HEP C
of 90 per cent. These high rates can be achieved even in the more difficult- to-treat cases, including individuals who have progressed to cirrhosis and those who have failed to be cured with a previous course of the older, less effective treatments, which usually included interferon and ribavirin. Treatment with the DAAs is associated with a much lower treatment burden than with the older regimes and requires less intensive monitoring of the patient’s progress.
The use of the DAAs is cost effective at all stages of liver disease and the cost effectiveness of these medicines increases as greater numbers of people are brought into treatment and there are consequently fewer people with newly transmitted infections. However the acquisition costs of DAAs are high and approaches for treating people with hepatitis C infection have centred on people with significant liver disease and the most pressing need for a cure, in order to keep costs within available resources. Treating all people who have hepatitis would deliver substantial health benefits for the population, but would come at substantial cost. There are also concerns that there may not be sufficient clinical capacity provided through established clinical pathways to accommodate the increased numbers of treatments that will be required to be delivered to eradicate hepatitis C for Scotland.
Treatment uptake for hepatitis C treatment amongst people who inject drugs is currently low, and prospective patients may have a number of barriers to overcome in order to access care. In particular, people who inject drugs may find it difficult to consistently attend medical clinics and may be reluctant to attend hospitals. In these established pathways of care, less than ten per cent of the OST population are tested for hepatitis C. Of those tested, at very best 25 per cent start treatment in one of the dedicated centres, with 70-80 per cent successfully completing. This means that only two-three per cent of this vulnerable population receive adequate treatment.3
However, the delivery of hepatitis C testing and treatment through community-based care pathways has been tested in several countries. Dried Blood Spot Testing (DBST) has been demonstrated to increase the uptake of testing from high-risk populations. This technique involves taking a finger prick of blood from a patient
and placing a drop of blood on a protein-saving filter paper. Analysis of the blood sample for hepatitis C antibodies can show that the patient has been exposed to the virus5. With appropriate training, DBST can be carried out by all pharmacy staff. Several practice-based projects across the United Kingdom have sought to implement DBST into pharmacy practice. Pharmacies in several Scottish health boards now offer dry blood spot testing. Recent results from a project with a small number of Tayside pharmacies indicated that OST patients may be twice as likely to take a test from a pharmacy6. Pharmacists have daily interactions with patients prescribed methadone and it seems likely that this relationship can be used to deliver not only increased rates of hepatitis C testing, but also to diagnose and treat this population.
The potential of community pharmacy practices to make a greater contribution to the care of OST patients has been recognised for some time and work has been on-going. A small pilot trial carried out in 2015 by the University of Dundee was used to work out the mechanics of community pharmacists diagnosing OST patients for hepatitis C infection and assessing them for treatment. A much larger trial - Super DOT-C - is currently being taken forward in several health boards to evaluate a pharmacy-led pathway in comparison to the conventional secondary care based pathway. Community pharmacists in Tayside started to recruit patients for this trial in December and pharmacists in Grampian are due to start recruiting at the end of January. A step-wise approach is planned to spread the trial across further centres in Scotland. The trial will aim to provide definitive evidence that people prescribed OST with a hepatitis Cc infection can be successfully cured through their daily interaction with a community pharmacist. The results from the study should be available mid-way through 2018. •
Cheryl Soderland and Irene Rose from Well Pharmacy in Perth took part in the pilot trial last year. They were delighted when patients they had tested were able to get the treatment they needed from the pharmacy without having to visit the hospital.
Lauren Clarke and Jan Phillips from Davidson’s in Forfar are taking part in Super DOT-C trial to test and treat hepatitis C patient in the pharmacy.
Lauren Clarke: ‘The pharmacy pathway makes it much easier for patients to receive treatment. Currently they have to travel to Dundee for tests and often miss appointments, so they have been lost to follow up.’
Jan Phillip: ‘I’m really looking forward to seeing the difference in the patients now that they have easier access to treatment. They have all been really positive about being involved in the study. It means they can be treated locally by someone they know and trust. They can also avoid the expense and difficulty of travelling to Dundee for treatment and testing.’
REFERENCES 1. Hepatitis C in the UK. Health Protection Scotland. Glasgow. 09 August 2016
http://www.hps.scot.nhs.uk/ewr/article. aspx 2. Scottish Intercollegiate Guidelines Network (SIGN). Management of hepatitis C. Edinburgh: SIGN; 2013. (SIGN publication no. 133). July 2013].
http://www.sign.ac.uk 3. Hepatitis C annual report: progress made, but much more to do. Public Health England. July 2014.
http://www.gov.uk/government/news/hepatitis-c-annual-report-progress-made- butmuch-more-to-do 4. Sexual Health and Blood Borne Virus Framework 2015-2020 Update. Scottish Government. Edinburgh. September 2015.
http://www.gov.scot/Resource/0048/00484414.pdf 5. Tait JM, Stephens BP, McIntyre PG, et al. Dry blood spot testing for hepatitis C in people who injected drugs: reaching the populations other tests cannot reach. Frontline Gastroenterol 2013;4:255–62.6. Radley A, Melville K, Tait J, et al. A quasi-experimental evaluation of dried blood spot testing through community pharmacies in the Tayside region of Scotland Frontline Gastroenterology Published online 080117 doi:10.1136/flgastro-2016-100776
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