Eliminating hepatitis C virus infection

The effectiveness of direct-acting antiviral agents led the WHO to launch, in 2016, global efforts to eliminate HCV worldwide. Ambitious targets have been set, including to reduce new HCV infections by 90% and HCV-related mortality by 65% by 2030 (WHO 2017).

NHS England (2022) has committed to eliminate HCV by 2025 through a pioneering agreement on direct-acting antiviral agents with biopharmaceutical companies and renewed efforts to find people at risk of HCV infection, test them and treat them if needed. In 2022, NHS England stated that deaths from hepatitis C, including from liver disease and cancer, had decreased by 35% following a five-year contract worth almost £1billion to buy antiviral drugs for thousands of patients. Through concerted efforts to eliminate HCV, further reduction in HCV mortality is expected in the future (NHS England 2022).

Innovative ways to increase HCV testing in England have been developed, including opt-out blood-borne virus testing in emergency departments in some NHS hospitals and an NHS website offering free confidential HCV testing (https://hepctest.nhs.uk/). The offer of free testing is available to everyone over the age of 16 years in England. The website is available in English but also in Urdu, since there is a higher prevalence of HCV infection among people from South Asian communities (NHS England 2023).

At a local level, the Addiction Recovery Community in Hounslow (ARC Hounslow), England, has sought to achieve the micro-elimination of HCV and thereby reduce health inequalities for its service users. Micro-elimination is a strategy that seeks to target specific populations, in particular at-risk groups (Mangia et al 2021). Implementing prevention and treatment strategies in identified population groups at a local level is deemed to be a realistic objective. Lazarus et al (2018) stated that micro-elimination can be a useful approach to achieve a national goal.

In April 2022, ARC Hounslow started a nurse-led HCV micro-elimination project, using a whole-team approach to increase access to testing for blood-borne viruses, in particular HCV, and access to treatment. Until then, HCV testing and treatment had been carried out by staff members and partner agencies in isolation. Teamwork, partnership and collaboration enabled ARC Hounslow to achieve HCV micro-elimination among its service users by April 2023, well ahead of the NHS England target of 2025, making it one of the first teams in England to achieve micro-elimination after the coronavirus disease 2019 (COVID-19) pandemic. This led ARC Hounslow to be named Team of the Year in the 2023 Royal College of Nursing (RCN) Nursing Awards.

This article details how the team at ARC Hounslow achieved HCV micro-elimination and makes recommendations for other teams seeking to achieve it.

The Addiction Recovery Community in Hounslow

In Hounslow, people with harmful drug and/or alcohol use, including people who inject drugs, can access ARC Hounslow for treatment and support. Treatments for harmful alcohol use and alcohol dependency are offered in accordance with Office for Health Improvement and Disparities (2023) clinical guidelines. Opioid substitution treatment with methadone hydrochloride or buprenorphine is used to manage opioid withdrawal symptoms and opioid dependence (Department of Health 2017). The ARC Hounslow service is jointly provided by Central and North West London NHS Foundation Trust and the charity Phoenix Futures (https://www.phoenix-futures.org.uk/).

Hounslow is a large borough in west London with a diverse population and communities from various ethnic backgrounds. The Hounslow Equality Impact report identified that the borough encompasses some of the most affluent areas of West London as well as many areas experiencing socioeconomic challenges, with a significant number of neighbourhoods being ranked among the most deprived areas in England (Oxford Consultants for Social Inclusion 2021).

Poverty and belonging to a disadvantaged community are key factors in experiencing marginalisation and stigma that can lead to health inequalities. People who inject drugs are more likely to experience stigma and marginalisation than others (Cheetham et al 2022). ARC Hounslow has been at the forefront of reducing health inequalities, especially among people who inject drugs, by offering health interventions such as increased access to blood-borne virus testing and HCV treatment.

ARC Hounslow offers ‘find and treat’ outreach initiatives, HCV testing, HCV treatment, follow-up support, harm reduction measures such as a needle syringe programme to reduce the sharing of equipment between people who inject drugs, and interventions aimed at preventing the transmission of HCV, including raising awareness of the risks of sharing injecting equipment. HCV testing is carried out using rapid or instant HCV fingerstick blood testing kits, dried blood spot testing kits, and on-site polymerase chain reaction (PCR) (ribonucleic acid (RNA)) tests via a machine that can diagnose HCV infection within one hour (Cepheid 2024).

Additionally, the service provides wider health and well-being interventions such as psychosocial mental health support and physical health checks – including liver fibroscans and electrocardiograms (ECGs) – to improve service users’ health and reduce drug- and alcohol-related deaths. Service users who access these interventions receive information about HCV and undergo HCV testing.

The hepatitis C virus micro-elimination project

The aims of the project conducted at ARC Hounslow were to reduce HCV infection, reinfection, morbidity and mortality and to achieve HCV micro-elimination. Central to achieving these aims were identifying service users with a history of injecting drugs and those with new or previous HCV infection as well as improving access to testing and treatment.

Innovative ways of working

ARC Hounslow team members – who include mental health nurses, recovery workers, administrators, managers, a doctor and an employment specialist – worked together to achieve HCV micro-elimination. This whole-team approach resulted in simpler and clear team processes. One improvement was a reduction in the duplication of data entries required when a service user receives an HCV test. Team members were previously required to document the same information for each service user in six different places. The documentation requirements were reduced to one initial HCV data entry for each service user who receives a test. This reduced staff’s workload.

Innovative ways of working were developed, including an outreach programme to reach service users who were unable to attend the service due to ill health or challenges in attending healthcare appointments. For example, one service user who experienced challenges in attending appointments had their HCV test kit, and subsequently their HCV medicines, delivered by staff to their home. The service user completed their HCV treatment and subsequently achieved HCV RNA negative status. The outreach programme also involved working with local park rangers, whereby ARC Hounslow team members attended local parks to engage with people consuming alcohol and/or injecting drugs.

ARC Hounslow team members approached local faith groups, attended places of worship and took part in health fairs and events in the community to raise awareness of HCV. Wider collaboration with partner organisations and stakeholders – such as the Hepatitis C Trust, a peer-led organisation which provides support from people with lived experience – enabled a wider reach and likely improved the outcomes of the project.

Collaboration and partnership working

Collaboration and partnership working with stakeholders to address local health inequalities have been shown to improve outcomes for service users and enhance resilience for service providers (Cubbon 2023). In the ARC Hounslow project, multi-agency collaboration and partnership working led to a significant increase in the number of people who were offered HCV testing and treatment. Collaboration and partnership working also enhanced the experience of service users, who were able to access a variety of skills and expertise.

Stakeholders included service users and partner organisations such as the Hepatitis C Trust. The Hep C U Later programme provided external data analysis, evaluation and monitoring. Hepatology specialists from West Middlesex University Hospital provided specialist input on HCV and monitored the effectiveness of direct-acting antiviral agents. Multi-agency partnership was made possible through policy support from Central and North West London NHS Foundation Trust (2024).

Working with a range of stakeholders initially presented challenges due to different expectations and ways of working, but these were overcome through communication. Monthly meetings supported optimal communication and the aligning of goals. This fostered collaboration and a move from silo working to integrated partnership working, while also creating a shared purpose in terms of addressing local health inequalities and improving care for service users (NHS Providers 2018). Micro-elimination of HCV became the responsibility of all staff groups, who worked together as one wider team.

Feedback

Evaluation is an important aspect of nursing practice and can be used to obtain feedback on the effectiveness of a service and identify what changes need to be made (Moule et al 2017). In March 2023, to evaluate the project, written feedback was sought from service users who attended HCV testing appointments at ARC Hounslow and from family members who accompanied them. The NHS (2023) Friends and Family Test, which is designed to assist services in gaining feedback from service users, was used.

Seven service users provided feedback on their experience of HCV testing at ARC Hounslow. All stated that they had been treated with dignity and respect. Comments received from service users included:

‘[I was] treated with respect, friendly worker.’

‘Diligence, kindness, empathy and instructional.’

‘Very quick, efficient service, very friendly.’

Two family members provided feedback, both of whom said that they had been treated with dignity and respect and that their experience of the service had been very good.

Feedback was also received from partner organisations and stakeholders. For example, Louise Hansford, Hep C U Later elimination coordinator, said:

‘ARC Hounslow hepatitis C micro-elimination project has been evaluated through the Hep C U Later monthly dashboards. Well done on your testing and maintaining your micro-elimination status – Congratulations, what an incredible team effort, #HepCULater’

This positive feedback encouraged staff to continue with the project. Furthermore, feedback from informal staff discussions, from staff meetings and from ARC Hounslow HCV multi-agency partnership meetings showed that achieving micro-elimination had positively affected staff morale, since team members felt that they were making a difference to service users’ lives, increasing service users’ satisfaction and contributing to service improvements (Moyo-Hlahla and Crossland 2023).

Learning for staff and changes in practice

Areas for improvement were identified through internal evaluation, leading to learning for staff and changes in practice (Moule et al 2017).

The culture of an organisation guides the behaviour and attitudes of its members and directly affects performance, outcomes and the quality of care provided (NHS Improvement 2017). Leadership is key in facilitating culture change, setting the tone and demonstrating the desired standards of the organisation (Fergusson 2024). The project lead (and author of this article) was instrumental in inspiring team members to achieve the project’s goals. Role-modelling and demonstrating a can-do attitude enabled a culture change.

ARC Hounslow staff took ownership of the project and developed their own initiatives. For example, they began to discuss HCV and offer HCV testing during outreach visits in the community, thereby reaching a wider range of marginalised groups such as homeless people and mental health service users living in hostels. Staff also attended local community events and met local faith groups to raise awareness of HCV. These initiatives likely contributed to increasing the number of service users who took up the offer of HCV testing.

Effective therapeutic relationships are crucial in engaging service users, gaining their trust and enabling them to adhere to their treatment (DeAngelis 2019, Wright 2021, Quinn 2022). Developing therapeutic relationships with service users was central to the project, with team members demonstrating kindness, empathy, compassion and respect – as advocated by The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018).

A literature review by Balsom et al (2023) has identified ‘fear of diagnosis’ as a barrier for people to accept being tested. ARC Hounslow staff took a person-centred approach, treating service users with dignity and respect, establishing rapport and developing a therapeutic relationship with them. Subsequently, many service users accepted HCV testing despite their anxiety about the test results. Balsom et al (2023) also stated that stigma associated with blood-borne viruses and drug use (particularly injecting drug use) is an additional reason why some service users prefer not to be tested. Other reasons may include service users perceiving themselves as being at low risk of HCV or having limited knowledge about HCV and the treatment options available. Staff were aware of these potential barriers and of how stigma can affect service users’ decisions regarding testing.

Service users who did not feel ready to have a test or start HCV treatment were supported by the team, provided with harm-reduction strategies (DrugWise 2022) and given time to consider having a test or starting treatment in the future. One service user had declined to have an HCV test for 12 years. Staff supported that service user and established a therapeutic relationship with them, and the service user eventually agreed to undergo testing.

Celebrating achievements fosters team cohesion, effectiveness and collaboration (Kashyap 2024). Staff were praised in team meetings if they had offered HCV testing to the highest number of service users in a given month or if they had managed to offer HCV testing to service users who found it challenging to engage with the service. Team lunches were held following a successful HCV testing event in January 2023 that saw the highest number of service users being tested in a single month. Celebrating achievements showed to team members that their efforts were being noticed, acknowledged and appreciated.

The Care Quality Commission (2022) emphasises that determination, perseverance, engaging colleagues and gathering support are important in driving the necessary changes to advance nursing practice. The ARC Hounslow team was able to use these qualities to advance HCV micro-elimination and support service users to achieve HCV RNA negative status.

Recommendations for nursing practice

Primary care services are well placed to contribute to HCV elimination and increase testing opportunities for people at risk of HCV infection who are not using drug and alcohol treatment services, since nurses working in primary care may be able to reach them when they attend primary care services for other health needs. Offering HCV testing or directing people to the HCV testing website (https://hepctest.nhs.uk/) may increase the number of people who are identified as requiring HCV treatment.

Nurses in all healthcare settings can incorporate information about blood-borne viruses into their practice. They can be involved in working towards HCV elimination directly or indirectly through updating their knowledge of HCV and other blood-borne viruses, keeping abreast of developments in HCV treatment and raising awareness of HCV. Discussing HCV with service users, and offering testing where appropriate, will contribute to health promotion. Communicating with teams and organisations already involved in HCV work – such as hepatology teams at the local hospital, the British Liver Trust and the Hepatitis C Trust – will promote integrated care (Department of Health and Social Care 2022).

Conclusion

Achieving and maintaining HCV micro-elimination has been a significant milestone for the team at ARC Hounslow. Leadership, teamwork, innovative ways of working and partnership working have been central to achieving this goal. Further work is needed to eliminate HCV across the UK and the author calls on all healthcare professionals, particularly those working in primary care, to contribute, directly or indirectly, to the elimination of HCV.