Introducing a blood borne virus testing facility within a substance misuse harm reduction service

The prevalence of blood borne viruses such as Hepatitis B and C and HIV has been found to be higher amongst injecting drug users than in the general population. Hepatitis C for example, can be up to 5 to 10 times higher amongst injecting drug users than in the wider population. If left undetected and untreated, blood borne viruses can cause significant morbidity and even potential loss of life. Hepatitis C can lead to cirrhosis, liver fibrosis, end stage liver disease or liver sarcoma, which can result in the need for liver transplantation, or may even result in loss of life.

Many injecting drug users may not be aware that they are infected with a blood borne virus, which could also pose a risk to them of unwittingly passing the virus onto others. And without a diagnosis, people are unable to then access specialist care or treatment. For people who are infected, once identified, and if appropriate for their case, treatments may be commenced that can make significant difference to the disease course. These treatments can potentially have a significant impact on the morbidity risk, health outcomes, and risk to mortality. Identifying infection at an earlier stage will help minimise the risks from living with a virus, such as liver damage. This can also improve treatment outcomes.

The Darlington NECA project lead introduced a blood borne virus testing and vaccination service to help meet needs of their clients by:

Providing a harm reduction element which is embedded throughout the whole integrated treatment service to reduce the effects of drug related harm on the residents and communities in the local area. Having all staff trained to screen clients accessing the service, and their friends/families/carers to enable as much coverage as possible. Using the dry blood spot testing kits that were developed by Professor Paul Clapper from Manchester Royal Infirmary, allows for non-clinicians to provide this non-invasive intervention on site and in community settings.

The Darlington NECA substance misuse service provides specialist harm reduction and treatment services across a region of approximately 110,000 (that's the approx. pop of Darlington) people. NECA has provided specialist drug and alcohol harm reduction and treatment services in the north east since 1974, and has services across the whole Northern Region.

Services include specialist recovery centres, a connected recovery model that encompasses peer support, fixed site and satellite support, including delivery within supported housing settings. Prior to the NECA blood borne virus testing service being set up, options for people using drugs or alcohol to be tested in Darlington were offered via their GP or hospital.

National strategies re BBV reduction, and increased prevalence with IDUs has enabled NECA to utilise the Dry Blood Spot testing kits in a non-clinical setting to offer maximum coverage for screening. Commissioners for Darlington included a requirement for a blood borne virus testing service and vaccination within the service specification for the adult substance misuse treatment service. Commissioners also stipulated that services bidding for the contract should reflect relevant NICE guidance recommendations from PH18, PH52, CG51 and CG52. Having secured the contract, the NECA team began to translate recommendations from the NICE guidance into practice. A key element of this was the creation on an overarching operational procedure, based on evidence based practice. The Operational Procedures provide specific aims and objectives relating to Harm Reduction including 100% offer of BBV screening and access to Hepatitis A&B combined vaccination schedule. The service has a Patient Group Directive (PDG) which it refers to and only qualified nurses can vaccinate clients. However non clinical staff who have been trained can provide the BBV screening intervention. There are robust Care Pathways for BBV Testing; Administration of Hep A&B (Twinrix) vaccinations as well as referrals to treatment for those testing positive. The procedures identify high risk/target groups and provides detailed instructions of the screening procedures including pre and post discussions with reference made to DOH & NICE guidance.

Providing BBV screening and access to Hep A&B vaccination was in the specification. NECA already had an established specific Harm Reduction Service in South Tyneside which has similar demographics and therefore developed a framework from there. NECA employ a Clinical Director who oversees all clinical interventions. Based on their knowledge and recommendations it was agreed offering the combined vaccine is a more appropriate intervention to drug/alcohol clients. The BBV screening and vaccination offer was already provided and well established in South Tyneside and it was agreed the same model would be used in Darlington. This made the mapping process to establish which points in the pathway would be best to offer the service, a lot smoother. The manager from South Tyneside provided training to all practitioners and re-visits annually for updates/refreshers where necessary. Only qualified nurses can vaccinate and they work to the PDG in place.

Manchester Royal Infirmary (MRI) provided 3 days intensive training. They provided sample paperwork to use which NECA developed and localised for the integrated service purpose. Traditional methods of BBV testing can prove challenging when delivering a testing service for injecting drug users. There may be problems with locating suitable veins to draw blood from, but also there is a need for staff to have clinical skills and competency in conducting blood tests. To help overcome this, and to enable BBV testing to be provided throughout the care pathway, the NECA project lead introduced a dry blood spot testing method, as it does not require medical or nursing staff to conduct it. A contract was established with MRI for the dry blood spot testing which included the provision of test kits, staff training and the processing and delivery of test results. In addition to the BBV testing, a hepatitis vaccination scheme was also introduced for clients using Twinrix a combination Hepatitis A and B vaccination which helps prevent infection from both the hepatitis A and B viruses.

For further details on our methods, including challenges overcome, please see the supporting material.

Outcomes achieved so far are:
- 211 people have been screened - of these, 19 people identified as Hep C positive - 2 people have been identified as HIV positive

40 clients have received vaccinations, with a significant number of current and past clients already having been vaccinated either in prison or as part of their treatment in another service. For clients where a BBV is identifieD, clear and robust pathways and referral protocols have been established.

PDU heroin, crack or amphetamine user, NECA staff work to engage client in structured treatment programme, and includes an established referral pathway into treatment for their BBV. A lot of engagement work takes place in Phase 1 (engagement) where the needle exchange facility is based and where consent is granted and clients are receiving structured treatment from other phases within the service, the Harm Min worker will liaise directly with the client's case manager to ensure a robust coordinated support plan is in place.

Pathways have been established for other clients, for example referral to hepatology specialist via the local trust GUM service. There isn't any service user group at present to gain feedback from but this is something we can look to develop in the future.

Although the service lead would ideally like the programme to be at the stage where 100% of clients are routinely offered and then screened for blood borne viruses, and go on to take up the offer of a vaccination. It has been important to recognise that introducing any new service programme will take time for it to be fully established. Although the concept and rationale behind blood borne virus screening was familiar to many of the NECA service's staff, introducing the programme has still been a developmental process, and it has taken time for both the workforce and the client group to become familiar with it.

Additionally, once a blood borne virus programme is fully embedded into a service's delivery, because of client choice, there may always be some clients who do not wish to take up the offer of screening or vaccination. But providing staff with training on the most effective methods for engaging clients in discussions about screening, providing clients with information on the rationale for why the offer is made, and the service also embedding and providing a number of stages during the care pathway where this offer is repeated is important.

Where possible, a service can maximise the opportunities to raise BBV testing with clients by incorporating questions on blood borne virus screening within the service admissions process, and at key stages throughout the pathway, for example, when a client moves between different stages of treatment. This can help maximise the number of opportunities for the service to raise and offer blood borne virus screening and vaccination with a client. Having the support of local commissioners has been crucial. And having this from the outset, through a requirement to provide a blood borne virus screening and vaccination service in the service specification has been useful. It has been important to still ensure a regular dialogue with local commissioners once the project plan was being put into practice.