Hepatitis C: models of care for drug services in Europe (topic overview)
Introduction
Hepatitis C virus (HCV) infection has a high prevalence in people who inject drugs (PWID) in Europe. However, currently HCV infection is both preventable and curable. The importance of targeting PWID as a key population for the elimination of hepatitis C in Europe and promoting their access to testing and all other elements of the cascade of care is highlighted in European and national hepatitis C policies. The collection of eleven case studies presented on this page, documents how this has successfully been done by drug treatment and harm reduction service providers in eight countries, using innovative and creative implementation practices and thus developing and testing new models of care for this important target group
Overview
Hepatitis C virus (HCV) infection has a high prevalence in people who inject drugs (PWID) in Europe, although HCV infection is both preventable and curable. Effective interventions that target the prevention of HCV transmission and the treatment of hepatitis C are needed, particularly for so-called ‘hard to reach’ and vulnerable populations. European clinical guidelines recommend that all patients with chronic liver disease as a result of HCV infection should be considered for therapy, regardless of disease stage. Furthermore, they recommend that treatment be provided to individuals at risk of transmitting the disease, including people currently injecting drugs.
The beneficial impact of hepatitis C treatment on the infected individual, and its indirect impact on reducing onward transmission in the community, make ‘testing and linkage to treatment’ a core component of the hepatitis C elimination strategy. The importance of targeting PWID as a key population for the elimination of hepatitis C in Europe and of promoting PWID’s access to testing and all other elements of the cascade of care is highlighted in European and national hepatitis C policies. The 11 case studies in this collection document how drug treatment and harm reduction service providers in eight countries are supporting PWID’s access to testing and treatment, using innovative and creative implementation practices and developing new models of care for this important target group. This publication provides key insights into the results, impact, sustainability and transferability of each practice to guide the implementation of these new models of care in other countries and settings.
Background and context
Hepatitis C virus (HCV) infection is very common among people who inject drugs (PWID) in Europe, with the prevalence of antibodies ranging from 18 % to 80 % in this population. Transmission usually occurs through the sharing of injection equipment, such as needles, syringes and other equipment.1 As infection is often asymptomatic for decades and becomes chronic in many cases, those with hepatitis C can be unaware of their status and so contribute to a hidden epidemic.
Chronic HCV infection can lead to serious liver disease: the risk of developing cirrhosis increases after 15 to 25 years of infection. As PWID in Europe are also an ageing population, it is expected that the burden of advanced liver disease will further increase in the near future, given the natural history of the disease.
HCV infection is both preventable and curable; therefore, interventions that both target prevention and treat the disease are increasingly needed. European clinical guidelines recommend that all patients with chronic liver disease as a result of HCV infection should be considered for therapy, regardless of disease stage.2 They recommend, furthermore, that treatment be provided to individuals at risk of transmitting the disease, including people currently injecting drugs.
The European Union (EU) drugs strategy (2013-20) calls on Member States to invest in research to achieve a substantial reduction in viral hepatitis, and the current EU action plan on drugs (2017-20) includes an objective to improve PWID’s coverage and access to relevant harm reduction and treatment services.3,4 Based on goal 3.3 of the 2030 agenda for sustainable development, the World Health Organization (WHO)’s global health sector strategy on viral hepatitis sets the elimination of hepatitis C, as a public health threat, as a goal for 2030.5
Evidence shows that retention in opioid substitution treatment reduces the frequency of use of injections and can reduce HCV transmission if combined with interventions on safer injection practices.6,7 Studies have shown that the combination of needle and syringe programmes with opioid substitution treatment reduces HCV transmission, and modelling studies show that treating HCV in PWID can slow down the epidemic and prevent further cases of infection.8-10 The beneficial impact of treatment on the infected individual, as well as its indirect effects on reducing transmission in the community, make testing and linkage to treatment a core component of the hepatitis C elimination strategy.
While extensive evidence exists on the importance of HCV testing in the field of harm reduction, fewer examples of concrete models of care exist. A model of care can be defined as the way in which health services are delivered. A model outlines how to ensure that specific individuals and populations can access the right care, provided by the right team, when and where they need it.11
This publication includes 11 case studies that document new models of care for implementing HCV testing, referral to care and hepatitis C treatment among PWID, integrated in or in close coordination with drugs services, in particular low-threshold harm reduction agencies. Each case study provides key insights into the results, impact, sustainability and transferability of the practice, which can guide the implementation of these new models of care in other countries and settings.
While contact persons from the projects provided feedback on the descriptions, the responsibility for any errors lies with the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
References
[1] Pouget, E. R., Hagan, H. and Des Jarlais, D. C. (2012), ‘Meta-analysis of hepatitis C seroconversion in relation to shared syringes and drug preparation equipment’, Addiction107(6), pp. 1057-1065.
[2] Pawlotsky, J.-M., Negro, F., Aghemo, A., Berenguer, M., Dalgard, O., Dusheiko, G., Marra, F., Puoti, M. and Wedemeyer, H. (2018), ‘EASL recommendations on treatment of hepatitis C 2018’, Journal of Hepatology69(2), pp. 461-511.
[3] European Council (2012), EU drugs strategy.
[4] Council of the European Union (2017), EU action plan on drugs 2017-2020.
[6] Gowing, L., Farrell, M., Bornemann, R., Sullivan, L. and Ali, R. (2008), ‘Substitution treatment of injecting opioid users prevention of HIV infection’,Cochrane Database of Systematic Reviews, doi:10.1002/14651858.CD004145.pub2.
[7] Hagan, H., Pouget, E. and Des Jarlais, D. (2011), ‘A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs’, The Journal of Infectious Diseases204, pp. 74-83.
[8] Turner, K. M. E., Hutchinson, S., Vickerman, P., Hope, V., Craine, N., Palmateer, N., May, M., et al. (2011), ‘The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence.’, Addiction (Abingdon, England)106(11), pp. 1978–88.
[9] Van Den Berg, C., Smit, C., Van Brussel, G., Coutinho, R. and Prins, M. (2007), ‘Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users’, Addiction102(9), pp. 1454-1462.
[10] Martin, N., Vickerman, P., Foster, G. R., Hutchinson, S. J., Goldberg, D. J. and Hickman, M. (2011), ‘Can antiviral therapy for hepatitis C reduce the prevalence of HCV among injecting drug user populations? A modeling analysis of its prevention utility’, Journal of Hepatology54(6), pp. 1137-1344.
[11] ACI (Agency for Clinical Innovation) (2013), Understanding the process to develop a model of care. An ACI framework. ACI, Sydney.
Models of care case studies
The models of care presented in this section are based on a study commissioned by the EMCDDA on hepatitis C models of care for drug services. This study contains more detailed information on each case as well as findings on effectiveness, sustainability and transferability.
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Location |
Characteristics |
Overview |
More information: |
|---|---|---|---|
HepCATT (UK) |
Location: England, UK |
Special nurse facilitators to increase HCV diagnosis and treatment in drug treatment services: the HepCATT study The Hepatitis C: Awareness Through to Treatment (HepCATT) study was implemented within eight drug treatment centres in England and ran for 12 months (2015-16). It was designed to determine the effect of integrating a part-time facilitator (a nurse) whose responsibility was to encourage PWID, who are traditionally regarded as a ‘difficult to reach’ patient group, to access HCV diagnosis, onward referral and engagement with local care pathways. The results showed a 3- to 20-fold increase in the number of PWID engaging with HCV treatment in the three intervention sites compared with the five control sites. The results of this prospective pilot study support the conclusion that the introduction of nurse facilitators in drug treatment settings can help to increase HCV testing and patient referrals and can lead to significant increases in engagement and HCV treatment among PWID within routine clinical care pathways. |
|
HepCare Europe (UK) |
Location: London, UK |
HepCare Europe: London — reaching at-risk groups through a low-threshold approach using peer support workers to improve HCV screening and linkage to care HepCare Europe is a project co-funded by the Third Health Programme of the EU, implemented between 2016 and 2019, carried out in four European cities (Dublin, Ireland; London, UK; Seville, Spain; and Bucharest, Romania) and based at University College Dublin (Coordinators: Prof Lambert and Prof Cullen). As part of this larger EU-funded project, HepCare London focuses on providing an ‘integrated care’ model for HCV treatment based on the joint participation of primary and speciality care practitioners to facilitate more efficient use of limited specialist resources. The project aims to (a) identify those not accessing care by using rapid HCV testing, (b) provide peer support (using community-based organisations) to assist those identified with HCV to access care and (c) develop nurse liaison links so that secondary caregivers go to the patient, rather than patients going to secondary caregivers. This is achieved by utilising a mobile health unit with a community-based outreach model targeting underserved populations such as homeless people and PWID. Early results of the project show a high burden of disease in the population and that peer advocacy can improve the engagement of patients with chronic HCV with healthcare services across the cascade of care and that the intervention is cost-effective. |
|
IN-Mouraria (Portugal) |
Location: Lisbon, Portugal |
IN-Mouraria: a community-based and peer support approach to HCV testing and treatment among people who use drugs IN-Mouraria, a community-based drugs service run by the non-governmental association Grupo de Ativistas em Tratamentos (Treatment Activist Group), is based in an urban quarter of Lisbon, Portugal. It provides an integrated response, offering social and health responses to people who use drugs (PWUD) to reduce the risks and harms associated with drug use. Its particular focus is on preventing infection, identifying people with human immunodeficiency virus (HIV) and/or HCV infections and linking them to treatment, and promoting their access to health and fundamental rights. In addition to providing services, IN-Mouraria’s mission is to advocate and produce knowledge, and the service is strongly committed to defending the rights of and ensuring meaningful participation among PWUD, particularly those living with or vulnerable to HIV and HCV infections. Strategies used to reach PWUD and migrant populations using drugs include peer-based outreach and referral to IN-Mouraria from other drug users and migrant associations. Services are provided to clients without an appointment, free of charge, without the need for personal identification and are combined with an extensive peer support programme. |
|
London Pharmacies (UK) |
Location: London, UK |
Increasing HCV testing and care for PWID through a community pharmacy setting A Public Health England report on HCV in London identified that over 60 000 people have been infected with HCV and are HCV antibody positive and that 69 % are HCV RNA positive. PWID are by far the most at-risk group, and national data show that PWID account for 90 % of all new HCV diagnoses. For those not currently engaging in community drug treatment services but actively injecting drugs, HCV testing and referrals to treatment are non-existent, and engagement with healthcare services by these socially isolated patients is sporadic. A pilot intervention including seven community pharmacies in London in 2017-18 piloted HCV testing to people who currently inject drugs and are accessing the pharmacies’ needle and syringe programmes (NSPs). The goal of the intervention was to offer HCV testing and referrals to treatment to socially isolated patients who are not currently engaging in community drug treatment services but are actively injecting drugs. Results from the intervention show that NSPs in community pharmacies provide an opportunistic point of contact for HCV testing, education and referral into treatment. |
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Luxembourg Mobile Clinic (Luxembourg) |
Location: Luxembourg |
Expanding HCV screening and hepatitis treatment and care for PWID to harm reduction centres The aim of this project was to expand screening and treatment for HCV among PWID in Luxembourg. An intervention research project was implemented at three harm reduction sites and at the national supervised drug consumption facility in the city of Luxembourg, offering HCV, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and syphilis serologies and viral load, liver biomarkers, and atransient elastography (non-invasive assessment of liver stiffness) for people currently injecting drugs. To accelerate access to treatment and limit HCV transmission among this key risk group, the provision of direct-acting antiviral treatment and virological follow-up for PWID with HCV infection was subsequently initiated at the harm reduction centres and the national drug consumption facility. The study demonstrated the feasibility of offering comprehensive HCV care at these low-threshold agencies for PWID, including proactive screening for a wider range of infectious diseases among this population. |
|
AERLI (France) |
Location: France |
Increasing HCV testing through a community-based educational intervention in harm reduction centres From 2011 to 2013, a national, clustered, multisite intervention study to assess the impact of the injection-centred face-to-face educational session was conducted in 17 low-threshold harm reduction centres in France. The peer-led, community-based educational intervention (Accompagnement et Education aux Risques Liés à l’Injection; AERLI) was conceived to provide training and education on safer drug-injecting practices to PWID. This included human immunodeficiency virus (HIV) and HCV transmission risk reduction, information on other injection-related complications and how to access HIV and HCV testing and care. The evaluation results showed that the intervention was effective in reducing HCV risk behaviours and risky injection practices, as well as associated cutaneous complications. It was also linked to increased HCV testing in PWID. In a population in which HCV prevalence is extremely high and access to care is often complicated, the results suggest that educational interventions can be effective additional means to increase the uptake of HCV testing among difficult-to-reach PWID. |
|
HepC detect II (Spain) |
Location: Catalonia, Spain |
On-site HCV RNA testing and awareness raising of HCV among PWID in harm reduction services In Catalonia, Spain, the coverage of antibody testing among PWID who attend harm reduction services is high. However, linkage to care for HCV RNA confirmation is limited. The HepCdetectII study was carried out with the aim of assessing the effectiveness of an on-site HCV RNA testing strategy in detecting HCV viraemic cases. It also aimed to promote, among treatment candidates, an awareness of HCV disease status and linkage to care, as well as to describe the local epidemics in current PWID. |
|
SACC (Denmark) |
Location: Copenhagen, Denmark |
Introducing shared care between drug treatment centres and infectious disease clinics to improve HCV treatment and care for PWID To improve access to health services for PWID, the Shared Addiction Care Copenhagen (SACC) project was developed as a cross-sectorial collaboration between 11 municipal drug treatment centres and two specialised infectious disease clinics. The drug treatment centres offered a range of services including counselling, drop-in services, opiate substitution therapies and syringe distribution. The aim of the intervention was to develop and implement a generic decentralised HVC shared care model for HCV testing, evaluation and treatment at the drug treatment centres, with the aim of decreasing HCV-related transmission, morbidity and mortality among PWID.The SACC project has helped break down barriers between different sectors in the healthcare system by establishing a cohesive treatment and care model for PWID with HCV.The key to the success of the SACC model has been the close collaboration and investment of multiple stakeholders including 11 municipal drug treatment centres, two infectious disease clinics and a research facility that provided IT support to develop the online database. Key personnel, including dedicated nurses and doctors at both facilities, need to be identified and act as resources to facilitate the intervention. |
|
The Antwerp model (Belgium) |
Location: Antwerp, Belgium |
The ‘Antwerp model’ — an integrated, multidisciplinary approach with a strong peer support programme to ensure the continuum of HCV care for PWID (Free Clinic) The aim of the ‘Antwerp model’ of hepatitis C care, developed by the non-governmental organisation Free Clinic in Antwerp, Belgium, is to provide holistic low-threshold harm reduction services for PWID. It is an integrated, multidisciplinary model of hepatitis C care with a strong nurse-led peer support programme for delivering a continuum of care, from information and education on and diagnosis of hepatitis C, to linkage to care, treatment and prevention of reinfection. The Free Clinic collaborates intensively with the hepatology unit in a large community hospital (ZNA - Ziekenhuis Netwerk Antwerpen) and uses a ‘C-Buddies’ system, namely a strong peer support programme in which people who formerly used drugs, and who have completed HCV therapy, offer support and guidance to peers. |
|
Ambulatorium Wien (Austria) |
Location: Vienna, Austria |
Ambulatorium Suchthilfe Wien: directly observed hepatitis C treatment for PWID at a low-threshold facility or pharmacy Chronic hepatitis C treatment in current PWID and in those who are in opioid substitution treatment (OST) is optimally managed if direct-acting antivirals are provided in the same location as the treatment for drug dependence. The goal of this intervention was to evaluate adherence to therapy and sustained virological response in patients who received OST together with antiviral treatment for hepatitis C under supervision at a pharmacy or by a healthcare professional (‘directly observed therapy’) in a low-threshold facility in Vienna, Austria (Ambulatorium Suchthilfe Wien). To evaluate the impact of the intervention, an open-label, non-interventional, proof of concept study was conducted.The study has now been completed and, owing to its success, the intervention is being continued as a regular treatment. A total of 233 patients have finished the treatment course and 12 weeks of follow-up. The adherence to antiviral therapy was excellent, with only 0.15 % of scheduled dates for ingestion of the antiviral therapy in combination with OST missed by patients. These results suggest that the intervention is successful in this population and setting. |
|
Hepatitis mobile team (France) |
Location: Perpignan, France |
Hepatitis mobile team (HMT): multidisciplinary ‘à la carte’ services for PWID In France, treatment for HCV should be provided to all patients and especially to people who use drugs and/or are incarcerated, even if they have no liver fibrosis. The hepatitis mobile team (HMT) ‘Le Fil Vert’ serves a population of 500 000 in Perpignan, France, and provides 15 different services divided into four main areas: early detection of viral hepatitis and human immunodeficiency virus (HIV); linkage to HCV care and fibrosis assessment; access to treatment; and follow-up during and after treatment for HCV. HMT is linked to the gastroenterology unit of Perpignan Hospital and has established multiple partnerships with community associations and care facilities. The training of both professionals working at HMT and patients is a key element of this intervention, which employs educational nurses for this purpose. Between 2013 and 2018, HMT’s services were used by 5 382 patients; more than one-fifth of the 3 053 HCV tests performed were positive, 2 302 examinations of liver stiffness were performed and HCV was cured in 651 patients. |