Interventions for Impact

: Studies on improving care for people at risk of hepatitis c virus infection

Abstract

Hepatitis C Virus (HCV) is a blood-borne virus which, at the time this thesis was commenced, was estimated to affect approximately 71 million people globally. In 2016, the World Health Organization released ambitious global targets to eliminate HCV by 2030 premised on scaling up HCV diagnosis and treatment among priority infected groups. This thesis, through quantitative and qualitative methods, examines strategic approaches to improving (HCV) care in specific groups, namely: People who Inject Drugs (PWID), People Living with HIV (PLHIV), and incarcerated people.

In chapter one, an overview of HCV is provided alongside diagnostic and therapeutic approaches to its management. A thematic literature review is undertaken in populations relevant to the work of the thesis and critical gaps are identified. The chapter concludes by outlining the overarching research questions of the thesis.

In chapter two, the extent to which Tayside has progressed toward micro-elimination of HCV among known PLHIV, infected with HCV via injection drug use, in the region was examined. The study found that Tayside has made good progress on HCV elimination in this cohort and quantifies the impact that Direct Acting Antiviral (DAA) treatment had in broadening access to treatment for this population.

In chapter three, the early results from Tayside regional scale-up of HCV testing and treatment among PWID were analysed among primarily HCV mono-infected PWID. It specifically assessed the contribution of novel decentralised care pathways relative to conventional care and quantified re-infection risk, post-treatment follow-up, and mortality risk in the cohort, to inform future priorities of the regional HCV programme in the coming years.

Chapter four continued the focus on HCV in PWID and represents the primary project of the thesis. It was an international cluster randomised controlled trial of point-of-care (PoC) HCV RNA diagnosis and DAA treatment for PWID receiving opioid agonist therapy at community pharmacies. The aim of this study was to determine if the experimental PoC pathway led to a proportionally higher number of PWID diagnosed with HCV achieving a cure.

Chapter five’s focus shifted to improving transition from HCV diagnosis to treatment initiation in a cohort of incarcerated individuals in Tayside’s principal prison. It was a retrospective service evaluation of a pilot project which saw PoC RNA testing for HCV integrated into routine on-site prison BBV care. This work aimed to understand if implementing PoC testing was associated with quicker treatment initiation for incarcerated people. It further sought to quantify the cost implications of this approach as well as the barriers and facilitators associated with implementing it from a healthcare provider perspective.

In the final chapter, due to the heterogenous nature of the work undertaken, an integrating discussion of the findings of the thesis is presented. It is argued that the thesis makes valuable contributions under two key themes: health service design, and real-world data. The findings are related to the wider literature base and compared, where possible, across chapters. The chapter concludes with a review of the limitations of the thesis and suggestions for future work.

Date of Award	2022
Original language	English
Awarding Institution	University of Dundee
Sponsors	Merck, Sharpe & Dohme & AbbVie UK Ltd.
Supervisor	John Dillon (Supervisor) & Michael Miller (Supervisor)