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Though we have improved detection of hepatitis C in recent years, we could be doing much better at getting people into treatment. Euan Lawson outlines the issues. Ed.


weighting toward IDUs has meant that the two biggest areas that have been identified in a public health response are: 1) providing access to sterile injecting equipment and 2) offering opiate substitution therapy to reduce or stop infection. These have both been shown to be effective measures. The effectiveness of the public health approach, led by the 2004 Hepatitis C Action Plan4


is less clear.


A recent study has looked at the impact of this plan and there has been little change in anti-HCV prevalence among recent initiates over the period – it has remained the same in 20085


. This also fits


with the outcomes from a recent paper in the Journal of Infectious Diseases6


.


Hepatitis C: individual aspects of a public problem


The problem with hepatitis C is that everyone knows it is a large public health problem but this doesn’t necessarily reflect the attitudes and behaviours of individuals. One might think that the numbers would speak for themselves – the Health Protection Agency estimates there are around 250,000 infected in the UK but some estimates have suggested the prevalence could be as high as 466,0001 2


. Yet, the issue of


hepatitis C virus (HCV) infection in the UK seems to have had very little impact on the consciousness of general practice beyond those services and clinicians with a specific interest in substance misuse. Overall, we are managing to detect more HCV but the number of individuals heading through into treatment remains very low: there are 13,000 new cases of hepatitis C infection in the UK per year yet we are only treating around 5,000 (half of whom will be successful in eradicating the virus)3


.


We know that the majority of hepatitis C infections are found in injecting drug users (IDUs) with an estimated 90% of infections in this group. This heavy


1 Health Protection Agency (2009) Hepatitis C in the UK: Annual Report 2009 London:


2 The Hepatitis C Trust and the University of Southamp- ton (2005) Losing the fight against hepatitis C London


3 The All Party Parliamentary Hepatology Group (2010) In the dark. An audit of hospital hepatitis C services across England London.


A cohort of IDUs in Baltimore followed since 1988 showed a decline in HIV – dramatically illustrated by the fact that not a single new HIV infection occurred within the first year of follow-up in the cohorts recruited from 1998 onwards. This has not been the case for HCV. There were some modest reductions in the HCV incidence and prevalence in the same period amongst younger and new initiates to injecting. However, older injectors and those with longer injecting histories still had practically the same HCV burden.


Individual attitudes and behaviours


There is evidence in a recent study in the States that highlighted nearly a quarter of young IDUs still shared needles and syringes and two-thirds shared other equipment at some time7


. However,


there was a significant reduction in these numbers if their injecting partner was known to be HCV positive. It highlights the point that individuals aren’t utterly self-destructive – they will modify their behaviour when necessary. Importantly, this study also pointed out that there was no difference when the injecting partner was HCV negative or when they simply didn’t know the HCV status of the injecting partner. This points toward the importance of detecting HCV and advising IDUs of their status – even if they choose not to be referred for treatment.


We need to remember just how poorly IDUs are engaged with health services in general. One predominant theme when drug users are interviewed about


4 Department of Health (2004) Hepatitis C Action Plan for England


5 Hope V, Parry JV, Marongui A, Ncube F (2011) Hepatitis C infection among recent initiates to injecting in England 2000-2008: Is a national hepatitis C action plan making a difference? J Viral Hepatitis 2011. Available online ahead of publication.


6 Grebely J, Dore GJ (2011) Prevention of hepatitis C vi- rus in injecting drug users: a narrow window of opportunity J Inf Diseases 2011;203:571-574


7 Hahn JA, Evans JL, Davidson PJ, et al (2010) Hepatitis C virus risk behaviours within the partnerships of young injecting drug users Addiction 2010; 105: 1254-1264


8


health care is that they often feel they have difficulty accessing care and they perceive hostility towards them when they do. As a consequence they have low expectations of health care and it is perhaps not unduly surprising that a positive hepatitis C result doesn’t significantly change this for many people8


. It isn’t realistic to expect a


positive test to transform someone’s attitude to health services – particularly when the treatment is lengthy, requires regular monitoring, is associated with multiple side effects and the individuals may have poor social support.


A couple of papers have looked at the attitudes of nurses and family doctors to the provision of hepatitis C care. A survey of Canadian family physicians showed that those who were involved were more likely to be older males, who practice in a rural setting, have IDUs in their practice and have higher levels of knowledge about the initial assessment9


.


This leads on to the authors’ suggestions that educational programmes need to target those likely to provide HCV care – i.e. family physicians in urban areas and those who don’t treat IDUs. A survey of nurses’ attitudes found, encouragingly, that nurses hold compassionate attitudes to people with hepatitis C irrespective of how the virus had been acquired10


.


However, it is not all rosy as the study showed that nurses employ differing infection control practices when caring for a client with known hepatitis C and these were felt to reflect negative stereotypes and caring attitudes.


Shifting toward an individual approach


Hepatitis C is an escalating problem and detection and diagnosis of the disease is clearly a fundamental step. However, it is just a step and we need to start thinking harder about how we will translate increased detection into increased treatment. It is crucial to consider how we engage individuals with the virus and it will be necessary to work out how we best engage individual clinicians in wider general practice beyond those already involved in substance misuse.


Euan Lawson, Clinical Lead for the RCGP Certificate in the Detection, Diagnosis and Management of Hepatitis B and C in Primary Care


8 Beynon C, Roe B, Duffy P, Pickering L (2009) Self- reported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom BMC Geriatrics 2009; 9:45


9 J Viral Hepatitis (2011) Knowledge, attitudes and be- haviours associated with the provision of hepatitis C care by Canadian family physicians. Available online ahead of publication.


10 J Adv Nursing (2011) Hepatitis C virus in primary care: survey of nurses’ attitudes to caring 67:598-608


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