Article by Andrew Radley, Consultant in Public Health Pharmacy, NHS Tayside
In 2016, the World Health Organisation advocated that Hepatitis C (HCV) could be eliminated as a public health problem by 2030. The current WHO factsheet for HCV tells us that:
HCV is a liver disease caused by the hepatitis C virus: the virus can cause both a mild illness lasting a few weeks or a serious, lifelong illness that can be fatal.
The most common route to infection is through exposure to small quantities of blood e.g. through injecting drug use. Across the world, an estimated 71 million people have chronic HCV infection. Approximately 399 000 people die each year from HCV, mostly from cirrhosis and hepatocellular carcinoma.
Hepatitis is as significant a cause of death as TB or HIV. Antiviral medicines can cure most people with HCV infection, but uptake of testing and treatment services is low. There are no vaccines for HCV; but research ongoing and some progress has been made in designing vaccines that provide immunity to single HCV genotypes. In Scotland, as part of the Government’s Sexual Health and Blood Borne Virus Framework, we are seeking to Eliminate HCV by 2025.
People-who-inject-drugs (PWIDs) visit pharmacies regularly to access Injecting Equipment Provision (IEP) and Opioid Substitution Therapy (OST); this group are at particularly high risk of HCV infection. Pharmacies are seen as one of the main routes through which we will eliminate HCV from the United Kingdom. Public Health Wales have recently published their plan for community pharmacy HCV services in WHC/2017/48. Pharmacies offer many advantages for delivery of HCV care because of their place in the heart of local communities; enabling increased access to testing and treatment and providing the infrastructure to increase capacity.
A series of projects across Scotland have shown that PWIDs can be tested for HCV by their pharmacy. People at risk of infection should be tested at least yearly. Dried blood spot tests (DBST) offer an easy method of obtaining a sample from a finger prick. A research project in Dundee showed that people prescribed OST were twice as likely to accept the offer of a DBST from a pharmacy, testing for Hep B, HCV and HIV. The pharmacies posted samples to the local laboratory and received the results back to inform the patient.
Advances in medicines technology now mean that the new Direct Acting Antivirals (DAAs) enable 95% of people completing a course of treatment to be cured with 8 or 12 weeks of daily tablets.
The SuperDOT-C study in Tayside, Grampian and Glasgow compared treatment provided in the pharmacy with conventional treatment provided by a specialist hepatitis teams. The pharmacy-led arm of the study had the pharmacy teams testing and diagnosing their OST patients for HCV, then assessing them for treatment and providing them with DAAs through a community pharmacist independent prescriber or by PGD. This study has recently closed and is regarded as successful. The preliminary results have been submitted for publication at the INHSU conference in September