Hepatitis C: policy context
In 2000, the Scottish Needs Assessment Programme (SNAP) published a report on hepatitis C that reviewed existing services and made recommendations on how prevention, diagnosis and treatment could be improved.
In 2005, the Scottish Executive released for consultation the Hepatitis C proposed action plan in Scotland which was designed to promote further implementation of the SNAP recommendations and the key messages in the hepatitis C consensus statement that emerged from a Royal College of Physicians of Edinburgh conference in April 2004.
Following an extensive consultation in 2005, the Scottish Government launched Scotland Action Plan for Hepatitis C in September 2006; its aims are:
· To prevent the spread of Hepatitis C, particularly among Injecting Drug Users (IDUs)
· To diagnose Hepatitis C infected persons, particularly those who would most benefit from treatment
· To ensure that those infected receive optimal treatment, care and support
Taking a two-phased approach, Phase 1 (undertaken during September 2006 to March 2008), comprised 41 actions spread across the areas of co-ordination, prevention, testing/treatment/care and support and education/training/awareness-raising, and involved increasing awareness about Hepatitis C among professionals and undertaking extensive research and consultation to inform proposals for the development of Hepatitis C services during Phase II. All but one of the 41 Phase I actions have been delivered; the outstanding action – the piloting of an in-prison needle and syringe exchange scheme – has been rescheduled to be implemented during Phase II.
Phase II, launched in May 2008, saw serious commitment from the Scottish Government, to tackle the Hepatitis C challenge facing Scotland, with an investment of approximately £43 million (the bulk of which is being allocated to NHS boards), over the three years of the Plan, to deliver 34 actions designed to dramatically improve prevention, diagnosis, treatment, care and support services for Hepatitis C throughout the country. In 2010, the second Phase II progress report was released.
Following on from the Hepatitis C Action Plan, the Scottish Government launched the Sexual Health and Blood Borne Virus Framework in 2012 (http://www.scotland.gov.uk/Publications/2011/08/24085708/0). Focused on an outcomes based approach, the Framework is firmly anchored in shared ownership and joint working with a key focus on challenging inequalities. Multi-agency, partnership working is central and the Scottish Government, the NHS, Local Authorities and the Third Sector all have vital roles to play in delivering the outcomes.
The Framework Outcomes are:
- Fewer newly acquired blood borne virus and sexually transmitted infections; fewer unintended pregnancies.
- A reduction in the health inequalities gap in sexual health and blood borne viruses.
- People affected by blood borne viruses lead longer, healthier lives.
- Sexual relationships are free from coercion and harm.
- A society where the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood borne viruses are positive, non-stigmatising and supportive.
The Framework also details a number of specific indicators with associated accountabilities within NHS Boards, Local Authorities and Scottish Government activity.
An updated framework covering the 2015-20 period was published in September 2015. The update does not replace the 2011-2015 framework; instead it outlines the progress made since its publication and highlights areas that require additional focus in 2015-2020 in order to help meet the five outcomes originally identified in 2011.
Significant developments have occurred in both Hep C treatment and prevention practices since the original strategy was published. The updated framework highlights a number of developments, including:
- An increase in Hep C testing, resulting in a rise in the estimated proportion of the total infected population who have been diagnosed (from 38% in 2007 to 55% in 2013).
- An increase in the number of people commencing antiviral treatment (from 470 in 2007/8 to 1,270 in 2014/15), coupled with the development of new and more effective antiviral therapies. The first of these was approved (with restrictions) by the Scottish Medicines Consortium in 2014, and more followed in 2015 and 2016. These therapies are not only more tolerable for patients they also offer higher viral clearance rates (which is considered a cure). See more on this below.
- Changes to the Misuse of Drugs Act that mean people who inject drugs can now be provided with foil via injecting equipment provision services, further reducing the harms associated with injecting (the foil can be used to smoke rather than inject drugs).
- New challenges associated with the rising use of new psychoactive substances (some of which are injected), and evidence from Public Health England that suggests men who inject performance and image enhancing drugs are at an increased risk of Hep C.
- The completion of the Penrose Inquiry into the transmission of Hep C and HIV via infected blood and blood products in NHS settings. It highlighted the importance of continued case-finding efforts by the NHS in order to diagnose individuals who may have contracted Hep C many years ago.
- The UK National Steering Committee’s updated review of screening for Hep B and C in individuals born outside the UK.
A target has been set to initiate antiviral treatment in 1,500 people per year in the 2015-20 period in order to bring about 75% reduction in the number of people with Hep C developing liver failure and / or liver cancer by 2020 (from 200 to 50). The treatment initiation target of 1,500 people per year represented an almost 20% increase in the number treated in 2014.
The updated framework can be found at http://www.gov.scot/Publications/2015/09/5740/0.