London: hepatitis C elimination depends on testing scale-up

Keith Alcorn
28 January 2020

London needs to step up the rate of testing for hepatitis C if it is to achieve elimination of hepatitis C, Professor Graham Foster of Queen Mary University London told the London Joint Working Group on Substance Use and Hepatitis C conference on hepatitis C elimination in London yesterday.

Although NHS England has exceeded its hepatitis C treatment target – “no other European country has achieved that”, said Professor Foster – expanded testing is the key to elimination, he said.

“We need to find people who started using drugs 30 or 40 years ago and don’t know they have it and are in real trouble – we need to start doing GP testing.” He also endorsed greater promotion of online self-testing services as a way of reaching people with a history of injecting drug use.

“We also need to start testing people who drink alcohol in addiction services – we have 4% prevalence in this group.”

“Local authorities really need to join us, step up and commission more services. If you do more testing now, you will avoid spending more money on treatment and care in the future.”

“We’re still not doing enough testing in drug services. Everyone working in drugs services – including the receptionist – needs to be able to do testing,” he said. The majority of new hepatitis C diagnoses are in people who inject drugs and hepatitis C transmission is highly concentrated in people who inject drugs and HIV-positive men who have sex with men in the United Kingdom.

Emma Burke of Public Health England revealed that a survey of local authorities in London shows major deficiencies in the provision of hepatitis C testing in drug services. Six of 33 local authorities in the Greater London area say no hepatitis C testing for clients of needle and syringe programmes is taking place in their boroughs. In 23 of 33 boroughs, no testing is taking place in pharmacies and in eight boroughs of 33, no HCV RNA testing for confirmation of chronic hepatitis C infection is being done.

Dr Kevin Fenton of Lambeth, Southwark and Lewisham Health Authority, Co-Chair of London HIV Fast-Track Cities, said that normalising HIV testing among gay and bisexual men in London had been critical for increasing the proportion of people with HIV on treatment and therefore unable to transmit HIV.

But he questioned whether a pan-London advertising campaign to encourage testing for hepatitis C is the best use of scarce resources. “Digital micro-targeting can be a more efficient way of reaching the undiagnosed,” he said.

“We need to do an over-50s study in GP practices in London and then do a targeted advertising campaign once we know more about the profile of people testing positive,” Professor Foster added.

Testing of migrants from countries with a high prevalence of hepatitis C also needs to be revised, the conference heard. Dr Ashley Brown, Consultant Hepatologist at St Mary’s and the Hammersmith Hospitals in west London, said that 58% of people diagnosed with hepatitis C in west London were born outside the United Kingdom – but they come from 104 countries. He argued against country-specific testing, as practiced in some parts of London, instead advocating testing all migrants over 40 years old, as “all [of the 58%] were over 40.”

'Peers are transformative'

“Peers have been transformative in this programme. Having peers going out and encouraging people to get tested and treated has had a massive impact,” said Professor Foster.

Rob Allan of the Hepatitis C Trust described how peer outreach workers are working with King’s College Hospital, London, on the Hep C Bus outreach project, which aims to engage homeless people in hepatitis C testing and care. The service has run 145 session at 45 locations in London and has proved highly acceptable to clients, who value the peer navigators and the community location.

Competing priorities such as drug use, the need to obtain money to buy drugs, probation service appointments or court appearances and urgent health priorities can all crowd out hepatitis C, undermining engagement with hepatitis C services, Rob Allan explained. Engagement can take multiple contacts and is intensive work. Peer workers need to win the trust of homeless and street drug users by demonstrating empathy and understanding.

“My job is to get hepatitis C up to higher priority. We might not get it above getting money to score drugs or going to score but we can get it higher,” he told the conference.

Further reports from the London Joint Working Group on Substance Use and Hepatitis C conference will be published in February.