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END-C: A novel community ‘one-stop’ liver clinic model to eliminate Hepatitis C

Updated on: 12 Jul 2022   First published on 11 Jul 2022

BSG CSSC Service Development Prize 2022 highly commended submission by Dr Adele Mourad.

Names of team involved: Professor Verma (Professor in Hepatology), Dr Adele Mourad (Clinical Research SpR in Hepatology), Emma Gray (Community Viral Hepatitis Research Nurse), Margaret O’Sullivan (Community Viral Hepatitis Research Nurse), Professor Heather Gage (Health Economist) and Ann-Marie Jones (Statistician).


Time Period: 2013 to present.

Summary of impact

Brighton and Sussex Medical School (BSMS)/ University Hospital Sussex (UHS) research led to the development of an innovative service. This is to achieve World Health Organisation (WHO) target to eliminate Hepatitis C (HCV) by 2030 and NHS England’s (NHSE) aiming to achieve it by 2025.Our community based model offering a ‘one stop’ liver clinic has been instrumental in delivering HCV treatment in vulnerable groups (people who use drugs (PWUD) and people who are homeless (PWAH)).

The overall impact has been, that the number of PWUD and PWAH in Brighton and Hove receiving HCV treatment increased by > 100%, contributing to a 48% reduction in HCV-related liver disease mortality over the same period (1) (2) (3) (4). Two of the largest national HCV centres (Operational Delivery Networks (ODN)) have adopted elements of our nationally commended good practice model to achieve NHS England (NHSE) HCV elimination targets.

Background

In England there are 118,000 people living with a chronic hepatitis C virus (HCV) infection (5). HCV predominantly affects marginalised and disenfranchised individuals such as PWUD and PWAH (6). In the UK, it has been reported that in 2018, 1 in 200 individuals were estimated to be homeless (7). There is a significant burden from HCV in PWAH . Unfortunately, such individuals do not engage with health services. Our prior work shows that only about 5% attend their hospital appointments (8). In the 2017 Unlinked Anonymous Monitoring (UAM) survey which studied PWUDs and HCV antibody status. Of those seen by clinical teams; 42% accepted and commenced HCV treatment, 34% declined the offer of treatment and 23% were not offered treatment (9).

From 2013 to present day we have developed an innovative community model to engage with vulnerable communities that are illustrated below. These community ‘one-stop’ liver clinics are led by Clinical Research SpRs and Community Research Viral Hepatitis Nurses. Treatment is discussed on a weekly basis in a multi-disciplinary setting at the Sussex ODN.

Project ITREAT 2013-2021 (funded by Gilead Sciences (IN-UK-337-1981) and Brighton and Hove Commissioners). An 8 year prospective community clinic in a substance misuse service environment. Service provided included blood borne virus testing (BBV) testing, safe injecting information, hepatic fibrosis testing, working closely with psychiatrists, peer workers and key workers to provide a holistic treatment for their HCV treatment and addiction.

Project VALID 2015-2018 (funded by Dunhill Medical Trust (R369/0714), Kent Surrey and Sussex Deanery and Gilead Sciences). A three year prospective study, based in homeless hostels in Brighton offered BBV testing, hepatic fibrosis testing and testing biomarkers of fibrosis. Also included in the consultations were liver health promotion, drug and alcohol referrals and HCV treatment.

Project END-C (2019-2-23) (funded by Gilead Sciences (IN-UK-987-5337) and Sussex ODN. Based on the success of Project ITTREAT and VALID we saw a need to develop and expand our model by establishing similar community “one-stop” clinics in homeless centres across multiple sites across all of Sussex. We are providing BBV testing, hepatic fibrosis assessment, HCV treatment as well as assessing patient reported outcomes using validated questionnaires and the cost per HCV case diagnosed.

Overall implementing these projects, we have screened > 1000 vulnerable adults and provided HCV treatment to > 300 people with SVR-12 rate (cure rate) ranging between 83%-87%.

Details of impact

The overall impact of this model can be summarised below

  • Increased access to treatment for HCV. Currently Sussex ODN treating about 70% of patients with HCV in the community, one of the few ODNs to do so.
  • Improved patients’ HCV care experience, understanding of HCV, and other health-related outcomes including improved health–related quality of life.
  • Developed a good practice care model, elements of which have been adopted nationally contributing to HCV elimination.
  • Contributed to Gilead Sciences new patient access to care pathway initiatives leading to their successful NHSE tender in 2019.

Professor Verma and her team have developed an easy to replicate holistic community model to help HCV micro-elimination in Sussex as well contribute to national elimination.

References

  1. PHE Liver disease profiles “Persons in drug misuse treatment who inject drugs – Percentage of eligible persons who have received a HCV test” B&H vs England,
  2. PHE Liver disease profiles ‘Under 75 mortality rate from HCV related end-stage liver disease/hepatocellular carcinoma’ B&H vs England [PDF available].
  3. Phillips, C, Schulkind, J, O’Sullivan, M, et al. Improving access to care for people who inject drugs: Qualitative evaluation of project ITTREAT—An integrated community hepatitis C service. J Viral Hepat. 2020; 27: 176– 187. https://doi.org/10.1111/jvh.13214
  4. O’Sullivan, M, Jones, A-M, Gage, H, et al. ITTREAT (Integrated Community Test – Stage – TREAT) Hepatitis C service for people who use drugs: Real-world outcomes. Liver Int. 2020; 40: 1021– 1031. https://doi.org/10.1111/liv.14403
  5. Public Health England. Hepatitis C in the UK 2020 Working to eliminate hepatitis C as a major public
    healththreat.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/943154/HCV_in_the_UK_2020.pdf
  6. Hepatitis C in England 2018 Report. http://fileserver.idpc.net/library/HCV_in_England_2018.pdf
  7. Hashim, A, Bremner, S, Grove, JI, et al. Chronic liver disease in homeless individuals and performance of non-invasive liver fibrosis and injury markers: VALID study. Liver Int. 2021; 00: 1– 12. doi:10.1111/liv.15122
  8. Marufu M, Williams H, Hill SL, Tibble J, Verma S. Gender Differences in Hepatitis C Seroprevalence
    And Suboptimal Vaccination and Hepatology Services uptake Amongst Substance Misusers. Journal
    of Medical Virology, 2012 Nov;84:1737-43
  9. Public Health England. Hepatitis C in England 2018 Report. 2018 [internet]. Available from: https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attac hment_data/file/732469/HCV_IN_THE_UK_2018_UK.pdf. Accessed date August 6, 2019

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