New strategies for offering hepatitis C treatment to ‘difficult to reach’ patient cohorts in Northern Ireland.

Authors

R O’Kane, O McCormick, K Patterson, G Wasson, A McCurley, N McDougall

Departments / Institutions

Regional Liver Unit, Royal Victoria Hospital, Belfast

Publication Date

Autumn 2018

Introduction

Chronic hepatitis C virus (HCV) infection can lead to cirrhosis and associated complications. The advent of highly effective all-oral HCV treatments has revolutionised the management of HCV and led to discussions regarding the possibility of HCV eradication. In light of treatment advances, the focus of HCV treatment is moving towards identifying and treating ‘difficult to reach’ cohorts.

Methods

The Regional Liver Unit, RVH has modified its traditional outpatient service to target difficult to reach cohorts, namely prisoners and homeless patients.

For the prison cohort, outreach clinics were offered at a single prison site when the prison service identified sufficient patients for review. For the homeless cohort, the Liver Unit liaised with the social services Outreach team and offered rapid access to a “One Stop Shop” (Consultant, nurse specialist, pharmacist, blood tests and Fibroscan all at single visit) within 4 weeks of referral. This initiative began in 2017 due to public health concerns regarding a cluster of new HCV cases in a homeless cohort.

These two interventions were reviewed to determine whether or not they led to a successful outcome (commencing treatment) for ‘difficult to reach’ patients.

Results

Since Autumn 2016, 20 prisoners have been booked in to a hepatology clinic in Maghaberry prison. Three refused to leave their cells, 3 were not able to stay in NI for treatment, and 14 (70%) agreed to treatment (8 already started). An additional 27 prisoners have been referred for treatment of HCV but were released from prison before a clinic appointment could be offered. Seventeen (63%) of the 27 were lost to follow-up, 6 commenced treatment and 4 remain on the waiting list.

For the homeless cohort, 20 patients were referred since the ‘onestop- shop’ began in Sept 2017. Only 6 (30%) engaged with the rapid assessment program and commenced treatment. The remaining 14 (70%) either failed to attend first appointment (8) or became too unstable to start treatment after being assessed (6).

Conclusion

70% of prisoners who are offered assessment while still in prison proceed to receive HCV treatment. However, if the offer of assessment/treatment waits until after release from prison, nearly two thirds are lost to follow-up. Therefore, efforts should be made to offer all HCV positive prisoners treatment before they leave prison.

Similarly, 70% of the homeless cohort fail to engage with a hospital based assessment despite support from Outreach teams and being prioritised for urgent appointments. New strategies delivering assessment in the community will be required to reach this cohort.