INF ECT ION PR EVENT ION & CONT ROL
to consider. Some patients may have been born or raised overseas, used drugs when much younger, had a tattoo while travelling abroad or received a blood transfusion in the UK prior to 1991 and be unaware that they are at risk. These persistent myths and sources of misinformation act as a barrier to testing and treatment. For example, many people might want to avoid testing for fear of the result. It’s important for me and others who work in HCV services to support them by reassuring them that, even if their test is positive, they can be treated and cured and people around them won’t know their test result or treatment access. The use of peer support has been key in tackling some of this misinformation. The Hepatitis C Trust has been running a peer support programme since 2010, and now its efforts are a core part of the elimination programme. Peer support workers can explain to people who are HCV positive that there is nothing to be concerned or ashamed about. This stigma surround HCV is very deeply ingrained, and anecdotally the stigma around HCV can be even stronger than that surrounding HIV, especially given fears about the original interferon treatments, which many people mistakenly believe are still the only treatments available. Prisons are high on the agenda. Estimated prevalence is particularly high among people in prison – 13% of female prisoners and 7% of male prisoners are thought be infected compared to 0.4% of the general population. An opt-out testing model for BBVs has been rolled out across all prisons in England, which has already led to testing levels rising from 5% in 2010/11 to 19% in 2017/18. All prisoners should be offered a test at reception in such a way that it is presented as routine, something that should happen unless they actively choose not to. This helps to tackle stigma from the start, embedding testing into the prison health landscape.
The prisons programme has already
been very successful. According to NHS England, the practice of going into prisons as ‘hit squads’ and implementing testing and treatment is working well and can be
replicated broadly. Several prisons have now even declared that they have achieved ‘micro-elimination’, having tested everyone they can on their patch and successfully treated those who needed it. The work has really shown the value of a ‘whole team approach’ when it comes to testing and treating blood-borne viruses, with prison staff, healthcare providers, peers and nurses all working together seamlessly. The work in prisons is a key part of the elimination effort, presenting a crucial opportunity to treat a high prevalence cohort. But it has wider benefits. Not only are prisoners who address their HCV much more likely to overcome other problems in life that contribute to the cycle of offending, such as substance abuse, but reducing the number of people infected will make for a much safer work environment for all prison staff. I was fortunate to be able to attend the Prison Governors Association annual conference last autumn and have the opportunity to speak to governors from across the country about the op-out testing programme and the unique opportunity that we now have to eliminate the virus. They seemed really engaged and positive, keen for further information and support to get the message out to their staff. There are various other areas of focus comprising the elimination programme. There have already been great strides made in drug and alcohol treatment centres, where people attending can be tested and referred
into treatment. Peer support programmes are operating within these settings too, where people with direct experience of living with HCV reach out to the substance use community to deliver core messages about the importance of prevention, testing and treatment assessment. People who use drugs often have chaotic lifestyles, and they can be among the hardest populations to reach in the first place, and the hardest to keep in touch with to ensure they complete their treatment. The work that peer support workers do is invaluable in keeping this part of the patient population motivated, and they play a crucial role in helping to change attitudes among substance users and the wider community.
As chair of the Hepatitis C Coalition, a group of clinicians, patient groups and others campaigning to eliminate the virus, we are delighted to see the progress that has been made over the last five years, and the potential for unprecedented success over the next five years.
There are also other avenues to explore. As the elimination programme continues apace, we will likely reach a point between now and 2025 when we have successfully reached patients who are easiest to engage and we will need to focus our efforts on those who are hardest to reach, including members of the South Asian community, among whom there is a high HCV prevalence combined with high levels of stigma which prevents people getting tested and treated. Industry and charity partners are working on tailored awareness campaigns aimed at hard to reach groups of this kind, and some ODNs are working on case finding initiatives in their local areas designed to target these at risk populations. They are doing this in a number of ways, such as offering oral swab testing for viral hepatitis in mosques and community centres and paying primary care physicians for case finding. Primary care is a key area of focus for the elimination programme going forwards. It’s no secret that GPs have heavy workloads and multiple demands on their time. They are also
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