Hepatitis C Good Practice Roadshow Friday 27 th September 2019 West - - PowerPoint PPT Presentation

Hepatitis C Good Practice Roadshow

Friday 27th September 2019 West London ODN #hepCwestlondon

Introduction and setting the scene

Emma Burke

Programme Manger, Alcohol, Drugs and Tobacco, Public Health England – London

Hepatitis C Good Practice Roadshow London Introduction and Setting the Scene

Emma Burke Programme Manager Public Health England, London

Aim of the Roadshow

• Showcase good practice examples of testing, commissioning and treating

hepatitis C patients, and encourage new thinking about how to address problems.

• Afternoon workshops will be held on identifying solutions to challenges

faced by the ODN, awareness and testing in drug services and hepatitis C in prisons

• Raise awareness and de-stigmatise hepatitis C infection
• Raise awareness of the new treatments
• Work together towards elimination of hepatitis C in London

4 Emma Burke, PHE

Background

• In the UK, around 143,000 (113,000 in England) people have chronic

infection with HCV. 95,600 people are unaware of their infection. Prevalence in the general adult population 0.4%

• The majority of people are from marginalised and under-served groups in

society: injecting drug users, migrants, MSM

• 80% people with acute HCV infection have no symptoms, or symptoms not

recognised as from hepatitis C

• 10-20% of those with chronic infection will develop severe liver disease

(cirrhosis & hepatocellular carcinoma)

• Global deaths from viral hepatitis are continuing to rise.

5 Emma Burke, PHE

6 Hepatitis C in the UK 2019 report

Challenges in tackling HCV

• Primarily affects ‘under-served’ groups: injecting drug users and migrants

from certain countries

• No vaccine available
• Limited awareness of new treatments among the public and healthcare

professionals

• Improved access to testing
• Access to treatment services in hospital based services
• Older treatments were intravenous, required monitoring, bad side effects,

poor cure rates

7 Emma Burke, PHE

New opportunities going forward

• Advent of directly acting antivirals since 2015
• All oral treatments
• Good safety and side effect profile
• Relatively short course (3 months or less)
• Excellent cure rates (>95%)
• For the first time, we have the opportunity to eliminate Hep C as a public health problem

BUT

• Access to treatment needs to improve and to do this we need to raise awareness, test more people

and de-stigmatise hepatitis C

8 Emma Burke, PHE

T ackling hepatitis C: What can be achieved with new therapies?

• Better uptake of a more acceptable treatment
• Improved SVR (cure)
• Fewer hospitalisations/deaths for ESLD/HCC
• Improved health for drug users
• Potentially easier to roll out in community settings (accessibility) as drugs

have fewer side effects, shorter courses and are easier to administer (all-

• ral, interferon free)
• Reductions in prevalence of HCV
• Interruption transmission amongst injecting drug users

9 Emma Burke, PHE

Tackling Hepatitis C

• Prevention of new

infections

• Increasing awareness of

infection

• Increasing testing and

diagnosis

• Pathways: Getting

diagnosed individuals into treatment and care

Progress

Four Action Areas

 Mortality from liver disease  Mortality from causes considered preventable  Mortality from cancer  Mortality from communicable diseases  Successful completion of drug treatment  Early diagnosis of cancer  Inequalities  Quality of life for those with long-term conditions  Recovery from ill health  Prevention of premature mortality  Positive experience of care

Data indicates that we’re beginning to see the early trends of declining deaths from HCV due to treatment with new direct acting antiviral (DAA) drugs

Emma Burke, PHE 10

Estimated proportion of people injecting psychoactive drugs reporting adequate* NSP in England, 2011-2017

11 Hepatitis C in England 2019 Report

• 18. Public Health England. People who inject drugs: HIV and viral hepaitits unlinked anonymous monitoring survey tables (psychoactive): 2018 update. 2018.

Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729816/UAM_Survey_of_PWID_data_tables_2018.pdf [Accessed: 19/03/2019].

Trends in the sharing of injecting equipment and associated paraphernalia in the preceding four weeks among people injecting psychoactive drugs in England 2007 to 2017

12 Hepatitis C in England 2019 Report

• 18. Public Health England. People who inject drugs: HIV and viral hepaitits unlinked anonymous monitoring survey tables (psychoactive): 2018 update. 2018.

Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729816/UAM_Survey_of_PWID_data_tables_2018.pdf [Accessed: 19/03/2019].

Provisional estimates of numbers initiating HCV treatment in England, 2007-2017/2018

13 Hepatitis C in England 2019 Report

Death registrations for ESLD* or HCC in those with HCV mentioned on their death certificate in England: 2005 to 2017**

14 Hepatitis C in England 2019 Report

The Office for National Statistics (ONS carried out the original collection and collation of the data but bears no responsibility for their future analysis or interpretation).

Hepatitis C Action Plan for London

PHE, the London Joint Working Group for Hepatitis C, the GLA and the Mayor’s office are working with regional partners to develop an action plan for elimination of hepatitis C in London

• Data
• Testing and Awareness
• Pathways
• Funding

Work is ongoing with an action plan in place in early 2020 to identify actions that can be taken across London to eliminate hepatitis C

15 Emma Burke, PHE

Going forward….

• Awareness: Public, primary care, drug and alcohol services to increase

testing and referral and reduce stigma

• System: joining up the health and social care system to make sure hep C is

given priority and services are linked via the London action plan.

• Improving testing levels: ensuring everyone at risk is offered a test and

repeat testing

• Pathways of care: so that hard to reach groups most affected by the disease

are tested, referred and treated effectively and efficiently

• Reducing barriers to care and treatment: physical, knowledge or stigma
• Data: needs to be improved: surveillance, commissioning, testing and

treatment

• Building on the positive work that has been undertaken and is on-going in

relation to HCV – London Hepatitis C Action Plan

16 Emma Burke, PHE

PHE / RCGP Hepatitis C Course – raising awareness

Newly updated with the latest treatment information

www.elearning.rcgp.org.uk/hepc Hepatitis C: Enhancing Prevention, Testing and Care FREE,AVAILABLE ONLINE NOW

17 Emma Burke, Alcohol and Drugs Team, PHE London

HCV Action: sharing good practice

Aidan Rylatt

Policy and Parliamentary Adviser, The Hepatitis C Trust

HCV Action: Sharing best practice

HCV Action: Who we are

Our network

• The HCV Action network brings together health professionals from

across the patient pathway, including GPs, specialist nurses, clinicians, drug service workers, public health practitioners, prison healthcare staff and commissioners.

Our aims

• To highlight and disseminate examples of best practice in hepatitis C

care.

• To support the improvement of hepatitis C services.

HCV Action: What we do

What we do  Stage events across the UK.  Produce and disseminate information and

resources to health professionals working around hepatitis C:

• Good practice case studies
• Monthly e-updates
• Hepatitis C Commissioning Toolkit

 Host an online hepatitis C resource library,

with over 300 resources.

Best Practice Examples

 Edinburgh Access Practice outreach

service:

• GP clinic providing healthcare for

homeless population, including hepatitis C treatment clinic.

• From March 2014 – December 2016, 80

referrals were received and, of these, 59 patients attended (70%).

• Compares with typical hospital clinical

attendance rates of 30-50% among this cohort.

Best Practice Examples

 Homecare treatment delivery

by Nottingham University Hospitals

• Homecare project established

November 2016

• Within six months, 116 patients started
• n treatment through Homecare
• 89 completed treatment, of those

who had reached 12 weeks post- treatment, 96% achieved SVR

• Cost savings of £218/patient

compared with secondary care

• All patients reviewed the service

positively

Best Practice Examples

 Harbour Housing/Addaction/NHS England:

Hepatitis C treatment for homeless community

• Collaborative work between housing, health and

addiction services

• Accommodation for homeless population in Cornwall
• Dedicated bed for individuals who are homeless and

have hepatitis C

• Seven individuals completed treatment in past year

How you can get involved

 Share your good practice:

• If you, or your service, is doing something innovative

with hepatitis C care, then let us know so we can share it!

 Join our network to receive monthly e-updates

(sign-up sheets on tables)

 Use our resources  Follow us on Twitter - @HCVAction

Thank you

www.hcvaction.org.uk hcvaction@hepctrust.org.uk @HCVAction

Local epidemiology

Hikaru Bolt

Epidemiology Scientist, Public Health England

Hepatitis C elimination: the next three years

Dr Christopher Tibbs

Medical Director, Commissioning, NHS England & NHS Improvement South East Region

Hepatitis C elimination: the next 3 years

Christopher Tibbs Medical Director Commissioning NHS-E and NHS-I South East Region

New structures, new team, new opportunities

• NHSE=NHSI
• Directorate of Direct Commissioning
• Specialised Commissioning
• Health and Justice
• Section 7 Public Health
• GP
• Medical Directorate
• Regional Medical Director
• Medical Director Commissioning
• Medical Director Medical Directors System Improvement and

Professional Standards

Service development

New technique Evaluation NICE Clinical Panel CPAG SCOG SSCC Procurement Commission current providers Commissioning criteria

Outputs

• Service specifications
• Circulars

POC CRG

The Journey so far

1987 1988 Interferon Interferon + Ribavirin Peg-Interferon + Ribavirin 1990s 2000s Epidemiology Molecular Epidemiology Molecular Biology 2010s Drug design Population dynamics Direct Acting Anti-virals 2020s Cure

E L I M I N A T I O N

SVR Cirrhosis HCC Transplant

Service development: systems can work

New technique Evaluation NICE Clinical Panel CPAG SCOG SSCC Commissioning criteria

POC CRG

2004: Interferon alfa (pegylated and non- pegylated) 2006: Peg IFN and RIBV and ribavirin 2012: Testing 2013: Peg IFN and RIBV in young people 2015: Ombitasvir–paritaprevir–ritonavir with or without dasabuvir 2015 Sofosbuvir 2015: Ledipasvir-Sofosbuvir 2016: Elbasvir-grazoprevir 2017: Sofosbuvir-velpatasvir 2018: Sofosbuvir-velpatasvir-voxilaprevir 2018: Glecaprevir-pibrentasvir 2019: HCV treatment in acute hepatitis C 2019: Retreatment

Establishment of HCV ODNs CQIN Procurement

Overview of Elimination plan

• We want to eliminate in 3-5 years
• Year 1 – Data, data, data
• Year 2-3 – Full steam ahead
• Year 4 – mopping up

Treating the population

• The Challenge
• Symptomatic and know patients largely treated
• Prisons provide a population based sample
• Hard to reach populations remain a challenge
• Drug users
• Homeless
• Those born in high prevalence areas
• Case finding
• Groups who do not engage with services or society
• Settings of care
• Institution phobia
• Community infrastructure

Treating the individual

• Diagnosis
• New diagnostic techniques
• Administration
• Making it easy
• Compliance
• 80% may be good enough
• Follow up
• On treatment
• Clearance
• reinfection
• Keys to success
• Timeliness
• Low risk therapy
• Light touch
• Narrow window of opportunity
• Shortest treament course
• Cultural challenge: taking the service

to patient, new settings of care

HCV – ODN support

ODN 1 ODN 2 ODN 3 ODN 4 ODN 5 ODN 22 ……….

ODNs control the local delivery solutions They are the key point of contact We will give you £500 per treated patient We will give you free testing kits

HCV – Towards 30K NHSE et al will provide solution options

ODN 1 ODN 2 ODN 3 ODN 4 ODN 5 ODN 22 ……….

Prison support

HCV – coordinated commissioning

• Direct commissioning now encompasses
• Specialised eg treatment centres in ODNs
• Health and Justice
• Prison medical services
• In-reach
• Section 7a Public Health
• Screening
• Immunisation
• Primary care
• Case finding in general practice and other community settings

(addiction services commissioned by Local Authorities)

HCV – global support

ODN 1 ODN 2 ODN 3 ODN 4 ODN 5 ODN 22 ……….

Drug service mapping and peers Prison support

HCV – global support

• Pharma will provide people to map services
• (list all sites, list all commissioners, arrange introductions etc)
• The Hepatitis C Trust will supply peers

HCV – global support

ODN 1 ODN 2 ODN 3 ODN 4 ODN 5 ODN 22 ……….

Drug service mapping and peers Prison support Needle exchange pharmacies

Pharmacy support

• NHSE contracts with pharmacies to supply services
• In this years negotiation we are offering a ‘Hep C testing’ service and

a ‘Hep C monitoring service’

HCV – global support

ODN 1 ODN 2 ODN 3 ODN 4 ODN 5 ODN 22 ……….

Drug service mapping and peers Prison support Needle exchange GP testing

HCV – global support

• We will pull data from GP records

(Locally at first, later centrally)

• We will analyse for HCV risk factors
• ODNs will be provided with a list

The Deal

• We must prescribe drugs in line with the contract:-
• Abbvie 16.7%
• MSD 23.8%
• Gilead 59.5%
• Failure to do so reduces level of support

Drugs come in different shapes and sizes

HCV – National Picture

• What we are up to
• What we have achieved
• Prisons

2019 – Year 1 Where are we?

• Registry

46,000

• Treated patients

41,551

• To be treated

4,449

• To be found

67,000

• PHE estimate of HCV population

113,000

2019 – Year 1 Where are we?

April – June 2018 = 2774 treatments April – 25 June 2019 = 2767 treatments

All HCV genotypes: SVR12 95.6% (95.2–95.9)

HCV – towards elimination How are we doing?

80 82 84 86 88 90 92 94 96 98 100

SVR12 (%)

No fibrosis Mild fibrosis Moderate fibrosis CC Past DC DC

How are we doing?

Deaths from HCV or HCC in patients with HCV (PHE report on HCV 2016)

5 10 15 2012-13 2013-14 2014-15 2015-16

% HCV

% HCV 100 200 300 400 500 600 700 2012-13 2013-14 2014-15 2015-16 Total OLT HCV OLT

Transplants for HCV % transplants for HCV in UK

Treatment of hepatitis C and possibilities for elimination in London

Professor Ashley Brown

West London ODN Clinical Lead

HCV CV Actio tion/P /PHE Hepatit itis is C Good Practic ice Roadshow, West London

Friday 27th September 2019

Prof Ashley Brown, Imperial College Healthcare NHS Trust, London, UK

NHS England HCV ODNs

• The ODNs were established by NHS England

as a way of ensuring equity of access and the responsible use of an expensive resource

• Each ODN has a lead who heads an MDT

(composed of hepatologists and/or ID physicians, CNS and pharmacists)

• Strict minimum and maximum treatment

targets were set to control budgets while achieving elimination by 2025 with severe financial penalties for failing to comply

• Heavy emphasis on data collection to

confirm RWE

• Strict prescribing rules in keeping with six

monthly price tendering rounds

HCV Operational Delivery Networks in London

Barts (East London) ODN

West London ODN

South Thames Hep Network ODN North Central London ODN

West London Working Together

West London ODN: Spreading Tentacles

A B 2 C 1 D 2 4 1 5 6 7 3 9 4 1 3 8 2 3 1 A. St Marys Hospital, Imperial College NHS Trust

• 1. Hammersmith Hospital
• 2. Charing Cross Hospital
• 3. St Charles’ Hospital
• 4. Turning Point, Soho
• 5. Turning Point, New Coach House
• 6. Turning Point, Acorn House
• 7. ARCC, Willesden Centre for Health
• 8. St. Mungo’s Broadway Centre
• 9. Offender Healthcare, HMP Wormwood Scrubs
• 10. Heathrow Immigration Removal Centre

A A. Chelsea & Westminster Hospital

• 1. Dean Street Clinic, Soho
• 2. St Stephen’s Centre
• 3. West Middlesex Hospital
• 4. Victoria Drug and Alcohol Service

B A. Northwick Park Hospital

• 1. Central Middlesex Hospital
• 2. Ealing Hospital
• 3. RISE, Ealing Broadway

C A. Hillingdon Hospital

• 1. ARCH Drug & Alcohol Services, Uxbridge

D

KEY

HUB SITE Site offering Testing, Diagnosis AND Treatment Site offering Testing and Diagnosis with onward referral for treatment ? ? ?

Testing and Treatment for HCV now available at 34 locations in West London ODN

Hospital Clinics (10) St Marys, Hammersmith, St Charles, Charing Cross, Chelsea & Westminster, West Middlesex, Ealing, Central Middlesex, Northwick Park, Hillingdon Drug & Alcohol Services (9) Turning Point Soho, Acorn Hall North Kensington, ARC Willesden, New Coach House Shepherds Bush, Ealing RISE, WDP Harrow, CGL Victoria, ARCH Uxbridge, ARC, Hounslow Homeless Hostels (7) Hope Gardens, The Old Theatre, Broadway Centre Shepherds Bush, St Mungos 209 Harrow Rd, King George Hostel, Pound Lane Hostel, St Mungos Edith Road GP Practices (2) Dr Hickey Practice, Great Chapel Street Sexual Health Clinics (4) Dean Street, Wharfside Clinic, Kobler Centre, Hammersmith Broadway Prisons (1) HMP Wormwood Scrubs Immigration Removal Centre(1) Coinbrook/Heathrow IRC Community Pharmacy (1) Portmans Pharmacy

Achieving the Mind Shift in HCV Care

BENEFIT TO INDIVIDUAL BENEFIT TO SOCIETY

Prevention of cirrhosis, HCC and premature death Alleviation of extra-hepatic symptoms Achievement of elimination as a public health issue Prevention of

• nward

transmission HCV AS A LIVER DISEASE HCV AS A PUBLIC HEALTH ISSUE

Those Living with HCV

Haemodialysis Patients Pregnant Women MSM Former PWID’s Iatrogenic pre-1989 People who use Drugs Prisoners Immigrant Communities Homeless Undocumented

Those Living with HCV

Haemodialysis Patients Pregnant Women MSM Former PWID’s Iatrogenic pre-1989 People who use Drugs Prisoners Immigrant Communities Homeless Undocumented

THE MAJORITY OF THOSE WHO WILL ATTEND SECONDARY CARE SERVICES HAVE ALREADY BEEN TREATED

Those Living with HCV

Haemodialysis Patients Pregnant Women MSM Former PWID’s Iatrogenic pre-1989 People who use Drugs Prisoners Immigrant Communities Homeless Undocumented

THOSE MAJORITY OF THOSE WHO ARE UNDIAGNOSED AND/OR UNTREATED ARE UNLIKELY TO ATTEND TRADITIONAL SERVICES

Changing Models of Care

Patient expected to come to hospital for diagnosis and treatment All diagnosis and treatment taking place in the community Testing and diagnosis in the community but patient comes to hospital for treatment

“TRADITIONAL MODEL” “OPTIMAL MODEL” “TRANSITIONAL MODEL”

Investing in Case Finding: Everyone’s a Winner!

CASE FINDING

THOSE WHO HAVE BEEN DIAGNOSED BUT HAVE DISENGAED AND/OR ARE UNAWARE OF AVAILABILITY OF DAA THERAPY THOSE WHO HAVE NEVER PREVIOUSLY BEEN DIAGNOSED WITH CHRONIC HCV

RAPID ACCESS TO CURATIVE TREATMENTS

THE PATIENTS

ACHIEVING RUN-RATE SECURES CQUIN PAYMENT

THE ODN

ENDING THE EPIDEMIC NATIONAL KUDOS

PUBLIC HEALTH

COST- EFFECTIVE ELIMINATION WHILE COSTS CAPPED THE NHS INCREASED PRESCRIBING PHARMA

Case Finding: The New Deal

£12m £7m 40m Case Finding Programmes CASE FINDING POT

The New Deal: Cross Cutting Funding

Barts & East London Central North London South Thames West London Leicester Nottingham Merseyside & Cheshire Greater Manchester South Yorks West Yorks North Yorks & Humberside Newcastle & North Cumbria Lancashire & South Cumbria Thames Valley Surrey East of England Birmingham Bristol SW Peninsula Wessex Sussex Kent PRISON PROJECTS PWIDS AND PEER PROJECTS NEEDLE SYRINGE PROGRAMMES GP CASE FINDING

Details of the New Deal

NHS Funded Pharma Funded

Drug & Alcohol Services

Point of care testing in DATs Data collection and regional pathway coordinators in DATs

Health & Justice

Point of care testing in prisons Pathway Mapping Cepheid machines in 30 prisons Orasure testing and HITT squads

Community Pharmacies

Payment for POC testing for NEx clients

General Practice

GP search tool ePR interrogation software South Asian projects

ODNs

Per patient payment Peer-to-peer, Peer coordinators and community liaison officers

The New Deal: Replacing the Stick with the Carrot

PREVIOUSLY

All funding from NHS Tight run-rate targets CQUIN emphasis on data collection and completion of treatment Tight prescribing restrictions Genotype essential Financially penalizing under performance

NOW

Collaboration between NHS and pharma No maximum to numbers treated CQUIN emphasis on getting patients

• nto treatment

Wider choice of treatments 20% can be treated as ’pan- genotypic’ Financially rewarding over performance

The New Deal: Per Patient Payment

• £500 per patient commenced on treatment
• Money MUST be reinvested in case finding programme
• Money can be distributed down the patient pathway

Changing Models of Care

HCVAb +ve patient expected to come to hospital for work-up and treatment All diagnosis and treatment taking place in the prison with external support from the specialist team Testing and diagnosis in the prison. Secondary care staff enter prison to treat

“TRADITIONAL MODEL” “IN-REACH MODEL” “IDEAL MODEL”

West London ODN: Prison Outcomes

• 95% screening rates at reception
• HITT squad planned to ‘mop-up’ those missed
• Full time Peer Worker
• Rapid POC pathways for those at highest risk
• Upskilling and empowerment of Prison HC team
• 58 prisoners commenced on treatment this year
• 22/58 achieved SVR12
• 18/58 not yet reached SVR12
• 1/58 treatment failure (<4w treatment)
• 17/58 LTFU (for time being!)

Addressing the ethnic mix of West London

Expanding Horizons

• New programme commencing at the Coinbrook Immigration

Removal Centre

• Permission to treat reinfections (and acute infections?) will have a

real impact in West London

• Development of pharmacy programmes

Review of 8017 HCVAb positive results in West London

1632 3229 320 313 611 156 48 1574 134 SPONT CLEAR TREATED DEAD PCR POS NO PCR KNOWN UNSUITABLE TO BE REVIEWED UNTRACEABLE

2763 Patients treated as part

• f the West London ODN Programme

39 7 5 9 96 147 186 92 127 129 207 136 150 225 257 189 175 165 157 141 124

50 100 150 200 250 300 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3

Treatment as Prevention Works!

PWID population within West London ODN

1000 2000 3000 4000 5000 6000 7000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Cirrhosis Moderate Mild Achieved SVR

West London ODN – ahead of the Curve!

71% 73% 78% 79% 80% 81% 82% 91% 92% 96% 98% 98% 101% 103% 117% 125% 127% 129% 139% 149%

188%

221% 0% 50% 100% 150% 200% 250%

Conclusion

• Collaboration between stakeholders remains crucial
• The switch of emphasis to case finding is essential if

elimination is to be achieved

• New models of care continue to evolve increasing

access to treatment in vulnerable populations

• West London is well on track to achieve elimination
• f HCV as a Public Health issue by 2025

Hepatitis C Good Practice Roadshow

Friday 27th September 2019 West London ODN #hepCwestlondon

Good practice case study: Hepatology nurse community

• utreach

Lorna Harrison

Clinical Nurse Specialist, Hepatology, Imperial College Healthcare NHS Trust

Good Practice Case Study Hepatology Nurse Community Outreach Lorna Harrison CNS Hepatology

Imperial College Healthcare NHS Trust

83

Content

2

• Relevant Patient History
• Patient seen at D&A Clinic
• Approved at WL ODN
• DNA Start Date. Why?
• Patterns of behaviour
• Team Work
• Outcome

Relevant Patient History

3

• 59 years old, white, British, male, single
• Unemployed
• Past PWID
• Attends D&A Clinic: Methadone 55mls OD
• HCV AB+ve for over 20 years

Patient Seen at D&A Clinic

4

• HCV treatment naïve
• FibroScan: 4.6 kPa
• Normal LFTS, FBC, U&E & PT
• HIV & HBV negative
• HBsAb >1000 Miu/mL
• HCV G.1a
• VL 650,00 IU/mL

West London ODN: Approved Patient for Harvoni, 8 weeks

5

6

Multiple DNA Start Dates!

Why?

7

• Evicted from stable accommodation
• Unpredictable attendance times at D&A

Clinic

• Patient has no mobile
• No NOK

Patterns of Behaviour

8

9

Patient, D&A staff, Hepatology Consultant, Community Pharmacist & CNS!

Outcome

10

24 weeks’ post HCV RNA negative.

Cured!

Good practice case study: The value

• f the peer

Stuart Smith

Director of Community Services, The Hepatitis C Trust

The Hepatitis C Trust Peer to Peer Education Testing & Treatment

Stuart Smith As a sustainable healthcare intervention

Target population:

People attending drug services, rehabs, detoxes, hostels and day programmes who are currently or previously affected by substance misuse

History

Reach into the substance user community and deliver core messages about the importance of prevention, testing and treatment assessment Deliver workshops based on a peers personal experience of hepatitis C diagnosis, care and treatment Improve awareness of hepatitis C amongst PWIDs Motivate people at risk to access testing Motivate people already diagnosed to access specialist services for liver assessment & treatment decision Ultimately – change attitudes towards hepatitis C amongst PWIDS & wider community

Objectives

First Hepatitis C Trust Peer Project 2010

Aims

• Trust leads to engagement
• Empower patients
• Leave No One Behind
• Provide vital link between community and

secondary care

• Current community services climate

PEERS

Community Drug Treatment Community Outreach

Community Pharmacy Primary Care

South Asian Community

Prisons

Why peers?

The last group I attended

Passing on Information

A number of interviewees explicitly indicated that they had passed on messages from the training to their peers: “I speak about it quite a bit with people I see in the service. I’ve also seen

• ther service users who’ve been to the sessions telling others about it
• utside the main building”

“I’ve spoken about what I learned in the session with my partner – we discussed the importance of being careful, the thing about notes which neither of us had known, and about the developments in treatment.”

Advanced Disease

Committed to Recovery

Stable on OST

Only in touch with NSP Residential Detox Hostels – Homeless Shelters Ex IDU – Now Alcohol Prisons Hard to engage NOT hard to find

Where are the patients?

We need to go beyond the current boundaries of care

Follow Me

Peer facilitates a workshop Client approaches peer after the talk Peer has direct number of clinic Referral made direct Peer attends clinic with patient

PPPPPPPPP PPPPP

Peer starts treatment This outcome is being achieved within 2 – 4 weeks

Support to treatment

639 Treatment starts 1423 HCV+ being supported

The Peer Support Lead

• Develop a network of Peers to deliver workshops & provide individualised

support for those seeking or accessing HCV treatment

• Contribute to the development of patient focused care pathways
• Form partnership working agreements with local community services
• Work with ODN’s to ensure that patient representation exists at every

level of decision making

• Work with ODN’s to establish 2 way data communication for monitoring

purposes

• Deliver & provide support to local testing initiatives and awareness

campaigns

• Coordinate Workforce development for frontline staff

Finding the right person

• Patient focused
• Personal experience
• Ability to lead
• Work experience

How it works

• Mapping of services
• Build relationships with service providers
• Advertise for peers & offer workshops
• Discover existing & Develop new pathways
• Training for peers & frontline workers
• Deliver Workshops, Coordinate Testing / identify HCV+

patients and accompany to clinic

What we need….

• A warm welcome
• Honorary contracts
• ISA’s
• Access to Trusts transport & incentives
• Active involvement in service design
• DBST provision

Don’t forget the indirect outcomes Thank You….

Patient perspective

Billie Hands

Hepatitis C Good Practice Roadshow

Friday 27th September 2019 West London ODN #hepCwestlondon

Panel discussion: problems & solutions for tackling hepatitis C and achieving elimination locally

Emma Burke, Hikaru Bolt, Chris Tibbs, Prof Ashley Brown, Lorna Harrison, Stuart Smith

Workshops

Workshop A: Identifying solutions to challenges faced by the ODN – Kathleen Lonsdale boardroom Workshop B: Awareness and testing in drug services – Hilda Clarke Suite (main room) Workshop C: Hepatitis C in prisons - George Bradshaw boardroom

Workshop A: Identifying solutions to challenges faced by the ODN

Dr Matthew Foxton

Consultant Hepatologist, Chelsea & Westminster Hospital NHS Foundation Trust

Identifying solutions to the challenges faced by the ODN

Dr Matthew Foxton Consultant Hepatologist Chelsea & Westminster Hospital (on behalf of West London ODN)

Case Finding

▪ New cases

– Where – Who – How often

▪ Historical cases

– Local databases – PHE databases

▪ Data sharing – LJWG report

Diagnostics - Where and How?

▪ HCV Ab testing

– Mouth swab – Finger prick testing – Venesection

▪ Further testing

– DBS – HCV Ag – Near patient RNA testing eg Cepheid – Venesection

Linkage to Care

▪ Pathways ▪ Hospital vs Community ▪ Opportunity ▪ Peer support

Drug Delivery

▪ Expensive drugs ▪ Which drug? ▪ Financial risk to prescriber ▪ VAT ▪ How much in one go?

Compliance

▪ Incomplete treatment courses ▪ Breaks in treatment

Outcomes

▪ SVR12 ▪ Data collection ▪ Long-term follow-up

– Cirrhosis – Risk reduction for re-infection – EtOH misuse

Workshop B: Awareness and testing in drug services

Archie Christian

Pathways Coordinator, The Hepatitis C Trust

HCV Engagement through Drug services

Peer based interventions and the need for work force development programmes Archie Christian

The Problem

A lack of engagement from people diagnosed with HCV Identifying the undiagnosed Reducing DNA’s

• Been in system for years – Old information/ Bad information
• Not in Drug services
• Old patients lost in the system
• Newly Diagnosed – No Information
• Asymptomatic
• Other priorities

The Hepatitis C Trust

The Patient

Hep C This is a medical condition. We have a treatment! So why don’t they want it?

• Stig

igma

• Fear
• Myt

yths

• Low pri

riority

• Lack of

f awareness

• Bad past exp

xperiences

• Rebellion
• Lack of

f self lf worth

Exercise: Engage clients with the hepatitis C care pathway

Scenario:

We have clients who we know are positive for hep C; they themselves know they are HCV+ They are not engaged with care. Similarly we have the undiagnosed; both in service & not engaged.

How do we support these groups to engage with the specialist care pathway?

The Hepatitis C Trust

Patient Psychological Barriers Service Barriers - Drug & Alcohol Service Barriers - Hospital Patient Physical or Practical Barriers

Patient Psychological Barriers

Barriers

• 1. Ambivalence
• 2. Fear of Interferon treatment
• 3. Negative experience with health care systems
• 4. Social anxiety/poor self image
• 5. Lack of belief in self
• 6. Denial
• 7. Distrust in confidentiality
• 8. Fear of losing anonymity regarding HCV+ status

Patient Physical or Practical Barriers

Barriers

• 1. Poor venous access
• 2. Carers responsibilities
• 3. Lack of stability
• 4. Homelessness
• 5. Lack of family or peer support
• 6. Poor time management
• 7. Other priorities- making money, buying drugs
• 8. Geographical or travel barriers.

Other barriers may be: no symptoms, doesn’t interfere with lifestyle, heard horror stories & have incorrect information (myths)

Service Barriers - Drug & Alcohol

Barriers:

• 1. Inconsistency of service provider
• Lack of continuity of care
• Loss of developed trust
• 2. Low priority
• 3. Staff training
• 4. Lack of point of contact testing
• 5. Lack of resources
• Financial
• High caseload

Barriers:

• 1. Inconsistent criteria for PWIDS
• 2. Unrealistic appointment times
• 3. Location
• 4. Transport
• 5. Communication barriers between

patient & consultant

Service Barriers - Hospital

Patient Psychological Barriers

Barriers

• 1. Ambivalence
• 2. Fear of Interferon treatment
• 3. Negative experience with health care

systems

• 4. Social anxiety/poor self image
• 5. Lack of belief in self
• 6. Denial
• 7. Lack of confidence in confidentiality
• 8. Fear of losing anonymity regarding HCV+

status

Possible solution

• 1. awareness/education
• 2. awareness/education/peer support
• 3. peer/staff support
• 4. peer support
• 5. support group/ Peers
• 6. awareness/ education
• 7. stringent, transparent policy & explicit

consent

• 8. peer support / awareness/ education.

Drug service campaign drive.

Patient Physical or Practical Barriers

Barriers

• 1. Poor venous access
• 2. Carers responsibilities
• 3. Lack of stability
• 4. Homelessness
• 5. Lack of family or peer support
• 6. Poor time management
• 7. Other priorities- making money, buying drugs
• 8. Geographical or travel barriers.

Other barriers may be: no symptoms, doesn’t interfere with lifestyle, heard horror stories & have incorrect information (myths) Peer education & awareness programs Possible solutions

• 1. DBST
• 2. Appropriate appointment times / Childcare provision
• 3. OST / Support group / Tailored care plan
• 4. Prioritise needs / Long term care plan
• 5. Peer support
• 6. Appropriate appointment times
• 7. Incentives
• 8. Peer support / Financial assistance/ community clinic

Service Barriers - Drug & Alcohol

Possible solutions

• 1. TUPE workers/Health passports/

Borough wide referral forms 2, 3 &5. Commissioner buy in / Investment / Prioritise Health Outcomes for disadvantaged group to address existing health inequalities

• 4. DBST training & testing by all staff

Barriers:

• 1. Inconsistency of service provider
• Lack of continuity of care
• Loss of developed trust
• 2. Low priority
• 3. Staff training
• 4. Lack of point of contact testing
• 5. Lack of resources
• Financial
• High caseload

Barriers:

• 1. Inconsistent criteria for PWIDS
• 2. Unrealistic appointment times
• 3. Location
• 4. Transport
• 5. Communication barriers

between patient & consultant

Service Barriers - Hospital

Possible Solutions

• 1. General referral form/ Advocacy/ self

referral

• 2. Afternoon appointments/ flexible clinics
• 3. community clinics
• 4. Funded transport/ community clinics
• 5. Staff support/ Peer support/ jargon free

literature

Is a change of attitude & approach. New strategies, underpinning knowledge, information, training & awareness. Static services not meeting the local need. Utilise the resources available in the ‘Peer’ community None of this will work if our frontline staff are not comfortable about talking to clients with confidence about hep C The support and assistance from commissioners is essential What we need..

Objectives

• Improve awareness of hep C amongst PWIDs
• Motivate people at risk to access testing
• Motivate people already diagnosed to access specialist care
• Improve understanding of hep c amongst staff in drug services
• Testing and appropriate pathways
• Ultimately – change attitudes on hep C amongst PWIDS & wider community

• Single point of care
• Discuss hep C with confidence
• Raise awareness, encourage safer practice
• Increased testing
• Improved referral / pathway
• improved support for people with HCV

Workforce development

How we do it

• Service Team meeting
• Identify immediate needs
• Round Tables
• Agreed actions
• Staff / Volunteers training
• Training of Peers
• Direct referral
• Community clinics
• Ongoing support

Hepatitis C Peer Support Programme

• Peers trained to offer support
• Appointment companions
• One to one visits (Coffee shop)
• Text Reminder / Diary service
• Hostel pick ups
• Reduction of patient DNAs
• Higher treatment completion

New Hepatitis C Trust initiative: Follow me

Peer facilitates a workshop or outreach Client approaches peer after the talk Peer has direct number of clinic Referral made direct Peer attends clinic with patient

PPPPPPPPP PPPPP

Peer starts treatment

(Peer tests ?)

Workshop C: Hepatitis C in prisons

Professor Ashley Brown

West London ODN Clinical Lead

HCV Action/PHE West London Roadshow

Workshop 3: Treating in Prisons

Prof Ashley Brown, Imperial College Healthcare NHS Trust, London, UK

The Prison Estate in England & Wales

Drug Use in Prisons

BBV in British Prisons

A study in 2012 showed the overall prevalence of HCV antibodies among Scottish prisoners to be 19%1.

• 1. (University of the West of England, University of Bristol, NHS Health Scotland, Hepatitis C

Prevalence and Incidence among Scottish Prisoners and Staff Views of its Management: Final Report, May 2012)

Foreign Nationals in Prisons in E&W

• 11% of the total prison population in England and Wales.
• Huge range of nationalities, languages cultural and

religious diversity

• Controversial eligibility for access to NHS treatment

http://www.justice.gov.uk

• The majority of addicts in prison will be

there because of crimes committed related to their addiction, theft, violent crime, supplying or possessing drugs.

• 47% of prisoners re-offended within a

year of release - 57% for those serving sentences of less than 12 months.

• Heroin, cocaine or crack use was higher

for prisoners sentenced to less than one year than for those serving longer terms (44% vs 35%)

Prison Reform Trust, The Bromley Briefings (June 2012)

Speaking in Short Sentences

Microelimination within prisons

Grebely J, Dore GJ. Antivir Res 2014;104:62–72. Data in Venn diagram taken from Australian figures

• The considerable movements

between PWID on OST in the community, and in the prison settings provides a unique

• pportunity to capitalise on these

settings as HCV treatment access points

• Decreasing HCV prevalence in

prisons will result in reduced HCV in the community

• High turnover and short

sentencing requires specific pathways

Welcome to my World!

• Local category B prison holding 1300 adult males – mix of remand and

sentenced, with over 30 admissions/day.

• >50% BME prisoners, >30% foreign nationals, and significant numbers

<21y and/or classified as vulnerable.

• Longstanding staffing issues and high levels of serious violence
• Central Healthcare Unit with part-time GP presence plus 55 bedded

Conibeere ‘detox’ unit

The duality of HCV

HCV AS A LIVER DISEASE HCV AS A PUBLIC HEALTH ISSUE

BENEFIT TO INDIVIDUAL BENEFIT TO SOCIETY

Prevention of cirrhosis, HCC and premature death Alleviation of extra-hepatic symptoms Prevention of

• nward

transmission Achievement of elimination as a public health issue

Overcoming Prejudice

GENDER AGE BODY SHAPE

SEXUALITY

RACE LIFESTYLE

ACCEPTANCE INCLUSION TOLERANCE PREJUDICE

Overcoming the Silo Mentality

This is a story about four people named Everybody, Somebody, Anybody and Nobody. There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it but Nobody did it. Somebody got angry because it was Everybody’s job.

Point of Care saliva tests Dried blood spot testing Point-of-care HCV RNA testing

• Results within

minutes

• No expertise or

laboratory required

• Can be self

administered

• Antibody result only
• Minimal expertise

required

• Suitable for mass

screening

• Results take 2-3 days
• Can give viral load
• Can test for other BBV
• Minimal expertise

required

• RNA result in an

hour

• Limited capacity
• Ideal for instant

linkage to care

Harnessing the new diagnostics

BUT WE NEED A WIDE RANGE OF PEOPLE WITH THE RIGHT KNOWLEDGE, SKILLS AND ATTITUDE TO DELIVER CARE IN PRISONS

Changing Models of Care

HEPATOLOGISTS ID SPECIALISTS GENERAL PHYSICIANS ADDICTION SPECIALISTS GASTROENTEROLOGISTS PRISON MENTAL HEALTH TEAM PRISON GPs PRISON OFFICERS PEER SUPPORTWORKERS KEY WORKERS SPECIALIST NURSES PHARMACISTS PRISON NURSES

Changing Models of Care

HCVAb +ve patient expected to come to hospital for work-up and treatment All diagnosis and treatment taking place in the prison with support from specialist Testing and diagnosis in the prison. Secondary care staff enter prison to treat

“TRADITIONAL MODEL” “IN-REACH MODEL” “IDEAL MODEL”

Prison Test and Treat

Opt out testing with DBS Confirmatory HCV-RNA testing with wet bloods Opt out testing with Orasure Confirmatory testing with Cepheid Expected Duration of Stay

<4 weeks >12 weeks 4-12 weeks

Appointment

• ffered on antiviral

unit week of release Genotype on System1 ? Start immediately with pangenotypic regimen Treat with genotype specific drugs

MAIN PRISON RECEPTION

Low Prevalence Low risk of transmission

CONNIBEAR DETOX UNIT

High Prevalence High risk of transmission

Yes No

Positive Positive

Harnessing the New Diagnostics

Grebely J, Dore GJ. Antivir Res 2014;104:62–72.

20 mins for Orasure swab 8 weeks for pan-genotypic treatment I hour for Cepheid HCV-RNA

“CONNIBEAR MODEL” 8-9 weeks

1 week for DBS result 1 week for doctor review 1 week for Fibroscan 4 weeks for genotype 1 week for MDT 12-16 weeks for treatment

“TRADITIONAL MODEL” 22-26 weeks

2 weeks for secondary medical review

Simplifying Prison Referrals

• Prison nurse completes

basic information and emails form to ODN

• Details reviewed by

doctor, nurse and pharmacist and treatment approved

• Drugs couriered to prison

pharmacy

• Prisoners commences

treatment without delay

So what are the problems?

• Problems with screening?
• Problems with the authorities?
• Problems with communications?
• Problems with prison staff?
• Problems with data collection?
• Problems with transfers?
• Problems with pharmacy?
• Problems with follow-up?

Thank You

Hepatitis C Good Practice Roadshow

Friday 27th September 2019 West London ODN #hepCwestlondon