Response of the UK Harm Reduction Alliance to the Hepatitis C Strategy for England
The UK Harm Reduction Alliance welcomes the publication of the Hepatitis C Strategy, which goes some way in establishing the responses required to tackle the many problems that Hepatitis C creates. However there are serious shortcomings in the current proposals for the implementation of the strategy, which only applies to England.
The hepatitis C strategy... concentrates on what needs to be done to improve services, with examples of good practice, rather than setting detailed prescriptive requirements on how it should be done. In line with these principles, the strategy does not impose national targets.
This departure from setting national targets has some positive aspects but overall we believe that the local freedoms that this will create for Primary Care Trusts will undermine equitable implementation of the strategy nationally. Local decision making, in line with Shifting the Balance of Power, is not going to provide an effective platform upon which to develop a comprehensive and equitable national strategy.
The new NHS structures have exposed financial pressures in many areas. The implementation of this strategy will have to compete against other initiatives that have the support of a National Service Framework to ensure delivery. The strategy does not identify any additional funding for treatment to support the implementation of the strategy, which will result in the continuation of postcode eligibility. It is crucial therefore that the strategy should be more than a national awareness campaign but be established as a fully funded strategy designed not only to increase numbers accessing testing but also able to receive treatment appropriate to their condition.
England is already behind Scotland in approving more effective forms of treatment. Pegylated interferon alfa-2a has been approved for use within the NHS in Scotland as an appropriate treatment for the management of adult patients with chronic hepatitis C in combination with ribavirin.
NICE is not conducting a technical appraisal until 2003 and if approved it is unlikely that funding would be found before 2005. The current guidance from NICE has been overtaken by the rapid advances in treatments. Pegylated interferon/ribavirin has improved treatment outcomes overall and weight adjusted dosing has further improved this, especially for Genotype 1.
There is a more robust approach adopted when considering drug users. The strategy recognises the role of injecting drug use in HCV transmission, which is generally positive as it acknowledges that this group is the one most affected after 1991, but fails to clearly promote the use of antiviral therapy amongst drug users. This is unacceptable, as it is unethical to deprive an individual appropriate treatment for their condition on the basis of lifestyle. The recommendation that testing should be generally available is positive. It must however be implemented as part of an integrated care pathway for treatment, so that referral processes are in place with clear criteria established.
The absence of any clear eligibility to treatment will discourage many from seeking testing. There will be little incentive to be tested if access to effective treatment is denied. Evidence exists to demonstrate that it is possible to treat current drug users successfully without many of the alleged difficulties - alleged because injecting drug users have not featured in the clinical trials.
Providing this treatment will also require liver specialists to examine the manner in which services are currently structured to enable the maximum benefit to be gained.
We have concerns that the offer to drug users of routine testing may become more than testing simply being available to those who want it. The establishment of a national standard of good practice allied to outcome indicators could have the effect of drug services coercing clients into tests to maintain performance.
Confidential testing needs to be in place and easily accessible from a number of places prior to the strategy being launched. Singling drug services out for performance monitoring is not the best way to achieve greater access to testing and subsequent treatment.
The strategy recognises the importance of prisons in the transmission of Hepatitis C. Prisons make a bad situation worse, 8% of the prison population is HCV+, 10x the rate in the general population, and prisons numbers continue to rise. The strategy concentrates on delivering a health promotion strategy within prisons when what is required are robust harm reduction initiatives.
There are no needle exchanges despite high levels of injecting. Continental experience shows these can be effectively introduced into prisons. Little opportunity has been made of providing sodium hypochlorite as an interim measure.
Drug treatment is poor and what is available is focussed towards abstinence even though many drug users serve short sentences - effectively undermining gains achieved in the community. The provision of methadone maintenance should be a priority for all prison establishments given that the majority of drug users receive short sentences that only serves to interrupt the consistency of treatment offered in the community. Given that there is a firm evidence base to the effectiveness of methadone maintenance, there is no reason why this treatment should be available in all prison establishments. The failure to provide access to effective methadone treatment not only increases the risk of drug users becoming infected with hepatitis C while in prison, but also increases the risk of overdose on release. Establishing methadone treatment in all prisons would also contribute to achieving targets for reducing drug related deaths.
Increasing evidence is emerging about tattooing as an infection route generally and prison tattoos are extremely high risk.
The proposal for a national standard for health promotion information about avoiding Hepatitis C is a totally inadequate response on its own. Any awareness campaign must be seen in the context of the provision of harm reduction initiatives and entitlement to testing and treatment.
The move to fully integrate prison medical services into the NHS by 2007, starting in 2003 is to be welcomed. This should ensure that health care is improved and entitlement to treatment should be provided on the same basis, though it will need to be monitored. The extra funding available should support this integration and access HCV testing and treatment services should be part of this improvement.
Funding will be the key to the successful delivery of this strategy. Without additional funding, especially for treatment, it is unlikely HCV will become a priority for implementation by PCTs. Greater recognition needs to be given to the economic costs of not funding the strategy as these will make themselves felt in other areas of the health service and more generally.
UKHRAs main concerns are the lack of detail and funding in ensuring effective implementation. The strategy is comprehensive in coverage BUT aspirational in implementation
Submitted on behalf of the UK Harm Reduction Alliance
The UK Harm Reduction Alliance is an active network of drug workers, health care professionals, drug users and researchers seeking to promote a harm reduction focus in UK drug policy.