Scotland is scaling up hepatitis C treatment for people who inject drugs, aiming to treat 500 individuals in two years through community services like needle exchanges and pharmacies. This matters because hepatitis C remains stubbornly common among people who inject drugs—around 40% still have chronic infections despite existing harm reduction measures like opioid substitution therapy and clean needle programmes. The newer direct-acting antiviral drugs cure over 90% of cases in just 8–12 weeks, but NHS guidelines currently restrict treatment to those with moderate or severe liver disease, leaving most infected people who inject drugs untreated. Without treating this group, the virus continues to spread. If successful, the project could cut chronic hepatitis C prevalence among people who inject drugs in Tayside from 29% to 10%—a 65% reduction—and drop new infections from 5% to 1.6%. The researchers will also develop a practical manual for scaling up community-based treatment across England, and design a definitive trial to provide the evidence NHS commissioners and policymakers need to change national treatment guidelines.
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Our primary aim is to generate UK empirical evidence on the effectiveness of HCV "Treatment as Prevention" (TasP) in people who inject drugs (PWID). In Work-Stream (WS1) we will demonstrate that rapid large-scale HCV treatment can be delivered to PWID through community services. In WS2 we will enhance HCV surveillance among PWID to measure the population impact of the intervention. Through record-linkage, we will assess if HCV treatment leads to improved addiction treatment outcomes. In WS3 we will undertake a qualitative study to understand the barriers and facilitators to scaling-up community-based HCV treatment and patients accounts of addiction treatment that will form basis of a manual of how to scale-up HCV treatment for WS5. In WS4 we will develop synthetic control methods to quantify the TasP intervention effect and use dynamic transmission models to determine cost-effectiveness in the NHS. In WS5 we will co-design a trial of HCV TasP in PWID in England to provide definitive evidence for patients, clinicians and policy-makers. Background:- HCV is the second most important cause of liver cirrhosis in the UK and injecting drug use is the major risk factor among 200,000 people infected currently. Chronic HCV is still 40% among PWID, despite effective opioid substitution treatment (OST) and needle and syringe programmes (NSP). Modelling suggests that HCV treatment is essential to achieve substantial reductions in HCV prevalence and incidence among PWID. TasP is now possible with newer DAA therapies combining high cure rates (>90%) and short treatment duration (8-12 weeks). We have conducted a successful pilot study that showed we can increase case-finding and successfully treat PWID in the community. HCV treatment is expensive (£12-40,000) so current NHS strategies restrict HCV treatment to people with moderate/severe disease, consequently few PWID (predominantly having mild disease) are treated. Therefore, we can evaluate HCV TasP in two ways. Firstly, we can conduct a non-randomised study of the impact of scaling-up HCV treatment to PWID (WS1-4). Secondly, if the current cost of HCV treatment falls, we will support HCV clinical leads to undertake a larger definitive evaluation of HCV TasP among PWID (WS5). Research plan:- In WS1 we scale-up HCV DAA treatment among PWID in NHS Tayside through existing services (NSP, OST centres, pharmacies and prisons) facilitated by community HCV nurse specialists. We will treat 500 PWID in two years which is projected to reduce chronic HCV prevalence from 29% to 10% (65% reduction) and incidence from 5% to 1.6%. Treatment response and re-infection rates will be monitored. In WS2 we support an extra Needle Exchange Surveillance Initiative (NESI) survey in Scotland (n=2500) and historical PCR testing (n=8000) of Unlinked Anonymous Monitoring Programme (UAM) in England to generate trends in chronic HCV outcomes in PWID from 2010 to 2021/22 for WS4&5. We use Multiple Parameter Evidence Synthesis methods to generate better estimates of PWID prevalence for WS4&5. We create a virtual cohort of 3600 PWID with information on HCV treatment, addiction treatment, and prison to test whether DAA treatment improves drug treatment outcomes and compare to WS3. In WS3 interviews with PWID (36-45) and focus groups (4) with service providers will explore perspectives on TasP; identify barriers and facilitators; and support a manual of how to scale-up HCV treatment in the community for WS5. Longitudinal interviews with 30-35 PWID successfully treated for HCV will assess whether their perspectives on addiction treatment and recovery alter. Trained peer researchers will be involved in data collection, analysis and dissemination. In WS4 we will model the effectiveness of the intervention in WS1, using outcomes measured in WS2. We will extend synthetic control methods to test for an intervention effect in NHS Tayside, with controls from the rest of the UK. Simulation exercises h
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