Transcript Hepatitis C and the work of Health Advisers in prison

Hepatitis C
HMP Holloway
Darren Tippetts
September 12th
SSHA Conference
Date of prep: June 2015
Job Code: PHGB/HIV/0115/0005a
Within these walls
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The Liver
Hepatitis C
Transmission
Treatment
HMP Holloway
– WHC
– Case studies
• BBV opt out
• Conclusion
The Liver
• Located in the upper righthand part of the abdomen,
behind the lower ribs.
• The largest single organ in
the human body.
• In an adult, it weighs about
three pounds and is roughly
the size of a football.
The liver is essential for life-so
don’t mess with it !
Hepatitis
• ‘hepat’ = liver
• ‘itis’ = inflammation
• Viral hepatitis….
– A
Faeco-oral, never chronic
VACCINE PREVENTABLE
– B
Blood, sexually transmitted, can be chronic
– C
Blood, sexually transmitted, often chronic
– D
Only with B, usually chronic
– E
Faeco-oral (Pork), rarely chronic
History of Hepatitis C
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Discovered 1989
Transmitted by blood
25% people clear virus
75% develop chronic disease
Causes inflammation and scarring of the liver
Can lead to liver cancer
Estimated 170 Million people with HCV
Infection worldwide 3-4 Million newly infected
each year worldwide (38 Million HIV)
Prevalence of infection
> 10%
1%-2.50%
2.5%-10%
NA
Figure 3: HCV Worldwide Prevalence1
1. World Health Organization 2008. Available at: http://www.who.int/ith/es/index.html. Accessed October 28, 2009.
Hepatitis C in the UK
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245,000 with chronic HCV
45% of IDU in England are HCV+
0.04% of new blood donors are HCV+
9% of HIV+ also HCV+ (7% MSM)
In England, 15,840 individuals will be living
with HCV-related cirrhosis or HCC by 2020 if
left untreated
Hep C Prevalence Amongst the Prison Population
The prison population in England and Wales (approximately
84,0001) is significantly more likely than the general population to
suffer from higher rates of hepatitis C.2
• According to the Health Protection Agency (HPA), around 1 in 10
inmates have hepatitis C. However, only 6% of inmates were tested
for the virus in 20113
• Many prisoners are at increased risk of infection, not only because of
drug misuse prior to prison, but also due to high-risk activity within
prison2
- Sharing drug taking equipment
- Unprotected rough/anal sex within prison
-Self tattooing (infections from ink and needles)
- Sharing toothbrushes
- Sharing razors/hair clippers
1. Ministry of Justice, Statistical Tables, Table 1.1a: Total population in custody by type of custody and
age group, on a quarterly basis, September 2011 to December 2012, England and Wales.
2. National AIDS Trust and Prison Reform Trust. HIV and Hepatitis in UK Prisons: addressing prisoners’
healthcare needs. 2005. Accessible http://www.nat.org.uk/Media%20library/Files/PDF%20documents/prisonsreport.pdf.
3. The Hepatitis C Trust. Leading prison health experts challenge NHS England to tackle the growing problem of hepatitis C in prisons. 2013. Accessible at:
Hep C Transmission1
• Hep C CAN be contracted in the following ways:
Sharing needles and other drug taking equipment
Razors/hair clippers
Sharing toothbrushes
Self tattooing
Rough/anal sex
• Hep C CANNOT be contracted in the following ways:
-Sweat, showers or toilets
1 Hep C Trust (2010) What Not To Share Leaflet
HCV: Survival outside body
• CDC/NHS:
– The Hepatitis C virus can survive outside the body at room
temperature, on environmental surfaces, for at least 16
hours but no longer than 4 days
– This is why we advise to not share toothbrushes, razors,
clippers etc
• Recent paper on HCV & drug equipment
– Can survive for up to 3 weeks in water and on filter papers
Hep C Genotypes
and Subtypes
Mediterranean countries
and the Far East
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5
South Africa
Middle East
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There are 6 different genotypes of
hepatitis C that we know about
which can be dominant in certain
parts of the world.1
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Europe
IVDU
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Figure 2: HCV genotypes3
1. World Health Organization. Global Alert and Response. 2011a [31 May 2011]
2. Craxi, A (2011). EASL Clinical Practice Guidelines: Management of hepatitis C virus
infection. J Hepatol:(In Press).
3. Simmonds P, Phil.Trans. R. Soc. Lond. B. 2001;356:1013-1026
USA , Northern Europe
Treatment and treatment
success will vary for each
different hepatitis C
genotype.2
6
Hong Kong, Vietnam
and Australia
Hepatitis C Treatment
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The goal of Hep C treatment is to cure the patient, by ensuring
that the hep C virus is no longer detectable in blood 6 months
after treatment has ended1
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The Hepatitis C Trust (2013). Overview of treatment. Accessible online at:
http://www.hepctrust.org.uk/Treatment/Considering+Treatment/Considering+treatment
HCV treatment
• Interferon – general antiviral-immune boosterinjection
• Ribavirin- Antiviral only used in conjunction
with interferon-oral
• HCV inhibitior – Direct acting antiviral – blocks
viral replication
New Hep C treatments
• Simeprevir
• Sofosbuvir
• Viekirax
• Exviera
A future without interferon – oral only BUT who would you prioritise ?
Summary
• High prevalence and under-diagnosis to HCV treatment in the offender
health setting
• There are logistical challenges for both staff and prisoners, however the
prison setting provides a unique opportunity for hard to reach and
chaotic patients to receive treatment
• Education of both staff and prisoners is imperative in order to provide
the best chance of achieving successful treatment
• Treatments available as per the new standard of care significantly
improve the chance of successful treatment
ALL PATIENTS HAVE THE RIGHT TO BE TREATED!
HMP Holloway
• 90 000 Prison population of England and Wales
• 60% of injecting drug users imprisoned by age 30
• 600 women in Holloway
• 45% of IDU in England are HCV+
• Holloway 24% drug related offences
• 52% women taken class A drug in month before incarceration
1 HPA National survey of hepatitis C services in prisons in England July 2012
• Infamous prisoners
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Suffragettes
Oscar Wilde
Ruth Ellis
Myra Hindley
• Who with the help of a female prison officer tried to escape
– Rose West
– Maxine Carr
– Vicky Pryce
Health Adviser Role
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Managing all WHC results
Giving sexual health advice
Positive results
Partner notification
Pre and Post test discussion for BBV
Counselling for HIV, sexual assault & terminations
CSW
Asymptomatic screening
HIV POCT
Training/education
HMP Holloway
Women referred to health advisers
– History of HCV
– BBV risk
– Booked appointment
– S/B health adviser
– BBV PTD
HMP Holloway
BBV PTD (HCV)
• Risk – shared works, snorting, CSW, HCV +ve partner,
tattoos, shared razors/toothbrushes, self-harm
• Past diagnosis
• Health promotion
• Expectations of result
• Treatment options
Audrey
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Audrey
51 years old
Started using crack/heroin age 23
Alcohol last 10 years 5 ‘heavy’
Family history of drug use
Drug related offences last 25 years
CSW
*Fictional patient study for educational purposes
Audrey
•07/09/12 HCV RNA 1,063 Genotype 3
•17/02/13 HCV RNA 2,638
•11/03/13 Started Rx (Pegasys, ribavirin)
•Attending HCV support group
•Insomnia & loss of appetite
•Eczema
•25/03/13 HCV RNA not detected
•17/12/13 HCV RNA not detected
Success
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Audrey ‘cured’
An achievement for the women
Springboard for better choices
Public health
Reduced risk of onward transmission
Sam
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43 years old
Holloway April 2014
38 previous convictions
Shoplifting, sex work, drunk disorderly
Amphetamines started age 22
Heroin age 25 (in prison)
Alcohol 1-2 litres of vodka a day
*Fictional patient study for educational purposes
Sam
• August 2013 Oraquick Hep C poct reactive
• August 2013 HCV RNA 636,308 Genotype 1a
• Challenge with Sam is that she is in and out of prison
and only ever in Holloway for short sentences.
• We liaise with probation and Dip workers but Sam
does not manage to attend any appointments on the
outside
Sam
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Sam is a typical patient
Some women DNA x 4 appointment
Never tested
In and out of prison
The longer a person has HCV = Poor health
outcomes
• August 2015 FS 24, cirrhotic so could access
new treatment
Maxine
• 27/02/14 – pt said diagnosed 1999 GT 1
• 17/03/14 – Was IVDU 15 years stopped 13
years ago, shared with sisters 2 HCV, 1 HIV
• 19/05/14 – Start rx Interfron, ribavirin (start
TVP @ at later date
• 2/06/14 – RNA dropped 1 log
*Fictional patient study for educational purposes
Maxine
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2/06/15
5/07/14
14/07/14
2/08/14
2/09/14
16/09/14
2/10/14
RNA 9,000 iu/l
Start TVL
RNA 102 iu/l
RNA 15 iu/l
RNA 12 iu/l
Pt told us not been taking TVL !!
RNA not detected
Maxine
• Pt released from Holloway November 2014
staying in St Mung0’s bedsit.
• Continued rx Interferon/ribavirin
• RNA detected @ week 38
• Pt disclosed relapse crack/herion
• Awaiting early access referral Harvoni
Reality Check
• Hepatitis doctor on 6/12 sabbatical
• Senior nurse on 1/12 holiday
• Healthcare staff ‘reluctant’ to take difficult
bloods
• Waiting for NICE!
• So no treatment offered for 6/12
BBV Opt out testing
feedback
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Phase 1 – April-September 2014
11 pathfinder prisons (9% of Estate)
Near doubling of BBV testing
No increase in proportion of patients testing
+ve for BBV
• 226/185 referred for HCV treatment
• Less people on treatment but waiting for new
treatments
New Treatments !
• It’s complicated
• RFH is Hub
• 5 ‘spokes’
• All decisions via MDT
• Blueteq prescribing for high cost drugs
• Hundreds of patients on waiting list
New Treatments
• We have the technology
• Do we have the money?
• Do we have the will?
Conclusion
• Need to be offering treatment to more people
• Increase up take of testing
– Targeted testing
– Opt out testing of all prisoners
• MDT support
• Better outcomes in the community
• Reduce the rates of HCV in UK !
Date of prep: June 2015
Job Code: PHGB/HIV/0115/0005a
Eradication of Hepatitis C by
2030