Cynulliad Cenedlaethol Cymru	National Assembly for Wales
Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon	Health, Social Care and Sport Committee
Ymchwiliad i Hepatitis C	Inquiry into Hepatitis C
HSCS(5) H08
Ymateb gan Fwrdd Iechyd Prifysgol Aneurin Bevan	Evidence from Aneurin Bevan University Health Board

Background

Wales is signed up to a World Health Organisation global health sector strategy, which sets out to eliminate Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) by 2030 (90% reduction in incidence and 65% reduction in mortality). New directly acting anti-viral medications have revolutionised the treatment of HCV so that the disease is now essentially curable in the early stages.

The Welsh Health Circular WHC/2017/048 outlined a series of expected measures from multiple organisations and partnerships to contribute to the elimination target:

Reduce and ultimately prevent ongoing transmission of HCV within Wales
Identify individuals who are currently infected with HCV including those who have acquired HCV outside the UK and are now resident in Wales

2.1 individuals infected with HCV who were not linked to care

2.2 identifying individuals infected with HCV, who have never been tested and are unaware of the infection

Test and treat individuals currently infected with HCV who are actively engaged in behaviours likely to lead to further transmission

The Health, Social Care and Sport Committee will be undertaking a one-day inquiry into Hepatitis C. This paper provides a written evidence to the questions raised in the Committee’s terms of reference of the inquiry.

Current situation

Given the availability of the new directly acting antiviral medication in 2015, each health board was assigned treatment targets. In 2017-18, only one health board achieved the minimum treatment target with Aneurin Bevan University Health Board (ABUHB) being ranked third among all health boards. In 2018-19, only two health boards are on target whereas others are falling behind including ABUHB. Based on the current treatment numbers ABUHB is unlikely to meet the 2018-19 target. The key issue is that not enough people have been referred to our Blood Bourne Virus (BBV) service to enable the required number of Hep C cases to be treated.

The ABUHB Blood Bourne Virus (BBV) team provides treatment services across Gwent and also covers Brecon and Llandrindod Wells. The current service model includes provision of treatment clinics in both hospital and community health care settings. Regular clinics are held in the Royal Gwent Hospital in Newport, Gwent Drug and Alcohol Services (GDAS) in Tredegar, Gwent Specialist Substance Misuse Service (GSSMS) in Newport and Caldicot GP Practice. Ad hoc clinics are provided in Caerphilly, Blackwood, Ebbw Vale, Blaenavon and various GP surgeries across Gwent. The BBV team also offers an outreach service, home visits and treatment clinics in two prisons, on mental health wards, and at the Wallich drop in centre in Newport for homeless people.

The actions being taken to meet the requirements of the Welsh Health Circular (WHC/2017/048) published in October 2017 and subsequently meet the World Health Organization target to eliminate Hepatitis B and Hepatitis C as significant public health threats by 2030 are:

· ABUHB has been engaged with Public Health Wales led national HCV re-engagement exercise. This involves identifying and offering assessment/treatment to individuals with historical tests indicating exposure to Hepatitis C who may still be infected, but they were not linked to care.

· ABUHB has been working with GDAS to increase Blood Bourne Virus (BBV) testing. There are around 2100 patients accessing GDAS services. In 2017-18, only 18% were tested for BBV, 6% declined the offer, and 66% were not offered the BBV test. The key barrier identified for this low BBV testing was lack of Hep B vaccination for the GDAS staff. ABHUB has agreed funding to offer Hep B vaccination to 50 staff members. This will help to increase BBV testing in GDAS in 2019-20.

· Gwent Specialist Substance Misuse Service (GSSMS) of ABUHB also offers BBV testing and Hep B vaccine to service users. However, the uptake has been very low. The BBV team have been working with GSSMS staff to identify barriers and ABUHB will be putting measures in place to increase uptake.

· People who inject drugs and the homeless population are at high risk of contracting BBV infection. However, due to the chaotic and transient nature of their lifestyles they many go untested for BBV’s. ABUHB is setting up a Dried Blood Spot (DBS) Testing Incentive Scheme for service users of the Needle Exchange service in Newport and the Wallich Homeless drop in centre. The scheme is waiting for the addition of Hep C Polymerase Chain Reaction (PCR) test to the DBS test to enable a complete diagnosis.

· Gwent has an established problem of use of steroid and image enhancing drugs (SIEDs) in Gwent. To address this problem the BBV team have set up a steroid clinic. This clinic offers harm reduction advice, general health screening, ECG and BBV testing.

· ABUHB provide health care services to the two Gwent prisons. BBV testing is offered to all new prisoners. Wherever indicated HCV treatment and Hep B vaccination is offered in the prisons.

· ABUHB provides BBV treatment clinics in both hospital and community health settings across Gwent. This ensures good engagement with service users and the Did Not Attend (DNA) rate is less than 25%. The BBV team has plans to further strengthen provision of treatment clinics in community health care settings to minimise the DNA rates.

· Given the short treatment course for Hepatitis C and few side effects, the compliance with the treatment is good.

How the knowledge and awareness of the public and health professionals of the Hepatitis C virus can be increased?

• Newport has the third highest ethnic minority community behind Cardiff and Swansea. It has a population of 147,400, of these 12,900 (8.8 %) are from an ethnic minority background. In recent years, there have been a small number of projects around the UK to try to engage with the south Asian community. The projects that are integrated with the mosques seemed to bring the better results. Working in collaboration with a local GP, the ABUHB BBV Team has been running BBV awareness and testing campaign at the local mosques. Two events have been held at two mosques so far. Further events are planned to revisit theses mosques on a rolling basis twice yearly. Other communities have also expressed interest in the project.

• The ABUHB BBV team undertakes the following activities to raise BBV awareness among the professionals

10.

Ø Annual Liver Conference

Ø Talks at GP annual training days

Ø Training for the ABUHB clinical staff

Ø Training for the GDAS and GSSMS clinical staff

11.

The scope to increase community-based activity e.g. the role of community pharmacies

· ABUHB is aware of developments at the national level to involve community pharmacies in BBV testing.

12.

· There have been discussions going on locally to run a pilot project in Newport using the national service specification and protocols.

13.

The long-term viability of treatment programmes

· The ABUHB BBV team provides the ABUHB HCV treatment service. It comprises of two full time hepatology clinical nurse specialists. A hepatology consultant supervises the clinical work.

14.

· The funding ABUHB receives to provide a BBV treatment service is sufficient for the current number of patients being treated. However, the anticipated rise in treatment rates could pose a cost pressure and to achieve the WHO elimination target it is imperative that BBV testing and treatment services are adequately resourced to ensure long-term sustainability.