Reaching people who receive methadone opioid agonist therapy
with the offer of an on-site hepatitis C test through their dispensing pharmacy
greatly improved the uptake of hepatitis C testing and treatment when compared
with standard procedures for hepatitis C screening, an international study has
reported.
The study, carried out in Scotland, Wales and Australia,
found that people offered point-of-care hepatitis C RNA testing at a pharmacy
were 18 times more likely to be tested for hepatitis C compared to people who
were directed to conventional testing venues by the pharmacist.
People with a history of injecting drug use are a priority
group for hepatitis C screening as they have a high prevalence of chronic hepatitis
C infection. But reaching this population with the offer of hepatitis C testing
can be difficult as they may not be engaged with conventional health services.
Offering hepatitis C testing through drugs services or pharmacies
that dispense methadone may be an acceptable alternative but not all pharmacies
have the resources to carry out point-of-care testing.
The pharmacy study was designed to test whether attaching a nurse
trained in point-of-care hepatitis C testing and discussion of testing to a
cluster of pharmacies resulted in a higher rate of hepatitis C testing and treatment
uptake and completion than pharmacist referral for testing.
The study recruited 1410 participants receiving methadone at
40 pharmacies in 20 study sites. Pharmacies were randomly assigned to the
testing intervention or to standard of care. Nurses attended intervention pharmacies
regularly for a week and carried out screening, providing results at a subsequent
visit in most cases.
People diagnosed with chronic hepatitis C underwent
confirmatory laboratory testing and could then initiate treatment with
glecaprevir/pibrentasvir (Maviret), under the supervision of a nurse prescriber
(United Kingdom) or a physician (Australia). Follow-up testing 12 weeks after
completion of treatment was carried out at the pharmacy by nurses.
At standard-of-care pharmacies, pharmacists discussed hepatitis
C testing if the opportunity arose and referred participants to community
outreach clinics (UK) or their general practitioner (Australia) for testing.
Direct-acting antiviral treatment was offered according to standard protocols
to people who tested positive at these services.
The study population was predominantly male with a median
age of 40 years.
The primary study outcome was the proportion of participants
in each study arm who achieved a sustained virologic response.
Ten per cent (62 participants) in the standard-of-care arm
agreed to test for hepatitis C, 17 actually underwent testing, six were
positive and five started treatment.
In the intervention arm, 19% (148) agreed to test for
hepatitis C, 97% (144) were tested, 23 were positive and 22 started treatment.
Two people in the standard-of-care arm (40% of those treated)
and 18 in the intervention arm (82% of those treated) achieved a sustained
virologic response.
Participants in the intervention arm were almost 17 times
more likely to test for hepatitis C, four times more likely to start treatment,
four times more likely to complete treatment and eight times more likely to be
cured of hepatitis C, a multivariable analysis showed.
Dr Christopher Byrne, from the School of Medicine at the University of
Dundee, said: “Our study is the first to implement nurse-led point-of-care
testing – with results available on the same day – and treatment for hepatitis C
in community pharmacies. Implementing models of care which bring hepatitis c testing
and treatment into venues frequently used by people who use drugs can help to
reduce the barriers to healthcare engagement, which is illustrated by the
results of the trial.
“The novelty of this research is that it provides evidence that engaging at-risk
individuals and curing them of their infection is feasible and safe in
community pharmacies, with little need for extra hospital visits, and that
community pharmacists can play an important role in hepatitis C care.”