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Hepatitis C HMP Holloway

Explore the impact of Hepatitis C within prison walls, focusing on transmission, treatment, and the liver's role. Learn about the prevalence of HCV, genotypes, and treatment options. Discover how the virus spreads, the importance of testing, and the challenges faced in managing HCV in the prison population. Stay informed about the risks associated with sharing needles, tattooing, and unprotected sex in prison settings. Educate yourself on prevention methods and the importance of timely treatment to prevent long-term liver damage. Together, we can combat Hepatitis C and protect public health.

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Hepatitis C HMP Holloway

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  1. Hepatitis C HMP Holloway Darren Tippetts September 12th SSHA Conference Date of prep: June 2015 Job Code: PHGB/HIV/0115/0005a

  2. Within these walls The Liver Hepatitis C Transmission Treatment HMP Holloway WHC Case studies BBV opt out Conclusion

  3. The Liver Located in the upper right-hand part of the abdomen, behind the lower ribs. The largest single organ in the human body. In an adult, it weighs about three pounds and is roughly the size of a football.

  4. The liver is essential for life-so don’t mess with it !

  5. Hepatitis • ‘hepat’ = liver • ‘itis’ = inflammation • Viral hepatitis…. • A Faeco-oral, never chronic • B Blood, sexually transmitted, can be chronic • C Blood, sexually transmitted, often chronic • D Only with B, usually chronic • E Faeco-oral (Pork), rarely chronic VACCINE PREVENTABLE

  6. History of Hepatitis C Discovered 1989 Transmitted by blood 25% people clear virus 75% develop chronic disease Causes inflammation and scarring of the liver Can lead to liver cancer

  7. Estimated 170 Million people with HCV Infection worldwide 3-4 Million newly infected each year worldwide (38 Million HIV) Prevalenceofinfection > 10% 2.5%-10% 1%-2.50% NA Figure3: HCVWorldwidePrevalence1 1. World Health Organization 2008. Available at: http://www.who.int/ith/es/index.html. Accessed October 28, 2009.

  8. Hepatitis C in the UK 245,000 with chronic HCV 45% of IDU in England are HCV+ 0.04% of new blood donors are HCV+ 9% of HIV+ also HCV+ (7% MSM) In England, 15,840 individuals will be living with HCV-related cirrhosis or HCC by 2020 if left untreated

  9. Hep C Prevalence Amongst the Prison Population The prison population in England and Wales (approximately 84,0001) is significantly more likely than the general population to suffer from higher rates of hepatitis C.2 • According to the Health Protection Agency (HPA), around 1 in 10 inmates have hepatitis C. However, only 6% of inmates were tested for the virus in 20113 • • Many prisoners are at increased risk of infection, not only because of • drug misuse prior to prison, but also due to high-risk activity within • prison2 • - Sharing drug taking equipment • - Unprotected rough/anal sex within prison • Self tattooing (infections from ink and needles) • - Sharing toothbrushes • - Sharing razors/hair clippers - 1. Ministry of Justice, Statistical Tables, Table 1.1a: Total population in custody by type of custody and age group, on a quarterly basis, September2011 to December 2012, England and Wales. 2. National AIDS Trust and Prison Reform Trust. HIV and Hepatitis in UK Prisons: addressing prisoners’ healthcare needs. 2005. Accessible http://www.nat.org.uk/Media%20library/Files/PDF%20documents/prisonsreport.pdf. 3. The Hepatitis C Trust. Leading prison health experts challenge NHS England to tackle the growing problem of hepatitis C in prisons. 2013. Accessible at:http://www.hepctrust.org.uk/News_Resources/news/2013/May/Leading+prison+health+experts+challenge+NHS+England+to+tackle+the+growing+problem+of+hepatitis+C+in

  10. Hep C Transmission1 • Hep C CAN be contracted in the following ways: Sharingtoothbrushes Sharingneedlesandotherdrugtakingequipment Razors/hairclippers Selftattooing Rough/analsex • Hep C CANNOT be contracted inthe following ways: -Sweat,showersortoilets 1HepCTrust (2010)What NotToShare Leaflet

  11. HCV: Survival outside body CDC/NHS: The Hepatitis C virus can survive outside the body at room temperature, on environmental surfaces, for at least 16 hours but no longer than 4 days This is why we advise to not share toothbrushes, razors, clippers etc Recent paper on HCV & drug equipment Can survive for up to 3 weeks in water and on filter papers

  12. Hep C Genotypes and Subtypes Mediterranean countriesand the Far East 1 2 USA , NorthernEurope 5 SouthAfrica There are 6 different genotypes of hepatitis C that we know about which can be dominant in certain parts of the world.1 4 MiddleEast Treatment and treatment success will vary for each different hepatitis C genotype.2 3 Europe IVDU 6 Hong Kong, Vietnam and Australia Figure2: HCVgenotypes3 1. World Health Organization. Global Alert and Response. 2011a [31 May 2011] 2. Craxi, A (2011). EASL Clinical Practice Guidelines: Management of hepatitis C virus infection. J Hepatol:(In Press). 3. Simmonds P, Phil.Trans. R. Soc. Lond. B. 2001;356:1013-1026

  13. Hepatitis C Treatment The goal of Hep C treatment is to cure the patient, by ensuring that the hep C virus is no longer detectable in blood 6 months after treatment has ended1 • • 1. The Hepatitis C Trust (2013). Overview of treatment. Accessible online at: http://www.hepctrust.org.uk/Treatment/Considering+Treatment/Considering+treatment

  14. HCV treatment Interferon – general antiviral-immune booster-injection Ribavirin- Antiviral only used in conjunction with interferon-oral HCV inhibitior – Direct acting antiviral – blocks viral replication

  15. New Hep C treatments Simeprevir Sofosbuvir Viekirax Exviera A future without interferon – oral only BUT who would you prioritise ?

  16. Summary • High prevalence and under-diagnosis to HCV treatment in the offender health setting There are logistical challenges for both staff and prisoners, however the prison setting provides a unique opportunity for hard to reach and chaotic patients to receive treatment Education of both staff and prisoners is imperative in order to provide the best chance of achieving successful treatment Treatments available as per the new standard of care significantly improve the chance of successful treatment ALL PATIENTS HAVE THE RIGHT TO BE TREATED! • • •

  17. HMP Holloway 90 000 Prison population of England and Wales 60% of injecting drug users imprisoned by age 30 600 women in Holloway 45% of IDU in England are HCV+ Holloway 24% drug related offences 52% women taken class A drug in month before incarceration 1HPA National surveyof hepatitisCservicesin prisonsin EnglandJuly2012

  18. Infamous prisoners • Suffragettes • Oscar Wilde • Ruth Ellis • Myra Hindley • Who with the help of a female prison officer tried to escape • Rose West • Maxine Carr • Vicky Pryce

  19. Health Adviser Role Managing all WHC results Giving sexual health advice Positive results Partner notification Pre and Post test discussion for BBV Counselling for HIV, sexual assault & terminations CSW Asymptomatic screening HIV POCT Training/education

  20. HMP Holloway Women referred to health advisers • History of HCV • BBV risk • Booked appointment • S/B health adviser • BBV PTD

  21. HMP Holloway BBV PTD (HCV) • Risk – shared works, snorting, CSW, HCV +ve partner, tattoos, shared razors/toothbrushes, self-harm • Past diagnosis • Health promotion • Expectations of result • Treatment options

  22. Audrey *Fictional patient study for educational purposes Audrey 51 years old Started using crack/heroin age 23 Alcohol last 10 years 5 ‘heavy’ Family history of drug use Drug related offences last 25 years CSW

  23. Audrey • 07/09/12 HCV RNA 1,063 Genotype 3 • 17/02/13 HCV RNA 2,638 • 11/03/13 Started Rx (Pegasys, ribavirin) • Attending HCV support group • Insomnia & loss of appetite • Eczema • 25/03/13 HCV RNA not detected • 17/12/13 HCV RNA not detected

  24. Success Audrey ‘cured’ An achievement for the women Springboard for better choices Public health Reduced risk of onward transmission

  25. Sam *Fictional patient study for educational purposes 43 years old Holloway April 2014 38 previous convictions Shoplifting, sex work, drunk disorderly Amphetamines started age 22 Heroin age 25 (in prison) Alcohol 1-2 litres of vodka a day

  26. Sam August 2013 Oraquick Hep C poct reactive August 2013 HCV RNA 636,308 Genotype 1a Challenge with Sam is that she is in and out of prison and only ever in Holloway for short sentences. We liaise with probation and Dip workers but Sam does not manage to attend any appointments on the outside

  27. Sam is a typical patient Some women DNA x 4 appointment Never tested In and out of prison The longer a person has HCV = Poor health outcomes August 2015 FS 24, cirrhotic so could access new treatment Sam

  28. 27/02/14 – pt said diagnosed 1999 GT 1 17/03/14 – Was IVDU 15 years stopped 13 years ago, shared with sisters 2 HCV, 1 HIV 19/05/14 – Start rx Interfron, ribavirin (start TVP @ at later date 2/06/14 – RNA dropped 1 log Maxine *Fictional patient study for educational purposes

  29. 2/06/15 RNA 9,000 iu/l 5/07/14 Start TVL 14/07/14 RNA 102 iu/l 2/08/14 RNA 15 iu/l 2/09/14 RNA 12 iu/l 16/09/14 Pt told us not been taking TVL !! 2/10/14 RNA not detected Maxine

  30. Pt released from Holloway November 2014 staying in St Mung0’s bedsit. Continued rx Interferon/ribavirin RNA detected @ week 38 Pt disclosed relapse crack/herion Awaiting early access referral Harvoni Maxine

  31. Reality Check Hepatitis doctor on 6/12 sabbatical Senior nurse on 1/12 holiday Healthcare staff ‘reluctant’ to take difficult bloods Waiting for NICE! So no treatment offered for 6/12

  32. BBV Opt out testing feedback Phase 1 – April-September 2014 11 pathfinder prisons (9% of Estate) Near doubling of BBV testing No increase in proportion of patients testing +ve for BBV 226/185 referred for HCV treatment Less people on treatment but waiting for new treatments

  33. New Treatments ! • It’s complicated • RFH is Hub • 5 ‘spokes’ • All decisions via MDT • Blueteq prescribing for high cost drugs • Hundreds of patients on waiting list

  34. New Treatments • We have the technology • Do we have the money? • Do we have the will?

  35. Conclusion • Need to be offering treatment to more people • Increase up take of testing • Targeted testing • Opt out testing of all prisoners • MDT support • Better outcomes in the community • Reduce the rates of HCV in UK !

  36. Eradication of Hepatitis C by 2030 Date of prep: June 2015 Job Code: PHGB/HIV/0115/0005a

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