Hepatitis C elimination: the next three years Dr Christopher Tibbs Medical Director, Commissioning, NHS England & NHS Improvement South East Region
Hepatitis C elimination: the next 3 years Christopher Tibbs Medical Director Commissioning NHS-E and NHS-I South East Region
New structures, new team, new opportunities • NHSE=NHSI • Directorate of Direct Commissioning • Specialised Commissioning • Health and Justice • Section 7 Public Health • GP • Medical Directorate • Regional Medical Director • Medical Director Commissioning • Medical Director Medical Directors System Improvement and Professional Standards
Service development New technique POC CRG Evaluation NICE Clinical Panel CPAG Outputs SCOG • Service specifications • Circulars SSCC Procurement Commissioning criteria Commission current providers
The Journey so far E Population Molecular L dynamics Epidemiology Epidemiology I Molecular Biology M Drug design Cirrhosis I Cure HCC SVR N Transplant A T Interferon Interferon Direct + Ribavirin Peg-Interferon I Acting + Ribavirin Anti-virals O N 2000s 2010s 1987 1988 1990s 2020s
Service development: systems can work New technique 2004: POC CRG Interferon alfa (pegylated and non- Evaluation pegylated) 2006: Establishment of HCV ODNs Peg IFN and RIBV and ribavirin CQIN 2012: Clinical Panel NICE Testing Procurement 2013: Peg IFN and RIBV in young people 2015: CPAG Ombitasvir – paritaprevir – ritonavir with or without dasabuvir 2015 Sofosbuvir SCOG 2015: Ledipasvir-Sofosbuvir 2019: HCV treatment in acute hepatitis C 2016: Elbasvir-grazoprevir 2019: Retreatment SSCC 2017: Sofosbuvir-velpatasvir 2018: Sofosbuvir-velpatasvir-voxilaprevir Commissioning 2018: Glecaprevir-pibrentasvir criteria
Overview of Elimination plan • We want to eliminate in 3-5 years • Year 1 – Data, data, data • Year 2-3 – Full steam ahead • Year 4 – mopping up
Treating the population • The Challenge • Symptomatic and know patients largely treated • Prisons provide a population based sample • Hard to reach populations remain a challenge • Drug users • Homeless • Those born in high prevalence areas • Case finding • Groups who do not engage with services or society • Settings of care • Institution phobia • Community infrastructure
Treating the individual • Diagnosis • Keys to success • New diagnostic techniques • Timeliness • Administration • Making it easy • Low risk therapy • Compliance • Light touch • 80% may be good enough • Follow up • Narrow window of opportunity • On treatment • Shortest treament course • Clearance • reinfection • Cultural challenge: taking the service to patient, new settings of care
HCV – ODN support ODN ODN ODN ODN ODN ODN ………. 1 2 3 4 5 22 ODNs control the local delivery solutions They are the key point of contact We will give you £500 per treated patient We will give you free testing kits
HCV – Towards 30K NHSE et al will provide solution options Prison support ODN ODN ODN ODN ODN ODN ………. 1 2 3 4 5 22
HCV – coordinated commissioning • Direct commissioning now encompasses • Specialised eg treatment centres in ODNs • Health and Justice • Prison medical services • In-reach • Section 7a Public Health • Screening • Immunisation • Primary care • Case finding in general practice and other community settings (addiction services commissioned by Local Authorities)
HCV – global support Prison support Drug service mapping and peers ODN ODN ODN ODN ODN ODN ………. 1 2 3 4 5 22
HCV – global support • Pharma will provide people to map services • (list all sites, list all commissioners, arrange introductions etc) • The Hepatitis C Trust will supply peers
HCV – global support Prison support Drug service mapping and peers ODN ODN ODN ODN ODN ODN ………. 1 2 3 4 5 22 Needle exchange pharmacies
Pharmacy support • NHSE contracts with pharmacies to supply services • In this years negotiation we are offering a ‘Hep C testing’ service and a ‘Hep C monitoring service’
HCV – global support Prison support Drug service mapping and peers ODN ODN ODN ODN ODN ODN ………. 1 2 3 4 5 22 Needle exchange GP testing
HCV – global support • We will pull data from GP records (Locally at first, later centrally) • We will analyse for HCV risk factors • ODNs will be provided with a list
The Deal • We must prescribe drugs in line with the contract:- • Abbvie 16.7% • MSD 23.8% • Gilead 59.5% • Failure to do so reduces level of support
Drugs come in different shapes and sizes
HCV – National Picture • What we are up to • What we have achieved • Prisons
2019 – Year 1 Where are we? • Registry 46,000 • Treated patients 41,551 • To be treated 4,449 • To be found 67,000 • PHE estimate of HCV population 113,000
2019 – Year 1 Where are we? April – June 2018 = 2774 treatments April – 25 June 2019 = 2767 treatments
HCV – towards elimination How are we doing? All HCV genotypes: SVR12 95.6% (95.2 – 95.9) 100 98 96 94 SVR12 (%) 92 90 88 86 84 82 80 No fibrosis Mild fibrosis Moderate CC Past DC DC fibrosis
How are we doing? % HCV % transplants for HCV in UK 15 10 % HCV 5 0 2012-13 2013-14 2014-15 2015-16 700 600 500 400 Total OLT 300 HCV OLT 200 Deaths from HCV or HCC 100 in patients with HCV 0 (PHE report on HCV 2016) 2012-13 2013-14 2014-15 2015-16 Transplants for HCV
Treatment of hepatitis C and possibilities for elimination in London Professor Ashley Brown West London ODN Clinical Lead
HCV CV Actio tion/P /PHE Hepatit itis is C Good Practic ice Roadshow, West London Friday 27 th September 2019 Prof Ashley Brown, Imperial College Healthcare NHS Trust, London, UK
NHS England HCV ODNs • The ODNs were established by NHS England as a way of ensuring equity of access and the responsible use of an expensive resource • Each ODN has a lead who heads an MDT (composed of hepatologists and/or ID physicians, CNS and pharmacists) • Strict minimum and maximum treatment targets were set to control budgets while achieving elimination by 2025 with severe financial penalties for failing to comply • Heavy emphasis on data collection to confirm RWE • Strict prescribing rules in keeping with six monthly price tendering rounds
HCV Operational Delivery Networks in London North Central London ODN Barts (East London) ODN West London ODN South Thames Hep Network ODN
West London Working Together
West London ODN: Spreading Tentacles A A. St Marys Hospital, Imperial College NHS Trust KEY 1. Hammersmith Hospital HUB SITE ? 2. Charing Cross Hospital 3. St Charles’ Hospital Site offering Testing, Diagnosis AND Treatment ? 4. Turning Point, Soho C Site offering Testing and Diagnosis with onward ? 5. Turning Point, New Coach House referral for treatment 6. Turning Point, Acorn House 7. ARCC, Willesden Centre for Health 8. St. Mungo’s Broadway Centre 9. Offender Healthcare, HMP Wormwood Scrubs 1 10. Heathrow Immigration Removal Centre 7 1 6 D 9 A 1 4 3 1 3 2 8 5 1 0 4 2 B A. Northwick Park Hospital C 3 2 1. Central Middlesex Hospital 2. Ealing Hospital B A. Chelsea & Westminster Hospital 3. RISE, Ealing Broadway 1. Dean Street Clinic, Soho 2. St Stephen’s Centre D 3. West Middlesex Hospital A. Hillingdon Hospital 4. Victoria Drug and Alcohol Service 1. ARCH Drug & Alcohol Services, Uxbridge
Testing and Treatment for HCV now available at 34 locations in West London ODN Hospital Clinics (10) St Marys, Hammersmith, St Charles, Charing Cross, Chelsea & Westminster, West Middlesex, Ealing, Central Middlesex, Northwick Park, Hillingdon Drug & Alcohol Services (9) Turning Point Soho, Acorn Hall North Kensington, ARC Willesden, New Coach House Shepherds Bush, Ealing RISE, WDP Harrow, CGL Victoria, ARCH Uxbridge, ARC, Hounslow Homeless Hostels (7) Hope Gardens, The Old Theatre, Broadway Centre Shepherds Bush, St Mungos 209 Harrow Rd, King George Hostel, Pound Lane Hostel, St Mungos Edith Road GP Practices (2) Dr Hickey Practice, Great Chapel Street Sexual Health Clinics (4) Dean Street, Wharfside Clinic, Kobler Centre, Hammersmith Broadway Prisons (1) HMP Wormwood Scrubs Immigration Removal Centre(1) Coinbrook/Heathrow IRC Community Pharmacy (1) Portmans Pharmacy
Achieving the Mind Shift in HCV Care HCV AS A HCV AS PUBLIC A HEALTH LIVER ISSUE DISEASE Achievement of Prevention of elimination as a cirrhosis, HCC and public health issue premature death Alleviation of Prevention of extra-hepatic BENEFIT TO BENEFIT TO onward symptoms INDIVIDUAL SOCIETY transmission
Those Living with HCV Iatrogenic Former Haemodialysis Pregnant MSM PWID’s pre-1989 Patients Women People who Immigrant Homeless Undocumented Prisoners use Drugs Communities
Those Living with HCV Iatrogenic Former Haemodialysis Pregnant MSM PWID’s pre-1989 Patients Women THE MAJORITY OF THOSE WHO WILL ATTEND SECONDARY CARE SERVICES HAVE ALREADY BEEN TREATED People who Immigrant Homeless Undocumented Prisoners use Drugs Communities
Those Living with HCV THOSE MAJORITY OF THOSE WHO ARE UNDIAGNOSED AND/OR UNTREATED ARE UNLIKELY TO ATTEND TRADITIONAL SERVICES Iatrogenic Former Haemodialysis Pregnant MSM PWID’s pre-1989 Patients Women People who Immigrant Homeless Undocumented Prisoners use Drugs Communities
Changing Models of Care Patient expected to come to hospital for diagnosis and treatment “TRADITIONAL MODEL” Testing and diagnosis in the community but patient comes to hospital for treatment “TRANSITIONAL MODEL” All diagnosis and treatment taking place in the community “OPTIMAL MODEL”
Investing in Case Finding: Everyone’s a Winner! CASE FINDING THOSE WHO HAVE BEEN THOSE WHO HAVE NEVER DIAGNOSED BUT HAVE DISENGAED PREVIOUSLY BEEN DIAGNOSED AND/OR ARE UNAWARE OF WITH CHRONIC HCV AVAILABILITY OF DAA THERAPY THE ODN THE NHS PHARMA THE PATIENTS PUBLIC HEALTH ACHIEVING ENDING THE COST- RAPID RUN-RATE EFFECTIVE EPIDEMIC INCREASED ACCESS TO SECURES ELIMINATION CURATIVE PRESCRIBING CQUIN WHILE COSTS NATIONAL TREATMENTS PAYMENT CAPPED KUDOS
Case Finding: The New Deal £12m £7m CASE 40m FINDING POT Case Finding Programmes
The New Deal: Cross Cutting Funding Barts & East London Central North London South Thames West London Kent Sussex Surrey NEEDLE SYRINGE PROGRAMMES Wessex PWIDS AND PEER PROJECTS Thames Valley GP CASE FINDING PRISON PROJECTS Bristol SW Peninsula East of England Birmingham Leicester Nottingham Lancashire & South Cumbria Merseyside & Cheshire Greater Manchester South Yorks West Yorks North Yorks & Humberside Newcastle & North Cumbria
Details of the New Deal NHS Funded Pharma Funded Point of care testing in Data collection and regional pathway Drug & Alcohol Services DATs coordinators in DATs Pathway Mapping Point of care testing in Cepheid machines in 30 prisons Health & Justice prisons Orasure testing and HITT squads Payment for POC testing Community Pharmacies for NEx clients ePR interrogation software GP search tool General Practice South Asian projects Peer-to-peer, Peer coordinators and Per patient payment ODNs community liaison officers
The New Deal: Replacing the Stick with the Carrot PREVIOUSLY NOW All funding from NHS Collaboration between NHS and pharma Tight run-rate targets No maximum to numbers treated CQUIN emphasis on data collection CQUIN emphasis on getting patients and completion of treatment onto treatment Tight prescribing restrictions Wider choice of treatments Genotype essential 20% can be treated as ’pan - genotypic’ Financially penalizing under Financially rewarding over performance performance
The New Deal: Per Patient Payment • £500 per patient commenced on treatment • Money MUST be reinvested in case finding programme • Money can be distributed down the patient pathway
Changing Models of Care HCVAb +ve patient expected to come to hospital for work-up and treatment “TRADITIONAL MODEL” Testing and diagnosis in the prison. Secondary care staff enter prison to treat “IN - REACH MODEL” All diagnosis and treatment taking place in the prison with external support from the specialist team “IDEAL MODEL”
West London ODN: Prison Outcomes • 95% screening rates at reception • HITT squad planned to ‘mop - up’ those missed • Full time Peer Worker • Rapid POC pathways for those at highest risk • Upskilling and empowerment of Prison HC team • 58 prisoners commenced on treatment this year • 22/58 achieved SVR12 • 18/58 not yet reached SVR12 • 1/58 treatment failure (<4w treatment) • 17/58 LTFU (for time being!)
Addressing the ethnic mix of West London
Expanding Horizons • New programme commencing at the Coinbrook Immigration Removal Centre • Permission to treat reinfections (and acute infections?) will have a real impact in West London • Development of pharmacy programmes
Review of 8017 HCVAb positive results in West London 134 1632 1574 SPONT CLEAR TREATED DEAD 48 PCR POS 156 NO PCR KNOWN 611 UNSUITABLE TO BE REVIEWED 313 UNTRACEABLE 320 3229
2763 Patients treated as part of the West London ODN Programme 300 257 250 225 207 189 186 200 175 165 157 150 147 141 136 150 127 129 124 96 92 100 39 50 9 7 5 0 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 2017 2017 2017 2017 2018 2018 2018 2018 2019 2019 2019 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
Treatment as Prevention Works! PWID population within West London ODN 7000 6000 5000 4000 3000 2000 1000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Cirrhosis Moderate Mild Achieved SVR
West London ODN – ahead of the Curve! 250% 221% 188% 200% 149% 150% 139% 117% 125% 127% 129% 91% 92% 96% 98% 98% 101% 103% 100% 71% 73% 78% 79% 80% 81% 82% 50% 0%
Conclusion • Collaboration between stakeholders remains crucial • The switch of emphasis to case finding is essential if elimination is to be achieved • New models of care continue to evolve increasing access to treatment in vulnerable populations • West London is well on track to achieve elimination of HCV as a Public Health issue by 2025
Hepatitis C Good Practice Roadshow Friday 27 th September 2019 West London ODN #hepCwestlondon
Good practice case study: Hepatology nurse community outreach Lorna Harrison Clinical Nurse Specialist, Hepatology, Imperial College Healthcare NHS Trust
Good Practice Case Study Hepatology Nurse Community Outreach Lorna Harrison CNS Hepatology Imperial College Healthcare NHS Trust 83
Content • Relevant Patient History • Patient seen at D&A Clinic • Approved at WL ODN • DNA Start Date. Why? • Patterns of behaviour • Team Work • Outcome 2
Relevant Patient History • 59 years old, white, British, male, single • Unemployed • Past PWID • Attends D&A Clinic: Methadone 55mls OD • HCV AB+ve for over 20 years 3
Patient Seen at D&A Clinic • HCV treatment naïve • FibroScan: 4.6 kPa • Normal LFTS, FBC, U&E & PT • HIV & HBV negative • HBsAb >1000 Miu/mL • HCV G.1a • VL 650,00 IU/mL 4
West London ODN: Approved Patient for Harvoni, 8 weeks 5
Multiple DNA Start Dates! 6
Why? • Evicted from stable accommodation • Unpredictable attendance times at D&A Clinic • Patient has no mobile • No NOK 7
Patterns of Behaviour 8
Patient, D&A staff, Hepatology Consultant, Community Pharmacist & CNS! 9
Outcome 24 weeks’ post HCV RNA negative. Cured! 10
Good practice case study: The value of the peer Stuart Smith Director of Community Services, The Hepatitis C Trust
The Hepatitis C Trust Peer to Peer Education Testing & Treatment As a sustainable healthcare intervention Target population: People attending drug services, rehabs, detoxes, hostels and day programmes who are currently or previously affected by substance misuse Stuart Smith
History First Hepatitis C Trust Peer Project 2010 Objectives Reach into the substance user community and deliver core messages about the importance of prevention, testing and treatment assessment Deliver workshops based on a peers personal experience of hepatitis C diagnosis, care and treatment Aims Improve awareness of hepatitis C amongst PWIDs Motivate people at risk to access testing Motivate people already diagnosed to access specialist services for liver assessment & treatment decision Ultimately – change attitudes towards hepatitis C amongst PWIDS & wider community
Why peers? Community Drug • Trust leads to engagement Treatment • Empower patients Community Prisons Outreach • Leave No One Behind PEERS • Provide vital link between community and secondary care South Asian Community • Current community services climate Pharmacy Community Primary Care
The last group I attended
Passing on Information A number of interviewees explicitly indicated that they had passed on messages from the training to their peers: “I speak about it quite a bit with people I see in the service. I’ve also seen other service users who’ve been to the sessions telling others about it outside the main building” “I’ve spoken about what I learned in the session with my partner – we discussed the importance of being careful, the thing about notes which neither of us had known, and about the developments in treatment.”
Where are the patients? Advanced Disease Committed to Recovery Stable on OST Only in touch with NSP Hard to engage Residential Detox NOT hard to find Hostels – Homeless Shelters Ex IDU – Now Alcohol Prisons
We need to go beyond the current boundaries of care
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