Hepatitis C case-finding – An opportunity for community pharmacy Paul Selby Lead Pharmacist, Eastern Hepatitis Network ODN

Eastern Hepatitis Network ODN Cambridgeshire & Peterborough Addenbrooke’s Hospital Peterborough City Hospital HCV Prevalence approximately 0.2% of poulation Over 2,300 patients treated with new direct-acting antivirals (network-wide) 30,000 patients treated nationally (on database; December 2018 - PHE)

Eastern Hepatitis Network ODN Hub Sub-hub Treatment Centre

Hepatitis C (HCV) Hepatitis C (HCV) is A blood-borne virus, spread mainly through blood-to-blood contact HCV can damage the liver, potentially causing cirrhosis and primary liver cancer 85% of those exposed go on to develop chronic HCV Chronic HCV leads to cirrhosis or liver cancer in 20% of patients over 10-30 years1 1. The Pharmaceutical Journal, Vol 299, No 7907, online | DOI: 10.1211/PJ.2017.20203548

HCV Treatments New treatments work by inhibiting viral replication Usually 2 or more different modes of inhibition are used in combination Treatment length is 8-12 weeks for the majority of patients although some patients may need longer treatment Treatment success (‘SVR12’) is >90% with various combinations for different genotypes Treatments are now oral only– no injections

Hepatitis C: Elimination WHO has a target to eliminate HCV by 20301 NHS England has a target to eliminate HCV by 20252 Goal: 90% of ever-infected patients treated Already achieved: 16% fall in deaths due to HCV3 39% fall in liver transplants due to HCV3 focused action to meet our commitment to reduce the incidence of chronic HCV infection by 80% and HCV mortality by 65% by 2030 at the latest. modelled estimates that suggest at least 53% of the ever chronically infected population had been diagnosed or successfully treated by 2018. While the first WHO target of 50% being diagnosed by 2020 has been met in England, more needs to be done if we are to reach the 90% target by 2030. 1. World Health Organisation (2016). Combating Hepatitis C and B to reach elimination by 2030. Geneva: WHO Press. 2. NHS England. NHS England sets out plans to be first in the world to eliminate Hepatitis C. NHS England, 2018 [29/01/19]. Available from: https://www.england.nhs.uk/2018/01/hepatitis-c-2/ 3. Public Health England. Hepatits C in England: 2019 report. London, 2019. Available from: https://www.gov.uk/government/publications/hepatitis-c-in-the-uk

Treatment outcomes Content removed

Patient experience

Hepatitis C: Elimination Not achieved: 113,000 people still chronically infected nationally1 People who inject drugs (PWID) is the most common risk factor (90%) 53% PWID are unaware of HCV status1 Significant barriers for patients accessing testing and treatment 1. Public Health England. Hepatits C in England: 2019 report. London, 2019. Available from: https://www.gov.uk/government/publications/hepatitis-c-in-the-uk

Identifying and treating patients Test Work-up/ approval Treat ~12 weeks 8- 16 weeks Test Work-up/ approval Treat Drug & Alcohol treatment centres Prisons GP Surgeries Hospital (IP/ OP) Operational Delivery Networks (ODNs) Hospital (IP/ OP) ‘Outreach clinics’ e.g D&A services Supply: Hospitals Community Pharmacies

HCV Testing Antibody test shows if patient ever had HCV infection HCV RNA shows if the virus is still present HCV Genotype tells us more about the virus and directs treatment

Pilot schemes Hepatitis C testing in Isle of Wight LJWG phase I LJWG phase II DOT-C Super DOT-C EHN Pharmacist Clinic

Verma S, LJWG (2018). HCV testing in NSP Community Pharmacies Pilot Phase I. London. Availble: http://ljwg.org.uk/wp-content/uploads/2018/05/LJWG-Pharmacy-Testing-Phase-1-final-report-.pdf

Location of care

Location of care

The Future Service expansion for hepatitis C Testing is key to get patients into services Testing at needle exchange centres Testing of OST Testing of at risk populations Increase public knowledge Commissioning of services will be important Commissioning of treatments prevents community pharmacy dispensing (for now) Improve links with secondary care providers Commissioned Testing only at pilot stages EHN aiming to expand Increase public awareness of knowledge Increase pharmacy knowledge ready to act on commissioning changes

Future Model Test Referral / Work-up Supply Treat Community Pharmacies ODNs/ Secondary care ODNs/ Secondary care Hospital GP Surgeries (genotyping) Community Pharmacies? Community Pharmacies D&AAS Prisons GP Surgeries Hospital clinic ‘outreach’ clinic NHS England target to eliminate hepatitis C by 2025 Community pharmacy tests patient GP completes screening (genotype) Specialist centre approves treatment Patient receives treatment via community pharmacy and monitored in primary care Treatment with pan-genotypic

What next? Awareness – briefing document; help patients understand risks, treatments and ease of testing Engagement – service design; testing pilots www.easternliver.net Email: add-tr.hepatitis@nhs.net Twitter: @EofEliver Blood transfusion ‘scandal’