How community care is helping to eliminate Hepatitis C
Professor Sumita Verma, a consultant hepatologist with Brighton and Sussex Medical School and Brighton and Sussex University Hospitals, has created a community-based approach to treating Hepatitis C in people who are homeless or with drug addictions. Its success is changing - and saving - lives.
Hepatitis C (HCV) is a virus that can cause serious and potentially life-threatening liver damage over many years. It affects 71 million individuals globally.
Since the introduction of direct-acting antiviral medication in 2014, with cure rates close to 100%, the World Health Organization (WHO) aims to eliminate the disease by 2030.
But the challenge for healthcare workers has been how to reach those infected. Of the 113,000 cases with chronic HCV infection in the UK, an estimated 70% remain undiagnosed and untreated.
Professor Sumita Verma, a consultant hepatologist with Brighton and Sussex Medical School and Brighton and Sussex University Hospitals, has been working with people in Brighton who use drugs or are homeless to create a community-based approach for those with Hepatitis C.
Her research has led to a dramatic improvement not just in identifying and treating those with the illness, but in creating a model for treatment that has been commended by Public Health England, the National Health Service and liver disease charities.
Injecting drug users at highest risk
Brighton has the fourth highest homelessness population in the UK, with one in 500 individuals in the city in drug treatment. Half of those in these populations have HCV.
Injecting drug users are at the highest risk of contracting the virus, many of whom are also homeless. They remain a vulnerable group and are unlikely to seek hospital treatment, says Verma.
“These individuals already have a very high prevalence of mental health issues, alcohol use disorder and spells in prison,” she points out. “They just don’t engage with hospitals. They have seen them as places where they would go to die.
“But the disease is dangerous because if you don’t treat it, up to a quarter can develop irreversible scarring of the liver with risk of developing potentially life-threatening complications. The virus also causes non-liver problems, including cognitive impairment, fatigue, kidney and skin problems.”
In addition, she says individuals with HCV feel stigmatised, which remains a major barrier to engagement. “Patients who have HCV feel unclean, they feel that they can’t get into a relationship, that they can’t tell their partners about it. It’s a complex issue.”
Before the advent of the new direct-acting antivirals, treatments not only caused significant side effects – such as mental health problems – but also had low cure rates. This exacerbated the difficulty of identifying those with the illness and encouraging them to attend hospital clinics.
In 2013 Verma developed a new, community-based approach in Brighton and Hove. It began with an experienced hepatitis nurse working full time at a community drug and alcohol treatment centre offering clients HCV screening blood tests. If the results were positive, a consultation was set up with a hospital hepatologist.
In the first stage of the programme, 40 clients were identified with the disease and referred to hospital, but only two turned up for appointments.
A one-stop care model
“This confirmed something we had increasing become aware of – that this model wasn’t going to work,” says Verma. “We realised that we had to create a model in which everything was based in the community – a ‘one-stop’ care model.”
Two projects – one based at the Drug and Alcohol Treatment service in Brighton (Integrated Test stage TREAT, or ITTREAT), and one based at a homeless hostel (Vulnerable Adults Liver Disease study, or VALID 2015-2018) - were created. “We provided all aspects of care in the community; the screening, the treatment, scanning for liver scarring, counselling, psychiatric support, peer support. And it worked like a charm,” says Verma.
The results have been outstanding. Brighton now has the third highest rates of individuals in drug misuse services across England. Between 2014 and 2018, 96 received HCV testing, with HCV cure rates of approximately 90%. Mortality from HCV-related liver disease in Brighton has reduced by 48% (compared to less than 20% nationally). While some of this reflects the effectiveness of the new anti-viral treatments, the community-based model of care has also most likely contributed.
Verma says: “We have shown a reduction in mortality and an improved quality of life after HCV cure in this cohort that has not been shown before.
“These projects can be delivered at a modest cost, although we cannot do a cost comparison because, previously, we were not treating HCV in people who were actively injecting drugs or drinking alcohol. They were perceived as not likely not to comply with treatment. Now, as long as they are engaged and motivated, we say we’ll treat you.”
Because individuals can get re-infected with HCV, Verma says it was important not just to treat them but to also provide opiate substitution treatment and harm reduction strategies. “It has to be a complete package because if you are just focusing on treating HCV, it’s not going to work.”
The research has now been extended to Hastings and Chichester, and Verma hopes it can be rolled out nationwide.
For all involved, it has been a highly rewarding experience, both professionally and personally.
“I have to admit that it was not easy when we started,” she says. “There was a lot of scepticism and nihilism. But we were really keen to treat these individuals, even if they were injecting drugs or drinking alcohol. There is so much judging of these individuals, but if you hear their stories you know that so many of them have been failed by society already. By denying them HCV treatment, we would be failing them again.”
She says those who have received treatment in their community have commented on how they prefer the personalised care they receive over attending hospitals, where they don’t feel they deserve to receive treatment because they perceive their illness as self-inflicted.
With WHO’s pledge to eliminate HCV by 2030, Verma’s work is recognised as a significant step towards achieving that goal.
“I’m delighted that we have been commended by Public Health England and NHS England, and that people are now wanting to know about our success,“ she says. “As for HCV, if we successfully eliminate this virus, this is going to be one of the first infectious diseases to be eliminated without a vaccine. From my viewpoint as a hepatologist, that’s amazing.”
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