Paul McIntyre

Hepatitis C virus among high and low risk pregnant women in Dundee : unlinked anonymous testing

Objective To determine the prevalence of the hepatitis C virus among pregnant women, to gauge the non‐injecting, particularly sexual, risk of them being hepatitis C virus infected and to assess the potential impact of selective antenatal screening.

Prevalence of hepatitis C among injectors in Scotland 1989-2000: declining trends among young injectors halt in the late 1990s.

We previously reported a continual decline in anti-HCV prevalence among young injectors from Glasgow and Lothian between 1990 and 1997. The original study was extended to ascertain if the anti-HCV prevalence among injectors from Glasgow, Lothian, Tayside and Grampian had changed since 1997. Residual sera from injectors who had undergone attributable anti-HIV testing were tested anonymously for anti-HCV. In all four regions, no significant changes in prevalence were found among those aged < 25 years during the late 1990s (Glasgow 1997-9/00: 43%-41%; Lothian 1997-9: 13%-17%; Tayside 1997-9: 45%-35%; Grampian 1996-9: 28%-29%). Among those aged > or = 25 years, significant decreases in prevalence were only observed in Glasgow (1997-9/00: 79%-72%, P = 0.03) and Lothian (1997-9: 54%-45%, P = 0.05). The findings highlight that existing harm reduction measures, acknowledged as having helped to reduce the spread of HCV, are not sufficient to bring this epidemic under control and reduce transmission to sporadic levels.

Rise in testing and diagnosis associated with Scotland's Action Plan on Hepatitis C and introduction of dried blood spot testing

Background A key aim of the Hepatitis C Action Plan for Scotland was to reduce the undiagnosed population through awareness-raising activities, for general practitioners and those at risk, and the introduction of dried blood spot (DBS) sampling in community drug services to overcome barriers to testing. This study evaluates the impact of these activities on testing and diagnosis. Methods Data on hepatitis C virus (HCV) testing undertaken between January 1999 and December 2011 in Scotlands four largest health boards were analysed. Segmented regression analysis was used to examine changes in testing following the (1) launch of the Action Plan and (2) introduction of DBS testing. Results Between the pre-Action Plan and Action Plan periods, increases were observed in the average number of HCV tests (19 058–29 045), positive tests (1993–2405) and new diagnoses (1221–1367). Since July 2009, 26% of new diagnoses were made in drug services. The trend in the number of positive tests was raised during the Action Plan, compared to pre-Action Plan, particularly in drug services (rate ratio (RR)=1.4, p<0.001) and prisons (RR=1.2, p<0.001); no change was observed in general practice. Following introduction of DBS testing, there was a 3-fold increase in testing (RR=3.5, p<0.001) and 12-fold increase in positives (RR=12.1, p<0.001) in drug services. Conclusions The introduction of DBS sampling in community drug services has made an appreciable contribution to efforts to diagnose the HCV-infected population in Scotland. These findings are important to other countries, with injecting-related HCV epidemics, needing to scale-up testing/case-finding initiatives.

The impact of a managed care network on attendance, follow-up and treatment at a hepatitis C specialist centre.

Summary.  Infection with the hepatitis C virus commonly occurs in patient groups who have difficulty accessing conventional medical care, reducing their chance of successful antiviral therapy. Managed care networks (MCNs) have been suggested as a mechanism of improving access to care; however, there is little evidence to support their use in patients with hepatitis C. The aim of this study was to evaluate the impact of a MCN for patients with hepatitis C. This was a retrospective cohort study of all individuals in our area who had received a positive hepatitis C antibody test between August 1994 and June 2008. The MCN introduced a new referral pathway, which included nonmedical referrals and outreach nurse‐led clinics. These interventions were introduced in 2004 and evaluated in 2008. After the introduction of the MCN, the proportion of individuals who accessed care increased from 61% (280/430) to 82.4% (721/875). There was an increase in nonmedical referrals with 81 (18.3%) being directly referred from Drug Problem Services and 75 (17%) from the Prison Service. The changes to referral did not have a negative impact on treatment outcomes as the number who completed treatment increased from 66.1% (43/65) to 73.7% (98/133) and the sustained virological response increased from 50.7% (33/65) to 60.9% (81/133). This study provides evidence that the collaboration of health care professionals within a network can have a radical effect in improving access to care in a traditionally hard to reach population. This has been achieved with little additional resource, but rather working smarter with existing staff.

Hepatitis C reinfection following treatment induced viral clearance among people who have injected drugs.

BACKGROUND Although people who inject drugs (PWID) are an important group to receive Hepatitis C Virus (HCV) antiviral therapy, initiation onto treatment remains low. Concerns over reinfection may make clinicians reluctant to treat this group. We examined the risk of HCV reinfection among a cohort of PWID (encompassing all those reporting a history of injecting drug use) from Scotland who achieved a sustained virological response (SVR). METHODS Clinical and laboratory data were used to monitor RNA testing among PWID who attained SVR following therapy between 2000 and 2009. Data were linked to morbidity and mortality records. Follow-up began one year after completion of therapy, ending on 31st December, 2012. Frequency of RNA testing during follow-up was calculated and the incidence of HCV reinfection estimated. Cox proportional hazards regression was used to examine factors associated with HCV reinfection. RESULTS Among 448 PWID with a SVR, 277 (61.8%) were tested during follow-up, median 4.5 years; 191 (69%) received one RNA test and 86 (31%) received at least two RNA tests. There were seven reinfections over 410 person years generating a reinfection rate of 1.7/100py (95% CI 0.7-3.5). For PWID who have been hospitalised for an opiate or injection related cause post SVR (11%), the risk of HCV reinfection was greater [AHR=12.9, 95% CI 2.2-76.0, p=0.002] and the reinfection rate was 5.7/100py (95% CI 1.8-13.3). CONCLUSION PWID who have been tested, following SVR, for HCV in Scotland appear to be at a low risk of reinfection. Follow-up and monitoring of this population are warranted as treatment is offered more widely.

Prevalence of antibodies to hepatitis C virus, HIV and human T-cell leukaemia/lymphoma viruses in injecting drug users in Tayside, Scotland, 1993-7

The prevalence of blood-borne viruses in injecting drug users (IDUs) in Tayside, Scotland was determined by testing serum samples from IDUs who underwent attributable HIV antibody testing during 1993-7. The prevalence of antibodies to HIV was 29/802, (3.6%); to hepatitis C virus (HCV) 451/691, (65.3%); and to human T-cell leukaemia/lymphoma viruses type 1 and 2 (HTLV) 0/679, (0.0%). The prevalence of HIV and HCV antibodies were higher in subjects over the age of 25 (P = 0.03 and P = 0.001, respectively). During 1993-7 the prevalence of HCV fell only in younger female IDUs (P < 0.01). HIV prevalence has declined dramatically since 1985, when a rate of 40% was recorded in similar populations. Harm reduction measures have failed to control HCV the spread of infection among IDUs in Tayside, as indicated by the high proportion of antibody positive IDUs, particularly males under the age of 25. Future studies should address the nature and effective reduction of continuing risk taking among IDUs in Tayside.

Dry blood spot testing for hepatitis C in people who injected drugs: reaching the populations other tests cannot reach

Objective The aim of the study was to evaluate the effectiveness of Dry Blood Spot testing (DBST) for hepatitis C within a geographical area. Design This is a prospective cohort study of all individuals living in Tayside who had received a hepatitis C virus (HCV) DBST between 2009 and 2011. Results During the study, 1123 DBSTs were carried out. 946 individuals had one test. 295 (31.2%) of these individuals were HCV antibody positive on their first test. Overall, 94.3% (902/956) individuals returned for the results of their test. During the course of the study 177 individuals were retested and 29 new cases of hepatitis C were detected. 249 individuals attended for further follow-up, and 164 (65.5%) were PCR positive. All 164 PCR-positive individuals were offered referral into specialist HCV services for further assessment. Data showed 62.5% were genotype 3, 65.1% had a low viral load (<600 000 iu/ml) and 77.5% had a Fibroscan score below 7 KPa. To date, 40 have commenced treatment and a further 16 are currently in the assessment period. Overall, we have retained in services or treated 63.6% (105/164) of patients who were initially referred and with effective support mechanisms in place we have achieved sustained viral response rates of 90%. Conclusions The study has shown that DBST is a complementary technique to conventional venepuncture for the diagnosis of HCV. The majority of patients have low viral loads and low fibrosis scores, so that while this group of patients may be difficult to reach and may be challenging to maintain in therapy, they are easier to cure.

Trends in the incidence of HIV in Scotland, 1988–2009

Objectives To estimate temporal trends in HIV incidence and prevalence in Scotland, according to three main risk groups for infection: men who have sex with men (MSM), injecting drug users (IDUs) and heterosexuals. Methods The authors extracted data for all single- and multiple-tested individuals from the national HIV test database covering the period 1980–2009 and calculated the incidence of HIV infection in each risk group and estimated RRs by fitting Poisson regression models. Results 620 of 59 807 individuals tested positive following an initial negative HIV test, generating an overall incidence rate of 3.7/1000 person-years (95% CI 3.4 to 4.0); 60%, 20% and 37% of the 620 were associated with the risk behaviour categories MSM, IDU and heterosexual, respectively. The incidence rate among MSM in Scotland remained relatively stable between the periods <1995 and 2005–2009 (overall: 15.3/1000 person-years, 95% CI 13.8 to 17.0), whereas the incidence among IDUs decreased between the periods <1995 and 2005–2009, from 5.1/1000 to 1.7/1000 person-years, and also decreased among heterosexuals, from 2.9/1000 to 1.4/1000 person-years. Conclusions The reduction in the incidence rate among IDUs suggests that harm reduction measures initiated from the late 1980s were effective in reducing HIV transmission in this risk group; however, the absence of a reduction in HIV incidence rates among MSM is disappointing and highlights the need for renewed efforts in the prevention of HIV in this major risk group.

Multidisciplinary managed care networks-Life-saving interventions for hepatitis C patients.

Successful hepatitis C virus (HCV) therapy depends on effective pathways of care. Over two decades, we have developed four sequential models of care latterly using a multidisciplinary managed care network to improve HCV testing, care and treatment. This was a cohort study to evaluate the effectiveness of care pathways, carried out using all HCV antibody‐positive individuals tested in a geographical region between 1994 and 2014. The study involved 3122 HCV‐positive patients. They were divided into four subgroups representing different care pathways defined by their date of HCV antibody diagnosis. The number who accessed treatment services within 1 year of diagnosis increased from 77 of 292 (26.3%) to 521 of 821 (72.9%). The rate of treatment starts within 1 year of diagnosis increased from 6 of 292 (2.0%) to 133 of 821 (16.2%), and the sustained viral response rate improved from 61.6% to 77.4%. All‐cause mortality decreased from 232 of 688 (33.7%) in subgroup A to 55 of 1207 (4.5%) in subgroup D, and multivariate analysis showed that pathway type was an independent predictor of mortality irrespective of age, sex, SVR status or HIV co‐infection with pathway in D having an odds ratio of 0.53(0.40‐0.77; P<.001) compared to pathway in A. At study end, 78% (3122) of an estimated 4000 HCV positive had been diagnosed. In total, 97.5% of HCV caseload was referred to specialist services and 89% attended for assessment. The introduction of a managed care network increased access to care and reduced all‐cause mortality.

Use of laboratory-based surveillance data to estimate the number of people chronically infected with hepatitis B living in Scotland

It is paramount to understand the epidemiology of chronic hepatitis B to inform national policies on vaccination and screening/testing as well as cost-effectiveness studies. However, information on the national (Scottish) prevalence of chronic hepatitis B by ethnic group is lacking. To estimate the number of people with chronic hepatitis B in Scotland in 2009 by ethnicity, gender and age, the test data from virology laboratories in the four largest cities in Scotland were combined with estimates of the ethnic distribution of the Scottish population. Ethnicity in both the test data and the Scottish population was derived using a name-based ethnicity classification software (OnoMAP; Publicprofiler Ltd, UK). For 2009, we estimated 8720 [95% confidence interval (CI) 7490-10 230] people aged ⩾15 years were living with chronic hepatitis B infection in Scotland. This corresponds to 0·2% (95% CI 0·17-0·24) of the Scottish population aged ⩾15 years. Although East and South Asians make up a small proportion of the Scottish population, they make up 44% of the infected population. In addition, 75% of those infected were aged 15-44 years with almost 60% male. This study quantifies for the first time on a national level the burden of chronic hepatitis B infection by ethnicity, gender and age. It confirms the importance of promoting and targeting ethnic minority groups for hepatitis B testing.