Two hundred and eighty three patients (80.1%) have had an SVR12 measured. The overall SVR12 rate is 91.2% on a per-protocol analysis and 73.1% on an intention to treat analysis.

The use of data sharing has also transformed the clinic. By utilising the NHS care record, GP records, London Care record, the national HCV register and UKHSA testing data, we have been able to identify patients with chronic HCV infection and build up a picture of those who need treating and those who have been successfully treated. We commonly perform SVR12 testing in individuals who have initiated therapy in other settings, especially prisons. We then share this result with the treating team.

The work of the clinic is ongoing, and is moving to the next phase, to treat the remaining individuals and the ongoing testing of those at risk of both new and recurrent HCV infection. This is likely to include a dedicated multi-agency MDT to assist in the engagement of this population and to aid the delivery of the WHO and NHSE elimination targets.