Hepatitis C: eliminating the virus among vulnerable communities of drug users and homeless people

There are currently estimated to be around 89,000 people living with the Hepatitis C Virus in England. In May 2016, the UK joined 193 other member states signing the WHO Global Sector Strategy with the aim of eliminating the Hepatitis C Virus by 2025, five years earlier than the WHO 2030 target.

This goal seems achievable with the rollout in 2015 of new effective oral, direct-acting antiviral treatments. However, people living with the virus still need to be urgently identified and treated to achieve Hepatitis C Virus elimination by 2025. Research from Brighton and Sussex Medical School has led to the development of a simplified Hepatitis C Virus care pathway for high-risk populations, particularly people who use drugs and the homeless, and, through this, has played a major role in helping to achieve the national goal of eliminating Hepatitis C Virus by 2025.

Some of the most vulnerable members of the community struggle to engage with secondary care Hepatitis C Virus treatment services

In England, Hepatitis C Virus prevalence is highest in under-served populations such as people who use drugs and the homeless. In Brighton and Hove, in 2016-17, Public Health England identified 2,065 cocaine and opiates users, one in every 300 of the population. In 2019, the homeless charity Shelter stated that one in every 75 members of the local population was homeless. Due to their lifestyle choices, competing priorities and perceived stigma, this vulnerable population does not engage with secondary care Hepatitis C Virus treatment services. With the availability of safer oral antiviral treatments, a novel solution is to move Hepatitis C Virus care from the traditional hospital to community-based sites such as addiction centres and homeless sites. These are the places that are attended by this most at-risk population.

On-going, pioneering work by Professor Sumita Verma and colleagues in BSMS has provided the research-based evidence for the successful delivery of such Hepatitis C Virus care models in community settings within Brighton and Hove. Sumita Verma collaborated with addiction specialists, social workers, peer mentors, GPs, qualitative researchers, health economists, charities and local commissioners, which led to three seminal studies. Results of these studies indicate a doubling of the numbers of people who use drugs and homeless individuals receiving Hepatitis C Virus treatment and halving the numbers with related liver disease mortality.

ITTREAT and VALID studies investigate the feasibility of an integrated Hepatitis C Virus service

The first study, conducted by nurse Mucha Marufu, and supervised by Sumita Verma, assessed the feasibility of undertaking blood borne virus screening at Pavilions, the largest addiction centre in Brighton, with subsequent referral to secondary care. The poor engagement with secondary care in this study highlighted the need for integrated Hepatitis C Virus services within a community setting.

Focusing on ‘one-stop’ care models, Sumita Verma and her team then conducted the ITTREAT study, investigating the feasibility of an integrated Hepatitis C Virus service at Pavilions. Community nurse Margaret O’ Sullivan, with Sumita Verma as supervisor, offered community-based Hepatitis C Virus screening/treatment and non-invasive assessment of liver scarring, working alongside addiction teams, peer mentors and social workers, and delivering a non-judgemental, personalised and holistic service.

ITTREAT was delivered in collaboration with Professor Heather Gage (University of Surrey) who led on the health economics, Dr Chrissie Jones and Professor Helen Smith (University of Brighton) who led on the qualitative analysis and Anna-Marie Jones (Sussex Partnership Foundation Trust) who led on the statistical analysis. The third study, VALID (2015– 2018), evaluated a similar model of care at homeless hostels in Brighton. The project was led by Sussex Research Fellow, Ahmed Hashim, and Verma, in collaboration with Professor Guru Aithal (University of Nottingham), Professor Stephen Bremner (University of Sussex) and Arch Healthcare, the only homeless primary care practice in Brighton.

A good practice care model for replication by Hepatitis C Virus healthcare professionals

These projects increased access to and treatment for Hepatitis C Virus sufferers, linking over 700 homeless individuals and people who use drugs into care services in Brighton and Hove. It improved patients’ HCV care experience and their understanding of the virus, resulting in improved mental and physical health, decreased distress and, most importantly, a reduction in the stigma associated with the Hepatitis C Virus. The research also developed a good practice care model for replication by Hepatitis C Virus healthcare professionals, with NHS England recognizing that ‘the ‘one-stop shop’ model of community service provision provided easy access for clients and provided a great model to replicate around the country’.

Sumita Verma and her team, via the ITTREAT and VALID projects, provided the research-based evidence essential to the development and implementation of this innovative community-based HCV model of care for high-risk populations. This has led to a substantial increase in access to and treatment of Hepatitis C Virus in the Brighton and Hove area, improving the care experience for vulnerable members of the community. It has also provided a robust good practice care model that is now leading the way for further replication of improved care services in England including an adoption of the integrated pathway for drug services by a leading international pharmaceutical company.