Chronic infection with the hepatitis C virus (HCV) is common and affects up to 50% of people who have injected drugs, either now or in the past. The virus is also common in many immigrant communities where poor medical practice and inadequate needle sterilisation techniques in their country of origin have led to the transmission of the virus during immunisation or other medical procedures. Until recently therapy for HCV involved a 6 to 12 month course of side effect prone treatment with interferon and ribavirin and led to viral eradication in fewer than 60% of those treated. Not surprisingly most patients declined the offer of this troublesome treatment.
The situation has now been transformed with the licensing of brand new, tablet only treatments that allow us to cure over 90% of patients with courses that may be as short as 8 weeks. The problem with the current therapies is the price – despite being highly cost-effective and NICE approved, the cost of the medications is considerable with standard treatment courses costing many thousands of pounds. Given that there are more than 100,000 infected people in England it is easy to see how funding these treatments immediately could seriously damage the NHS budget and, potentially, reduce access to other important therapies. To resolve this paradox and to improve access for all patients with chronic HCV, NHS England have set up a nationwide series of Operational Delivery Networks (ODNs). Each of the 22 networks is responsible for managing patients with chronic HCV in their defined geographical area. The networks are generously funded through CQUIN payments and are obliged to link up with local services to encourage identification and referral of infected patients.
Although the networks are based at large regional centres a key feature is that therapy can be provided by any motivated prescriber and ODNs have authority to delegate treatment to local service providers. In the East London network, for example, the local specialist addiction team see patients in their unit, discuss the cases at the regional multidisciplinary meeting and then prescribe and monitor the patients in the local drug centres. This approach allows patients to receive both expert advice and therapy close to home without ever needing to attend a hospital.
At present the budget for hepatitis C treatment allows 10,000 patients to be treated. In line with NICE guidance this number will increase year on year and, as the cost of the medicines reduces, even more patients will be offered therapy. To-date most ODNs have focussed on treating patients with cirrhosis but as patients in greatest need are cured the networks will look to expand therapy further and more and more networks are reaching out to their communities to engage with greater numbers of infected patients.
The populations at risk from chronic HCV infection (chiefly those with a past or present history of injection drug use or immigrants exposed in their country of origin) are relatively hard to access and, increasingly, networks are looking to establish out-reach services that will allow them to engage with the more inaccessible patient groups. General practitioners will play a key role in this expansion – their expertise in identifying patients at risk and their skills in persuading patients to engage and comply with therapy will be crucial to the success of the programme. For general practitioners with a particular interest in this disease area there is an opportunity to link in to the local network and take an active role in prescribing for patients with HCV. Since the costs of therapy are funded centrally and as a full panoply of support is provided by the ODNs we hope that many GPs will take advantage of this opportunity to play a role in managing chronic HCV infection.
For many years the mortality and morbidity from chronic HCV infection have been rising. Following the introduction of effective antiviral drugs in 2014 we have seen a sharp fall in the number of patients requiring liver transplantation for chronic HCV and mortality from HCV has reduced by 11%. These encouraging results indicate that with increasing use of these highly effective therapies we can reduce the burden of disease dramatically and some are beginning to question whether we can eliminate HCV infection completely. To achieve these goals we will require the active support of our colleagues in primary care and we hope that many will look to join us as we try and reduce the significant morbidity and mortality associated with this debilitating infection.
How to get involved in this programme
Colleagues who wish to become involved in the HCV treatment programme should contact their local Operational Delivery Network in the first instance. If access proves difficult, the author is happy to assist, contact email address is firstname.lastname@example.org.
- Graham R Foster FRCP PhD
Professor of Hepatology, Queen Mary University of London