Increased diagnosis and treatment of hepatitis C in prison by universal offer of testing and use of telemedicine

Abstract

Summary With recent advances in antiviral therapy, there is an opportunity to eliminate hepatitis C virus (HCV) from the UK population. HCV is common in incarcerated individuals, with previous estimates suggesting ~7% of the UK prison population is anti‐HCV antibody positive. Increasing diagnosis and treatment of HCV in prison is a priority in seeking to eliminate transmission in the general population. Thus the study aimed to assess the impact implementation of: (a) A universal offer of blood borne virus testing (UOBBVT) using dry blood spot testing for prisoners at reception to increase diagnosis; (b) Telemedicine clinics (TC) within North East England (NEE) prisons to increase HCV treatment rates. UOBBVT was initially implemented at Her Majesty's Prison (HMP) Durham, commencing March 2016. From March 2016 to February 2017, 2831 of 4280 (66%) new receptions were offered blood borne virus (BBV) testing. Of these, 1495 (53% of offered) accepted BBV testing, of whom 95 (6.4%) were HCV antibody positive, with 47 of those 95 (49.5%) HCV RNA positive, suggesting a prevalence of active infection in the tested population of 3.1% (95% CI 2.4%‐4.2%). Between August 2015 and October 2017, 80 individuals were seen in the TC and 57 (71%) commenced antiviral therapy. Of those with known outcome (n = 29), 100% achieved sustained virological response. In the year prior to implementation, only four patients received HCV treatment. In conclusion, a universal offer of BBV testing to inmates presenting at HMP reception coupled with linkage into specialist care via TC can substantially increase rates of testing, diagnosis and treatment of HCV in this high‐prevalence population.

High rate of hepatitis C reinfection following antiviral treatment in the North East England Prisons

“…In this review, we have demonstrated a high percentage of initiation of HCV treatment (71%) following diagnosis of active HCV within the NEE prisons using a treatment pathway that incorporates nurse‐led in‐reach and consultant delivered telemedicine clinics. This represents a large increase when compared with previous treatment data in our prisons (14%) and data reported elsewhere . However, approximately 30% of HCV viraemic individuals still do not commence antiviral treatment, mainly due to short sentences.…”

“…Following a pilot in HMP Durham and HMP Northumberland beginning in March 2016, all seven NEE prisons had fully operational UOBBVT and HCV treatment pathways by April 2017. All BBVT was conducted using dry blood spot testing (DBST) and tested for HCV, HBV and HIV as previously described . Individuals in receipt of a positive HCV RNA result on the DBST were reviewed in Prison Healthcare and had a venous sample taken to confirm active infection using HCV RNA along with other pre‐treatment blood tests, such as genotype.…”

“…Individuals in receipt of a positive HCV RNA result on the DBST were reviewed in Prison Healthcare and had a venous sample taken to confirm active infection using HCV RNA along with other pre‐treatment blood tests, such as genotype. Any individuals confirmed as being HCV RNA positive were referred to the treatment pathway, which involved an assessment with the viral hepatitis nurse in the prison, followed by consultant review via telemedicine as previously described . Following discussion in the multidisciplinary team meeting (MDT), patients were offered DAA treatment in line with NHS England recommendations.…”

“…This has become a realistic target given the wide availability of direct‐acting antiviral drugs (DAA), with which, more than 95% of HCV‐infected individuals treated with an 8‐ or 12‐week course of a once a day oral combination of DAAs achieve a sustained virological response (SVR), defined as a HCV RNA negative test 12 weeks post‐treatment . A particular focus of elimination efforts has been to address the burden of infection in the prison population, which has an estimated HCV prevalence of 3%‐7%, much higher than the general UK population (0.5%) . The high prevalence of HCV in prisons is explained principally by the fact that an estimated 60% of injecting drug users have been incarcerated at some point during their lives, and 68% of individuals in prison have injected drugs within the last year …”

“…In March 2016, a formally commissioned universal offer of blood‐borne virus testing (UOBBVT) programme and a new treatment pathway using consultant‐led telemedicine clinics and nurse‐led in‐reach were introduced to Her Majesty's Prison (HMP) Durham and HMP Northumberland. This led to a substantial increase in BBV testing (164 to 1495/year) and a high treatment initiation for those with active HCV . Following this successful pilot, the UOBBVT programme and new treatment pathway were rolled out to all seven NEE prisons by April 2017 and a similar BBVT uptake has been seen.…”