If ever there was an area of healthcare where place-based care could have a major impact on local public health gains it is the identification and treatment of hepatitis C virus (HCV) infected patients. However the same reasons that point to place-based health systems being of value for this condition also make it one of the most difficult challenges to take on. If place-based care can be made to work for treating HCV it can be made to work across the system.
HCV is a blood borne virus that is often asymptomatic, and symptoms may not appear until the liver is severely damaged. As a consequence, many individuals with chronic HCV infection remain undiagnosed and fail to access treatment. These individuals can then present late with complications of HCV-related end-stage liver disease (ESLD) and cancer, which have poor survival rates. In the UK, it is estimated that around 214,000 people are living with chronic HCV. Injecting drug use continues to be the most important risk factor for infection with around half of people who inject drugs (PWID) thought to have been infected in England and Wales. Prevalence of infection varies around the UK and is also higher among other at-risk groups such as black and minority ethnic populations who have close links to countries with a high prevalence of HCV infection. The upshot is that HCV disproportionately affects populations who are marginalised and underserved and have poorer access to healthcare and health outcomes and represents a significant public health issue.
Screening, diagnosis and identification of these patients is currently falling between the gaps of local government and the NHS as the range of public services they deal with are atomised. There is no cohesive or standardised pathway for them and the potential avoided future health and social care costs that are there to be realised through effective treatments are dispersed across budgets. The challenge to place-based care for these patients is lack of effective education and awareness among at-risk populations and the non-medical professionals who support them.
Over the past three years, AbbVie has been working with a range of partners in the NHS and third sector addiction services to trial new ways of working to tackle HCV that offer some clues as to how place-based care could happen for this disease.
This week, the findings of a three year Addaction / The Hepatitis C Trust pilot with services in the South West have pointed to two measures that could help join the dots; peer-to-peer education and addiction services workforce development2.
Volunteer peer educators were trained to deliver a personal message to service users about HCV testing and attendance at hospital appointments. Through talks at various sites across the South West, the peer educators used their personal stories to help dispel fears of the unknown and encourage service users to get tested for HCV following the talk reducing the gap and, if appropriate, enter treatment.
The pilot is believed to be a cost-effective intervention, delivering training on five core messages about HCV awareness and prevention over more than 110 sessions for 806 people accessing Addaction’s services. 70 per cent of attendees indicated their knowledge of the condition had increased massively or a lot. Longitudinal follow-up interviews with attendees indicate that long-term retention of information is good with near universal recall of transmission routes, the role of blood-to-blood contact and treatment. Some of those interviewed indicated they had gone on to get tested as a direct result of the training and a number that they had shared the messages with family, friends and peers. The approach shows promise as a means of spreading HCV awareness, encourage testing and onward referral, as appropriate within a difficult-to-reach community.
Over the course of the programme around 200 Addaction staff members were provided with training to help them confidently discuss HCV with service users, enabling the majority of keyworkers to be in a position to provide informed advice on testing, treatment and sources of help. Evaluation for this aspect showed a very strong increase in reported confidence levels for understanding of symptoms, high-risk behaviours, availability of local services, treatment options and supporting clients. .
Helping at-risk communities better understand the condition and strengthening the ability of local government services to spot and support clients who may be at-risk could have a major impact at every point of this disease. Targeted education is one tool that will underpin place-based care that can have gains in preventative behaviour that reduces transmission through to improving testing and treatment for those that need it.