People attending specialist addiction centres in England where
a facilitator enabled access to hepatitis C care services were ten times more
likely to be referred to hepatology services and to start treatment for hepatitis C virus (HCV), a
pilot study found. The study findings are published in advance online in the
The prevalence of hepatitis C is high among people who
inject drugs but rates of diagnosis, engagement in care and treatment tend to
be low unless special efforts are made to overcome barriers in engagement in
health care and treatment.
In the United Kingdom everyone attending a specialist addiction
clinic should be offered a test for hepatitis C, but the implementation of this
recommendation varies widely.
The Hepatitis C – Awareness Through to Treatment (HepCATT)
study was designed to test the effect of placing a facilitator in specialist addiction
clinics on engagement in care and treatment. The facilitator was expected to
carry out a range of actions that might improve engagement, but the precise mix
of activities was not specified in advance for each clinic.
The non-randomised study compared three intervention sites
with five control sites where at least 200 people who inject drugs attended the
service each year. One intervention site was in a rural area, the others were
situated in inner-city areas.
Facilitators were either specialist hepatitis nurses
assigned half time to the addiction clinic, or a nurse employed by the local
The facilitators undertook a range of activities designed to
improve the offer of testing and engagement with care. These included:
- Conducting training on hepatitis C natural history and
treatment for all clinic staff in direct contact with people who inject drugs.
- Training on how to engage clinic clients in pre- and
- Direct engagement with clients to talk about HCV testing,
treatment and care.
- Scheduling of hepatology clinic appointments to align with
addiction clinic appointments, especially for those receiving opioid
- Active follow-up of all clients who had not been tested for
- Active reminder system for appointments and re-booking of
appointments when the client missed one (this was thought to be the most
effective intervention at two out of three centres).
- Establishment of peer support system to help attendance at
- Introduction of dried blood spot sampling for HCV testing.
The primary outcome of the study was the change in
engagement in HCV therapy at the intervention sites compared to control sites.
Engagement was chosen as the primary outcome because not everyone who engaged
in care would qualify for treatment at the time the study took place. Engagement
was defined as viral load testing, staging of liver disease and discussion of
treatment with a consultant.
The study included 5225 people who inject drugs, of whom
1055 were diagnosed HCV positive.
Engagement in care increased by 31% at the three intervention
sites but declined by 12% at the control sites. The odds ratio of engagement
with care at the intervention sites was 9.99 (95% CI 4.42 -22.56) compared with
the control sites. However, engagement varied between clinic sites, ranging
from 55% of those who tested positive to 28.8% at another site. In comparison,
engagement at control sites ranged from 0 to 8%.
The secondary outcomes of the study were changes in HCV antibody
testing, referral for hepatology investigation and changes in treatment initiation.
Testing increased by 17% at intervention sites but fell by 2% at control sites
(odds ratio 3.9, 95% CI 2.7-5.5, p < 0.001). Referral for hepatology
assessment increased by 38% at intervention sites but fell by 12% at control
sites (odds ratio 16, 95% CI 8.0-32.2, p < 0.001).
Treatment initiation increased by 13% at intervention sites but
remained unchanged at control sites (OR 21.4, 95% CI 8.2-56.1, p < 0.001).
The cascade of care showed that 246 people were referred for
specialist assessment from intervention sites, of which 65% attended a clinic
appointment and just under a third were eventually treated. The most common
reasons for disengagement from care were social, lifestyle or mental health
issues, constraints on getting to the clinic, or testing PCR negative after a
positive antibody test. Almost half of those who engaged with care were still
awaiting a decision on treatment eligibility at the end of the study period but
were ready to start treatment in the view of consultants.
The investigators conclude: “We believe the keys to the success of HepCATT were the employment of
enthusiastic research nurses with a determination to break down barriers and
overcome stigma associated with HCV infection in PWID [people who inject drugs] […] and a guiding
philosophy of placing individual PWID at the centre of the care pathway, with
subsequent adjustment of provision of healthcare services, rather than
insisting that individual clients should fit in with preconceived ideas of how
healthcare should be delivered.”