Kathryn OakesSenior Nurse for Viral Hepatitis

Kings College HospitalNovember 2011

� Background to the AVT outreach project

� Referring into the service and the role of the Physical Health Harm Reduction Nurse (PHHRN)

� Milestones

� Referral, assessment and treatment data

� Substance misuse levels

� Barriers to project success

� HCV - 85% chronicity rate with 20% cirrhosis rate1 and 3-5% risk per annum HCC2

� HCV most common cause transplantation in western population3 – 40% transplants at KCH = 168 pa

� Mortality rate planned to triple by 20304 with an £8 billion economic burden to the NHS5

� HCV prevalence in IDU’s up to 66% in London6

� Population reluctant to attend secondary care7

� LHH 1000 to 1200 clients with 10-15 new p.w1. Alter MJ Semin Liver Dis 1995; 15:Management of Hepatitis C NIH Consensus Statement 1997; March 24-26:15(3). 2. Cabrera R, Nelson D R. (2009) Review article: the management of

hepatocellular carcinoma. Alimentary Pharmacology and Therapeutics, 31: 461-476. 3. Lodato et al. (2008) Clinical trial: peg-interferon alfa-2b and ribavirin for the treatment of genotype-1 hepatitis C

recurrence after liver transplantation. Alimentary Pharmacology and Therapeutics, 28: 450-457 4. Cheruvu et al. (2007) Strategies to control hepatitis C infection among injection drug users. Hot

Topics in Viral Hepatitis, 6: 23-30. 5. British Liver Trust. (2010) Facts about Liver disease (online). 6. Health Protection Agency. (2009) Shooting up. Infections among injecting drug users in the United Kingdom 2008: An update. 7. Foster G. (2008) Injecting drug users with chronic hepatitis C: should they be offered antiviral therapy? Addiction, 103: 1412-1413

1

� Kosh Agarwal, Lead Consultant for VHS, KCH

� Mike Kelleher, Clinical lead for LA

� Kathryn Oakes, Senior Nurse VHS, KCH

� Mick Collins, Borough Lead for LA

� Tony Docherty, Deputy borough Lead for LA

� Mags O’Sullivan, Kristen Stone – PHHRN and Integrated Care Nurses, VHS KCH

� Martin McCusker, service user

� Dee Cunniffe, Reckitt Benckiser

� Fenella Jolly, Team Leader BBV/Homeless Team

� Alcohol intake does not exceed 40 units weekly

� Ideally no IV Crack Cocaine

� Client agrees to regularly attend appointments and consents to appropriate drug screening

� Stable housing with fridge

� Agree to enter needle exchange programme

� Stable from a psychological perspective

Is Client stable ? Assessment of client stability re: addiction

issues

Referral to Hepatitis Team

Appointment for

screening and education with Hep

CNS within 14 days

Client not

suitable for

AVT

Client

suitable for

AVT

Hepatology

review

Delivery AVT16 to

72 weeks

Cirrhotic or HBV offer Follow up at

Kings

Referral back to

Drug/alcohol advisory service

Contact Hep CNS team for

advice

Yes

No

Client tests Positive HCV/HBV

REFERRAL PATHWAY

� Contact known HCV RNA positive clients

� BBV testing and HBV vaccination

� Work with the substance misuse teams to identify clients for treatment and co-ordinate referral into the service

� Engagement of clients, education and harm reduction advice

� Acts as a resource and contact for patients on treatment and attends all KCH appointments

� Strategic role in service development

Working group established

Operational Policy and SLA finalised

Initial appt PHHRN

Transfer of PHHRN post

Meet service users

First treatment clinic

PHHRN appointed

1st assessment/education clinic

First medical clinic

Action plan formulated

Jan 2009 June 2010 Feb 2011 May 2011 July2011 Sept 2011

� RAISING AWARENESS & EDUCATION

ReferralSource Number patients Referred to Kings

Keyworkers at LHH 89 26 (29%)

FenellaJolly 2 1 (50%)

DRR 4 0 (0%)

RIOTT at MH 8 8 (100%)

Triage 15 0 (0%)

Previous bloods (Fenella) 9 1 (11%)

WHD + keyworker 3 2 (66%)

WHD 3 1 (33%)

Relative 1 0 (0%)

Total 133 * 39

•* 81 known HCV, 52 tested – 25 HCV RNA pos and 26 tested RNA negative, 1 HCV ab pos on

DBST and refusing venous sample•Data collection period 29/06/2011 to 26/10/2011

39 Booked for assessment and education

with KCH viral hepatitis CNS team

1 removed –

unfavourable

genotype and

IL28

16 booked for

future

assessments

17 completed

assessment

3 DNA’d& 1

declined

assessment

1 assessment

delayed –

social issues

Genotype Disease stage

Patient Genotype Treatment week Response

One 1 non cirrhotic 9 Complete EVRTW9

Two 1a non cirrhotic 14 RVR

Three 1b cirrhotic 0 N/A

Four 3a non cirrhotic 19 Complete EVRTW9

Five 3 cirrhotic 5 RVR

Six 3a non cirrhotic 14 RVR

Seven 3 non cirrhotic 5 5 log drop at TW4 to 9.92 E1

IU/Ml

Eight 3 non cirrhotic 5 3 log drop at TW4 to 1.06 E2

IU/Ml

Nine 3 non cirrhotic 3 N/A

%

Alcohol Number Abstinent Substitute Drug Level of drug use Number Substitute

Units p.w drugs Prescribing use Prescribing

0 26 15 (3 OT) 3 RIOTT 11 Cannabis 3 1 RIOTT

1 No substitutes Heroin or crack smoked once a week 4 (3 OT) 10 substitute

11 substitute IV heroin once or twice a week 1 (1 OT)

IV heroin once to three times a week 1 (1 OT)

IV heroin two to four times a week 2

0 - 20 8 4 2 RIOTT 4 Cannabis 1

2 substitute Occasional speed 1 (1 OT)

Heroin or crack smoked once a week 1

IV heroin use and crack smoked 1 - 2

wk 2

20-40 4 3 1 RIOTT 1 Cannabis and smoking crack 1 RIOTT

2 substitute

60 1 0 1

Heroin/IV skin popping 3 times a

week 1 1 substitute

Total 39 22 17

� Lack of awareness amongst substance misuse population; concerns about the side effects; previous experiences in secondary care; chaotic lifestyles – competing priorities

� Resource and time needed for engagement, education and referral

� Working across two sites; IT, medication dispensing, transportation samples, honorary contracts

� Different cultures and organisational changes

� Project is a work in progress

� We have learnt a lot about this population and working across sites/specialities

� To date a model that integrates specialist viral hepatitis and addiction services appears to work well

� Treatment outcomes will give us more insight into the effectiveness of the model

� The role of the PHHRN has been essential to engage clients and bridge services