Real‐world outcomes of rapid regional hepatitis C virus treatment scale‐up among people who inject drugs in Tayside, Scotland

Abstract

Summary Background In 2017, Tayside, a region in the East of Scotland, rapidly scaled‐up Hepatitis C Virus (HCV) outreach and treatment among People Who Inject Drugs (PWID) using novel community care pathways. Aims We aimed to determine treatment outcomes for PWID during the scale‐up against pre‐determined targets; and assess re‐infection, mortality, and post‐treatment follow up. Methods HCV treatment was delivered in community pharmacies, drug treatment centres, nurse‐led outreach clinics, prisons, and needle exchanges, alongside conventional hospital care. We retrospectively analysed clinical outcomes and compared pathways using logistic regression models. Results Of 800 estimated HCV‐infected PWID, 718 (90%) were diagnosed. 713 treatments commenced among 662 (92%) PWID, delivering 577 (81%) Sustained Virologic Responses (SVR). SVR was 91% among those who attended for testing. Forty‐six individuals were treated more than once. Needle exchanges and community pharmacies initiated 49% of all treatments. Regression analyses implied pharmacies had superior follow‐up, but there was no difference in likelihood of achieving SVR in community pathways relative to hospital care. Re‐infection occurred 39 times over 256.57 person years (PY), yielding a rate of 15.20 per 100 PY (95% CI 10.81‐20.78). 54 deaths occurred (29 drug related) over 1,553.04 PY, yielding a mortality rate of 3.48 per 100 PY (95% CI 2.61‐4.54). Drug‐related mortality was 1.87 per 100 PY (95% CI 1.25‐2.68). Conclusions Rapid HCV treatment scale‐up to PWID in community settings, whilst maintaining high SVR, is achievable. However, other interventions are required to minimise re‐infection; reduce drug‐related deaths; and improve post‐SVR follow‐up testing regionally.

Improved health‐related quality of life after hepatitis C viraemic clearance among people who inject drugs may not be durable

“…Since the introduction of DAAs in 2014, a considerable number of HCV-infected PWID have been treated in Scotland [5] and in other countries. For example, community-based pathways have facilitated scale-up of DAA treatment among individuals who actively inject drugs, particularly in Scotland's Tayside region where there is evidence of a substantial reduction in the population prevalence of HCV among PWID [6][7][8]. Therefore, the impact on QoL from successful antiviral treatment (i.e.…”

Laying the foundations for hepatitis C elimination: evaluating the development and contribution of community care pathways to diagnostic efforts

“…Screening within the conventional healthcare pathways – primary and secondary care – showed a large volume of testing without a corresponding large proportion of cases diagnosed which suggests these pathways were not effectively reaching the primarily infected population which, in Tayside, is known to be PWID [ 10 ]. Through developing community pathways embedded within environments frequently accessed by PWID, Tayside has been able to bring targeted low-threshold diagnosis to most HCV-infected people in the region, thereby effectively laying the foundations for work which was recently shown to have led to the substantive elimination of HCV as a public health threat in the area [ 6 , 21 ].…”

“…At the end of the study period, immediately prior to the treatment scaleup phase among PWID in Tayside (reported elsewhere) [ 6 ], HCV testing and treatment with DAAs was available through primary care/secondary care; drug treatment services; needle and syringe provision (NSP) sites, community pharmacies; and the prison estate, aligned with national guidelines [ 19 ]. The functional features of these pathways are outlined in Fig.…”

“…Concurrent to the rapid adoption of this new approach, underpinned by a community-embedded care ethos, and access to safe, effective, DAAs, National Health Service (NHS) Tayside, a large health board in the East of Scotland, initiated a natural experiment of diagnosis and treatment of HCV with the aim of facilitating elimination of HCV as a public health threat in the region [ 5 ]. Initial results from the treatment phase of this work suggested the programme had achieved its aims of diagnosing and treating most chronically infected People Who Inject Drugs (PWID) in the area, who represented the primary infected population [ 6 ]. Prior to this treatment phase (2017–20), multiple decentralised diagnostic care pathways were iteratively developed to improve outreach to potentially infected individuals in the region.…”

Can Telemedicine Optimize the HCV Care Cascade in People Who Use Drugs? Features of an Innovative Decentralization Model and Comparison with Other Micro-Elimination Strategies

“…Compared to conventional pathways, this management strategy has been able to produce a greater number of diagnoses as well as simplify the initiation and completion of numerous antiviral treatments. A subsequent analysis also demonstrated how SVR rates are comparable to those obtained through other HCV care pathways (conventional hospital care, drug treatment centers, needle exchanges, nurse-led outreach clinics, and prisons) [ 44 ].…”