Integration of hepatitis C care into community drug and alcohol clinics
This program integrated hepatitis C testing and treatment into community and primary care services with a focus on drug and alcohol treatment services. Visiting nurses led “pop-up” education, testing and treatment clinics to reach marginalized individuals, including those who are unstably housed or who use drugs. The program diagnosed 341 people with a current hepatitis C infection over a 2.5-year period, with 74% of those going on to start treatment. This study demonstrates that an integrated, nurse-led hepatitis C care model is both feasible and effective in reaching marginalized communities.
This program employed hepatitis C nurses who visited seven clinic sites and one homeless shelter in the inner suburbs of Melbourne, Australia. The seven clinics offered drug or alcohol treatment services and all had opioid agonist treatment (OAT) or needle and syringe programs (NSP). These sites primarily served people at high risk of hepatitis C, including people who use drugs, who were experiencing homelessness, or who had mental health issues.
Pop-up testing and treatment clinics
The nurses held biweekly or weekly pop-up clinics at each site. People were referred to the nurse by on-site staff or were engaged directly by the nurse during their visit. The nurses provided harm reduction advice, hepatitis C testing services and referral for treatment.
As part of the referral for treatment, nurses completed treatment workup for those who were starting treatment. This included using a portable ultrasound machine to assess liver injury and organizing telephone consults with infectious disease or hepatology specialists as needed.
Most sites had an on-site or nearby general practitioner or nurse practitioner who could prescribe treatment after the visiting nurse completed the treatment workup. A specialist also occasionally attended the pop-up clinics and could prescribe treatment if an on-site provider was not available. Anyone with suspected cirrhosis or who had a hepatitis B or HIV co-infection was referred to a specialist.
The nurse provided testing 12 weeks after individuals completed treatment to confirm hepatitis C cure (sustained virologic response, also known as SVR12).
Hepatitis C diagnosis
In a 2.5-year period between 2017 and 2019, 640 people participated in the pop-up clinics. Of the 518 people who were tested for hepatitis C, 381 (74%) tested positive for a chronic hepatitis C infection. Of those who tested positive:
- 62% had a known history of injecting drugs, nearly 70% of whom had injected in the past six months
- 47% were currently or had previously been on OAT
- 16% consumed more than six drinks of alcohol per day
- 22% were homeless or unstably housed
- 55% had a diagnosed mental health issue
Hepatitis C treatment
Of the 381 people who were determined to have a chronic hepatitis C infection, 74% (281 people) started treatment. The lowest uptake was at the homeless shelter, with only 44% beginning treatment. All other organizations had over 70% of people begin treatment.
People engaged in OAT were more likely to begin treatment while those who were unstably housed were less likely to start treatment.
Among the 281 people who began treatment, only 57% (161 people) returned for a test 12 weeks after completing treatment to assess whether they were cured (SVR12 test). Of those, 98% were cured. Of the four people who were not cured, two were suspected to have reinfections, and the other two had confirmed non-adherence to treatment. Across all clinics, no site had more than 70% of people return for their SVR12 test.
More than 70% of prescriptions were written by general practitioners or nurse practitioners. Of the cases involving specialists (e.g., infectious disease physicians), 44% were among people with confirmed or suspected cirrhosis.
What does this mean for service providers?
This study shows that a nurse-led hepatitis C program integrated with other health services is feasible and effective. The program successfully diagnosed, treated and cured a relatively large number of people at high risk of hepatitis C, including people who use drugs. Integrating hepatitis C care where people are already accessing other services is an effective way to reach those who are most marginalized.
As we strive toward hepatitis C elimination in Canada, integrating visiting nurses into new settings may be an efficient and rapid way to scale up hepatitis C services. Nurse-led models are also key in helping to provide client-centred and accessible care, especially for marginalized communities. In combination with engaging more primary care providers as prescribers, this could greatly expand the reach of testing and treatment beyond hospitals or specialty clinics.
Although this study looked primarily at integration into clinical settings, there are successful examples of integration into other community-based services, including harm reduction sites and shelters. However, more intensive or additional support may be needed in these settings, as this study demonstrated lower treatment uptake among people who were unstably housed.
Harney B.L., Whitton B, Paige E et al. A multi-site, nurse-coordinated hepatitis C model of care in primary care and community services in Melbourne, Australia. Liver International. 2021;00:1-10.