The most important lesson we’ve learned during the pandemic is that collaboration and partnership have carried us through. Tracey Kemp, Rebecca John, Helen Hampton, Debbie Moores, William McCully, Simon Morton and Shayon Salehi on how the future looks promising for hepatitis C testing in drug treatment settings.
By the start of 2020, the vital role that drug treatment services (DTS) across England were having in testing and linking individuals with hepatitis C to care was well established. A snapshot taken between September 2019 and February 2020 shows that five national providers were responsible for conducting an average of 6,700 HCV tests per quarter. The well-defined protocols ensured that a positive test was followed up promptly and infected individuals started their journey towards treatment.
HCV is a devastating disease. It accounts for more than 300 deaths in England each year, despite treatment being available. Many of the people dying of HCV-related complications, such as cirrhosis or liver cancer, have a history of drug use. When the World Health Organization (WHO) turned its attention to eliminating HCV as a public health concern in 2016, it was clear that strategies to tackle the high rates of HCV in individuals injecting drugs would be essential.
In England, these essential strategies were underpinned by initiatives conducted in DTS. Service providers and peer-workers understood their clients well and effectively broke down the barriers that may have stopped this at-risk group from accessing healthcare in the past. The success was clear, and it was making a substantial difference to the life of clients. In collaboration, Gilead Sciences and the NHS addictions provider alliance (APA), Change Grow Live, Humankind, We Are With You and Turning Point developed an ambitious programme, Hep C Free, driving the widespread implementation of established best practice pathways with the aim to eliminate HCV across DTS by 2023.
When Covid first hit
When the COVID-19 pandemic hit, testing for HCV and other blood-borne viruses (BBV) slipped rapidly down the list of healthcare priorities. During the first lockdown in England, the priority was the immediate safety of clients and minimising the risk of them becoming infected with coronavirus. The reality was that clients could no longer access the settings that provided the tests that could change their lives. Testing for HCV within DTS was paused. During the first national lockdown between March and May 2020, HCV tests conducted per quarter were down to just over 2,400 – one third of that achieved earlier in the year.
Looking back, Rebecca John from Turning Point acknowledges that the impact on the services provided was understandable given that everyone thought that the lockdown would be short lived. ‘In the future, it’s important to continue pushing the importance of BBV testing and treatment and ensure a culture whereby BBVs are considered a central element to client wellbeing – even during lockdowns.’
After the initial shock caused by the COVID-19 crisis the providers rapidly refocused, Debbie Moores from Humankind explains. ‘With the realisation that the pandemic wasn’t going anywhere soon, we needed to develop a response and a plan. Clinic appointments were used as opportunities to test, and unnecessarily long pathways were shortened to get more people into treatment.’
Regular communication within services and with external organisations such as the HCV operational delivery networks (ODNs), other providers, pharma and the Hepatitis C Trust was essential to allow effective plans to be put in place. The introduction of a virtual forum, part of the Gilead initiative, had a substantial impact. William McCully from Gilead Sciences explains: ‘Through working in partnership with DTS and NHS England, we were able to leverage our collective experience to overcome many of the challenges posed by the pandemic. As a result, we have become stronger partners and established innovative pathways that will continue to have a positive impact on HCV elimination post-pandemic.’ This was reaffirmed by Rebecca John. ‘We learned from each other and reaped the benefits of sharing best practice,’ she says. ‘Without the help of the others, we would not have been able to recover as rapidly.’
Coronavirus forced service providers to think radically about how teams could come together to do things differently. Service users were supported remotely and the approach to HCV testing taken for each individual was based on risk and practicality. Face-to-face screening – which was always the preferred option – was now one of several ways clients could access testing. Self-screening at the centre where individuals could conduct the test themselves appealed to some, but for those unable or unwilling to travel, tests could be distributed by post or by their peers. The number of people being tested started to increase.
A Captive audience
During the pandemic, innovation has abounded. Clinical outreach vans have been successful, bringing test and treat clinics to suitable locations for those patients not currently engaged in services. ‘The absolute biggest lesson for me,’ explains Helen Hampton from We Are With You, ‘was that the captive audience of homeless individuals being temporarily housed was an ideal opportunity for test and treat. We didn’t have to track individuals as they were together, which has the potential to stop the spread of the disease within that group.’
‘Pop-up’ events were also established where staff came together to provide Cepheid testing, an innovative technology for rapid HCV viral load testing. ‘It is now possible for someone who did not know they had HCV to be tested and start treatment within 90 minutes,’ explains Simon Morton from Hep C U Later.
So when it comes to HCV testing now, are the numbers back to pre-pandemic level? The immediate adaptations to service provisions such as incorporating postal testing increased mean tests per quarter to almost 4,000 between September 2020 and February 2021 – an impressive recovery. However, since then numbers have soared – an average of 8,400 HCV tests per quarter have been reported since March 2021, demonstrating how flexibility, thinking differently, sharing best practice and learnings across providers can pay dividends.
The ultimate goal
The past 18 months have been incredibly challenging, but in partnership the DTS have ameliorated the impact of the pandemic. Helen Hampton reflects on her experiences: ‘Elimination will not work in isolation – we need to partner up to work together for the ultimate goal of elimination,’ she says.
Tracey Kemp, from Change, Grow, Live sums it all up. ‘Together we emerge stronger as providers who support people – people who need our help,’ she says. ‘The past 12 months have been extraordinary, but we have worked tirelessly to keep testing alive and treatment pathways active. We look to the future with hope and optimism as we aim to cure more people than ever before from the hepatitis C virus.’
With the remarkable recovery of testing levels beyond those pre-pandemic, the fulfilment of the 2023 elimination goal within DTS looks more attainable than ever, but we need to sustain and build on this momentum to realistically look ahead to a future without HCV.
This article has been created and fully funded by Gilead Sciences Ltd. Medical writing support was provided by Elements Communications