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‘ The headline is that fewer people are dying or getting cancer from hep C .’
PROF GRAHAM FOSTER
we should go into drug services and actively treat people there was massive opposition to that . We were berated by colleagues for wasting NHS money on drug users , but now they ’ re all getting access to treatment . If you go into a drug service you will get tested and you will get treatment – that is transformative .’
The challenge , however , was to keep that going – which was not
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going to be easy . ‘ You need people out on the streets , finding people , engaging them and getting them into treatment . But the funding for that will disappear in 18 months .’ HIV was a ‘ poster child ’, he said , ‘ but why are we second fiddle ? There ’ s more hepatitis C in London than HIV , so why isn ’ t it “ Give the finger to HIV and hepatitis C ?”’ There were also a number of hospitals that still weren ’ t engaged , he said , and where the numbers of people treated remained inadequate . ‘ And we still haven ’ t got a community pharmacy programme . I ’ m going to call the mayor out , I ’ m afraid . We ’ ve heard a lot about some very good work in many areas but we haven ’ t seen any money for hep C . In 18 months NHS England will walk away , which is where we need the mayor to step up .’
COORDINATION What was needed was a mayoral post to coordinate the strategy and keep the elimination goals going , he stressed . ‘ Given the large amount of money put into HIV I don ’ t think it ’ s unreasonable to ask for that . Look at the work being done – people are coming from primary care , from drug services , and we ’ re treating people in the most deprived areas . We ’ re getting to people that nobody else gets to , and we give them a hand up . We tell them that they ’ re not on the margins of society , and just because they use drugs it doesn ’ t mean we don ’ t care . We ’ ve got to think about how we maintain this as the NHS steps back .’
‘ If we can do it with HIV we can do it with hep C ,’ agreed senior project manager , HCV elimination specialised commissioning at NHS England , Specioza Nabiteeko . ‘ We need to build on those pathways that already exist ,’ and take an overall , genuinely holistic , BBV approach .
Every time someone offered a test , supported someone through the process or signed a prescription they were working towards elimination , said head of programme for HCV elimination , NHS England , Mark Gillyon-Powell . There had been a massive increase in testing in drug services and people accessing treatment since
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2015 , and a 37 per cent reduction in deaths . ‘ So we ’ ve already met the WHO targets way early – but it ’ s not good enough , we need no one to be dying . We keep treating people so we ’ re emptying the bath , but until we switch off the taps of new people being infected we can ’ t get to the point of elimination .’
There was still a long way to go in preventing onward transmission and reinfection , he said , while in post-treatment more could be done in terms of offering dedicated support to those more prone to reinfection . ‘ If we can identify what the risk factors are for reinfection in a much clearer way , how can we support people better ? We need to optimise the support that ’ s available to enable them to protect themselves .’
GREATEST RISK ‘ We really need to think about which populations are at greatest risk of reinfection and think about how we might access them ,’ agreed consultant epidemiologist and head of hepatitis C and BBVs at UKHSA , Dr Monica Desai . While there was new focus on harm reduction through the drug strategy , it was also crucial to make sure that investment continued and ‘ we monitor needle and syringe provision to fully understand what coverage looks like and where we may have gaps .’
When it came to reinfections , it was essential to make sure harm reduction services were bolstered and that there was genuinely joined-up commissioning , said the Hepatitis C Trust ’ s director of community services , Stuart Smith . ‘ You can ’ t have one body commissioning treatment and another commissioning harm reduction and preventing new infections .’
LJWG had just begun phase 2 of its work on developing a peerbased needle exchange for London ( DDN , February , page 5 ), said LJWG coordinator Dee Cunniffe . ‘ We ’ re looking at the phase 1 recommendations and seeing what a model to do that would look like . We ’ re doing a start-up – we ’ re not calling it a pilot because it really has to be long-term ’. It would have peer leadership embedded , she
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stressed , and be fully replicable as a pan-London approach . ‘ So any commissioners out there , come and speak to us now .’
‘ For me , elimination is simple ,’ said Foster . ‘ It means you use drugs and you ’ re pretty sure you ’ re not going to catch hep C . And if you do catch it , you get it diagnosed and treated very quickly . High-risk people get tested when they go to their GP . That ’ s elimination . Once we ’ ve done that , we ’ ve cleared it . That ’ s real .’
Dynamic commissioning was essential , he said – ‘ doing something , seeing it doesn ’ t work , then doing it differently . We ’ ve got to move quickly , keep the momentum going . But we ’ ve got to maintain the discrimination-free approach . When I started HIV and hepatitis C were feared diagnoses because there was terrible , overt discrimination . All of that ’ s gone , but it will come back if we ’ re not careful . So we ’ ve got to maintain the focus – to keep talking about stigma and getting rid of it .’
Underfunding and fragmented care were among the levers creating stigma , along with other issues like restrictive and coercive treatment policies , said principal public health specialist at the London Borough of Hackney , Maggie Boreham . A recent paper had stated that illicit drug use was the most stigmatised mental and physical health condition worldwide , ‘ because it ’ s considered to be about bad choice , bad character , some form of weakness ’, she said . ‘ This is 2022 – it ’ s just not good enough .’
WORKING TOGETHER ‘ We ’ re all thinking in the same way , and working together as a system – and that ’ s pretty rare in healthcare ,’ director of corporate services at the Hepatitis C Trust , Leila Reid , told delegates . ‘ We ’ re in a brilliant place , with a couple more years of the elimination programme , and it ’ s been amazing seeing the role of people with lived experience being so front and centre to this . We ’ re doing brilliantly on treatment , brilliantly on engagement but we ’ re not doing quite so brilliantly on harm reduction . So that will be pivotal over the next couple of years .’ DDN
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