Development and optimisation of a reception testing protocol designed to eliminate HCV in the UK prison population.

Background & Aims: Micro-elimination of hepatitis C virus (HCV) in high-risk populations is a feasible approach towards achieving the World Health Organization's targets for viral hepatitis elimination by 2030. Prisons represent an area of high HCV prevalence and so initiatives that improve testing and treatment of residents are needed to eliminate HCV from prisons. This initiative aimed to improve the HCV screening and treatment rates of new residents arriving at prisons in England. Methods: A rapid test and treat pathway was developed and implemented in 47 prisons in England between May 2019 and October 2021 as a healthcare service improvement initiative. Prison healthcare staff performed opt-out HCV testing for all new residents at each prison within 7 days of arrival, and those who were positive for HCV RNA were offered treatment with direct-acting antivirals (DAAs). The Hepatitis C Trust provided peer support for all residents on treatment and those who were released into the community. Results: Of 107,260 new arrivals, 98,882 (92.2%) were offered HCV antibody testing, 63,137 (63.9%) were tested and 1,848 were treated. Testing rates increased from 53.7% in Year 1 to 86.0% in Year 3. Between May 2020 and October 2021, 40,727 residents were tested, 2,286 residents were positive for HCV antibodies and 940 residents were HCV RNA positive, giving an antibody prevalence of 5.6% and an RNA prevalence of 2.3%. A total of 921 residents were referred for treatment and 915 initiated DAA treatment (97.3% of whom were HCV RNA positive). Conclusions: This initiative showed that an opt-out HCV test and treat initiative in prison receptions is feasible and can be adapted to the needs of individual prisons as a viable way to achieve HCV micro-elimination. Impact and implications: Prisons represent an area of high HCV prevalence and so initiatives that improve testing and treatment of residents are needed to eliminate HCV from prisons. The reception testing protocol improved HCV screening in new arrivals across 47 prisons in England and could be a viable way for countries to achieve HCV micro-elimination in their prison systems. The reception testing protocol presented here can be adapted to the individual needs of prisons, globally, to improve HCV screening and treatment in this setting.

Chronic hepatitis C elimination prison initiative: HCV-intensive test and treat, a whole prisoner population HCV test-and-treat program in England.

Background and Aim: Prison residents are at high risk for hepatitis C virus (HCV) infection. HCV test-and-treat initiatives within prisons provide an opportunity to engage with prison residents and achieve HCV micro-elimination. The aim of the prison HCV-intensive test and treat initiative was to screen over 95% of all prison residents for HCV infection within a defined number of days determined by the size of the prison population and to initiate treatment within 7-14 days of a positive HCV RNA diagnosis. Methods: An HCV-intensive test and treat toolkit was developed based on learnings from pilot HCV-intensive test and treat events. From January 2020 to September 2021, 13 HCV-intensive test and treat events took place at prisons in England selected based on high levels of reception blood-borne virus testing and good access to peers from The Hepatitis C Trust. Results: Among a total of 8487 residents, 8139 (95.9%) underwent testing for HCV. Across the 13 prisons included, HCV antibody and RNA prevalence was 8.2% and 1.5%, respectively. The treatment initiation rate among HCV RNA-positive individuals (n = 124) was 79.0%. Conclusion: The HCV-intensive test and treat initiative presented here provides a feasible and rapid test-and-treat process to achieve HCV elimination within individual prisons. The HCV-intensive test and treat toolkit can be adapted for rapid HCV testing and treatment events at other prisons in the United Kingdom and worldwide.

Patient pathway: the ideal approach.

Hepatic encephalopathy (HE) can be a devastating complication of cirrhosis, affecting patients and their families. Multidisciplinary community and specialist teams must work together with patients and their families to recognise HE, identify and treat problems early, and minimise time spent unwell or in hospital. Primary care provides an ideal setting for patient education and reinforcement of the salient points on self-care. In the acute setting, the use of care pathways can ensure that the critical aspects of pharmacological, dietetic and supportive care are offered in a timely fashion to reduce morbidity and mortality. This article discusses strategies that can be used in primary and secondary care to help teams deliver excellent practice in HE management.

Is increased hepatitis C virus case-finding combined with current or 8-week to 12-week direct-acting antiviral therapy cost-effective in UK prisons? A prevention benefit analysis.

UNLABELLED: Prisoners have a high prevalence of hepatitis C virus (HCV), but case-finding may not have been cost-effective because treatment often exceeded average prison stay combined with a lack of continuity of care. We assessed the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies. A dynamic HCV transmission model assesses the cost-effectiveness of doubling HCV case-finding (achieved through introducing opt-out HCV testing in UK pilot prisons) and increasing treatment in UK prisons compared to status quo voluntary risk-based testing (6% prison entrants/year), using currently recommended therapies (8-24 weeks) or interferon (IFN)-free direct-acting antivirals (DAAs; 8-12 weeks, 95% sustained virological response, £3300/week). Costs (British pounds, £) and health utilities (quality-adjusted life years) were used to calculate mean incremental cost-effectiveness ratios (ICERs). We assumed 56% referral and 2.5%/25% of referred people who inject drugs (PWID)/ex-PWID treated within 2 months of diagnosis in prison. PWID and ex-PWID or non-PWID are in prison an average 4 and 8 months, respectively. Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/quality-adjusted life years gained compared to current testing/treatment and is 45% likely to be cost-effective under a £20,000 willingness-to-pay threshold. Switching to 8-week to 12-week IFN-free DAAs in prisons could increase cost-effectiveness (ICER £15,090/quality-adjusted life years gained). Excluding prevention benefit decreases cost-effectiveness. If >10% referred PWID are treated in prison (2.5% base case), either treatment could be highly cost-effective (ICER<£13,000). HCV case-finding and IFN-free DAAs could be highly cost-effective if DAA cost is 10% lower or with 8 weeks' duration. CONCLUSIONS: Increased HCV testing in UK prisons (such as through opt-out testing) is borderline cost-effective compared to status quo voluntary risk-based testing under a £20,000 willingness to pay with current treatments but likely to be cost-effective if short-course IFN-free DAAs are used and could be highly cost-effective if PWID treatment rates were increased. (Hepatology 2016;63:1796-1808).

Can antiviral treatment for hepatitis C be safely and effectively delivered in primary care?: a narrative systematic review of the evidence base.

BACKGROUND: The burden of hepatitis C (HCV) treatment is growing, as is the political resolve to tackle the epidemic. Primary care will need to work more closely with secondary care to succeed in reducing the prevalence of chronic HCV. AIM: To identify research relating to the provision of antiviral treatment for HCV in primary care. DESIGN AND SETTING: A narrative systematic review of six databases. Method Medline, Embase, Cinahl, PsycINFO, Web of Science, and Cochrane were searched. Relevant journals were searched by hand for articles to be included in the review. Reference lists of relevant papers were reviewed and full-text papers were retrieved for those deemed to potentially fulfil the inclusion criteria of the review. RESULTS: A total of 683 abstracts led to 77 full-text articles being retrieved, of which 16 were finally included in the review. An evidence base emerged, highlighting that community-based antiviral treatment provision is feasible and can result in clinical outcomes comparable to those achieved in hospital outpatient settings. Such provision can be in mainstream general practice, at community addiction centres, or in prisons. GPs must be trained before offering such a service and there is also a need for ongoing specialist supervision of primary care practice. Such training and supervision can be delivered by teleconference, although, even with such ready availability of training and supervision, only a minority of GPs are likely to want to provide antiviral treatment. CONCLUSION: There is emerging evidence supporting the effectiveness of antiviral treatment provision for patients with chronic hepatitis C in a wide variety of primary care and wider community settings. Training and ongoing supervision of primary care practitioners by specialists is a prerequisite. There is an opportunity through future research activity to evaluate typologies of patients who would be best served by primary care-based treatment and those for whom hospital-based outpatient treatment would be most appropriate.