HCV elimination: when the incarcerated hold the key
In the battle against hepatitis C, prisons are on the front line. But to Consultant Hepatologist and Operational Delivery Network Lead, Dr Stuart McPherson, they are not a threat but instead places of opportunity.
Dr Stuart McPherson has a lofty ambition for his network: to be the first in England to eliminate HCV. It’s a tall order but, even in a region with traditionally patchy service provision, his team is well-placed to do it.
Dr McPherson has been a Consultant Hepatologist at Freeman Hospital in Newcastle since 2010. Today he’s also Lead for the North East & Cumbria Operational Delivery Network (ODN), coordinating HCV care across the entire region.
Achieving his goal will take a step-change in care. But despite setbacks along the way, it’s a task he relishes.
See more about Dr McPherson’s work and his team's progress here
A circulating threat
Treatment may have improved but hepatitis C (HCV) is a common infection with many infected individuals remaining undiagnosed. Local incidence appears to be rising: new positive antibody test reports leapt from 239 to 630 in the two years to 20181 and chronic infections could follow suit.
Around 7,400 people within North-East England (NEE) and Cumbria are already living with HCV, more than 8% of them with cirrhosis.2
Prevalence is particularly high in areas such as in Teesside,1 where access to treatment has been inconsistent. A 2018 study of local drugs service users with HCV showed that as few as 20% (858 of 4,243) were being treated (as they are likely to have been receiving treatment for their addiction given they are attending a drug treatment service for their HCV infection).3
With a potential health time bomb on their hands, the team searched for ways to improve uptake of testing and treatment.
Prison shows promise
One avenue showed most potential: working with prisons and young offenders’ institutions (YOI). 68% of incarcerated individuals have injected drugs within the previous year meaning a proportion are at risk of being infected with hepatitis.4 HCV transmission is therefore a concern in prison.5
It’s perhaps no surprise that 20 times more UK prisoners have come into contact with HCV than the general population.4
While positivity rates seen were high, testing and appointment attendance rates in the region’s prisons had always been low.4 For Dr McPherson, the setting was ideal: as well as making locating patients relatively simple, prison offered a supportive environment to deliver treatment.
Realising they had a golden opportunity, the team made a plan and set to work.
Making testing less testing
Universal opt-out blood borne virus testing (BBV) on arrival – introduced across all NEE prisons from 20164 – was a positive move. However, convincing prisoners to accept it was another matter.
Back then it was routine to use venepuncture to take blood, which was understandably unpopular with prisoners. Obtaining samples from those most at risk of infection – people who had injected drugs4 – could also be difficult.
To improve HCV test uptake, the team piloted an offer of dry blood spot (DBS) antibody testing to all new inmates at HMP Durham, a remand prison with high throughput of prisoners.4
Samples were sent for analysis and, once results returned, inmates testing negative were given harm minimisation advice, while the DBS samples from those testing positive underwent reflex HCV RNA testing. If the virus was detected, a blood sample was collected from the prisoner for determination of their genotype and viral load and they were then linked to the prison’s antiviral treatment pathway.
Telemedicine helps treatment
The new HCV treatment pathway is not only robust but also innovative – with new, consultant-led telemedicine clinics.4
After a successful pilot at HMP Northumberland, all patients with HCV RNA detected on DBS are now reviewed by a viral hepatitis nurse at a prison in-reach clinic. They then undergo a full pre-treatment medical examination including medical history, blood tests and liver imaging (using ultrasound and transient elastography).4
Confirmed HCV RNA positive patients are seen by a hepatology consultant via video conference link, except in complex or challenging cases.4 "Reviewing patients over a video link is a good and efficient way of seeing patients with hepatitis C to enable them to access antiviral treatment," says Dr McPherson. “You could speak to them over the telephone, but it is much more personal if you can see them – you could do it on an iPad; I could do it on my mobile phone.”
Safeguarding health, saving time
With thousands of patients on Dr McPherson’s list, using telemedicine makes the best use of time and resources, he says.
A nurse sits with each inmate in the prison, while he connects remotely from wherever else he needs to be. “I rely very much on the nurses looking after them,” he says. “It is so quick – because [the nurses] have done all the blood tests prior to the clinic, the consultation can be very focused on the key aspects of their care."
After assessment, the regional multidisciplinary team (MDT) discusses each inmate and makes a go/no-go treatment decision, before direct-acting antivirals (DAAs) are prescribed in line with NHS England recommendations.4 Prison staff then take care of most of the monitoring.6
The majority of cases are uncomplicated but even more complex cases could be dealt with remotely with support in place, Dr McPherson believes: "There are some inmates that we discuss in the MDT who I really need to see... they can usually be seen via telemedicine whereas previously they would have had to come to hospital."
From pilot to practice
Results from the HMP Durham testing pilot were very encouraging. Among the 2,831 new receptions offered BBV testing between March 2016 and February 2017, more than half (53%) accepted, and active infection prevalence was 3.1%.4
The team’s BBV testing approach is now standard throughout the region, with 83% of around 19,000 new receptions offered a test so far.1 Prison telemedicine has also been a success story.
In the HMP Northumberland pilot, over 70% of prisoners (57/80) assessed remotely started antiviral treatment with DAAs and, where outcomes were known (n=29), 100% achieved sustained virologic response (SVR).4
Across 7 prisons, satisfaction with the telemedicine clinics is high (80% of inmates rated them “good” or “excellent”), and time from test to treatment is typically under 4 weeks.6 Some 71% of RNA-positive inmates identified (266/374) have commenced DAAs and, of those with a known outcome, 87% have achieved a cure.7
Cured, and more: individual successes
Every patient cured of HCV is worth celebrating. However, for Dr McPherson, some cases stand out.
One inmate, originally diagnosed in a drug treatment service in 2013, managed only 4 weeks of pegylated interferon (PEG-IFN) and ribavirin (RBV) before discontinuing due to side effects. He spiralled into depression, drank increasingly heavily and ended up in prison. But the support he found there gave him the strength to try again. After assessment in a prison HCV clinic in 2017, he completed treatment with a DAA and achieved SVR.1
Another inmate with HCV has even gone on to help others. He was diagnosed in 2009 and had tried unsuccessfully to clear the virus with PEG-IFN and RBV twice. In 2017 he was re-tested in prison, treated with a DAA and finally achieved SVR in 2018. It proved to be the springboard he needed – he’s now a substance misuse support worker.1
“Often they don’t think anyone cares about them,” says Dr McPherson. “To get attention from a caring viral hepatitis nurse who takes the time to go through everything with them, and shows them that they are actually important, is very good.”
To eliminate, innovate
Dr McPherson firmly believes that to eliminate the disease, new thinking on testing is vital.
He is now working to introduce rapid point-of-care testing using oral swabs, with polymerase chain reaction (PCR) testing in antibody-positive cases, to further cut the time between diagnosis and treatment.
Dr McPherson also wants to skip pre-treatment genotyping and any unnecessary scans for most patients – but cautions that determining the best course of action for some does require an experienced eye.
“If someone had cirrhosis, for example, then you probably do need someone who can take some blood from the inmate, and they need an ultrasound to make sure they don’t have liver cancer,” he says. “In situations like that, you do need that experienced team to push hard to do those investigations.”
Turn potential into progress
With a “very ambitious” NHS England elimination target of 2025 to meet, Dr McPherson believes it is time to shake up HCV care and treatment.
Healthcare teams taking a softer approach will have to shift their focus towards maximising numbers treated, he argues. “It is important that you don’t forget that they are individuals, and not just a number,” Dr McPherson says. “But if you are trying to eliminate an infection and you have many thousands to treat, we do have to move forward.”
Find out more
See more about Dr McPherson’s work here
This article and video were produced and funded by Gilead Sciences Ltd in collaboration with Dr Stuart McPherson. The views expressed in this video are Stuart’s own and reflect his personal experiences.
BBV = blood-borne virus; DAA = direct-acting antiviral; DBS = dry blood spot; HCV = hepatitis C virus; HMP = Her Majesty’s Prison; MDT = Multidisciplinary team; NEE = North-east England; ODN = operational delivery network; PEG-IFN = pegylated interferon; PCR = polymerase chain reaction; RBV = ribavirin; RNA = ribonucleic acid; SVR = sustained virologic response; YOI = young offenders’ institution.
- McPherson S, personal communication.
- Public Health England. Hepatitis C: Operational Delivery Network (ODN) profile tool. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/727758/ODN_Area_HCV_Profile_Tool_July_2018.xlsx. Accessed June 2020.
- Simpson H et al. J Public Health (Oxf) 2019;41(4):700−706.
- Morey S et al. J Viral Hepat. 2019;26(1):101–108.
- Crowley D et al. Harm Reduction J. 2018;15:62.
- McPherson S. Poster presented at the BSG Annual Meeting 2019. Glasgow, 17–20 June 2019.
- Bhandari R et al. J Viral Hepat 2019; doi: 10.1111/jvh.13240. [Epub ahead of print].
This article is fully funded and developed by Gilead Sciences Ltd.
UK-HCV-2020-03-0031 • Date of Preparation: June 2020