Injecting drug users.

As the study by Tompkins et al1 highlights, many injecting drug users receive less than adequate care with regard to hepatitis C virus (HCV) testing and follow up. In response to this situation, an innovative model of care has been developed between Nottingham City Hospital and an inner city GP surgery. The practice provides enhanced GMS/PMS to an unselected population of substance misusers — many of who are homeless, currently numbering 212 per year. Five doctors have completed the RCGP Certificate, and with support from specialist drug treatment workers work to agreed Shared Care Protocols. Retention in treatment is at the 75% level at 1 year. Hepatitis testing is offered to all, either serum or buccal depending on ease of obtaining samples. An initial audit of our cohort revealed that the prevalence of HCV infection among 174 currently active clients is 47%, 72% of whom have not been polymerase chain reaction tested. Only one previous patient has been successfully treated with pegylated interferon and ribavirin. Hospital non-attendance rates in Nottingham for hepatitis C clinics are approximately 15–40% (M Holiday and M Nicholls, personal communication, April 2005) and only 11 of our cohort have been seen in secondary care. The highest risk group for new infections are injecting drug users who share among themselves, and mathematical modelling indicates that behavioural interventions may have only a limited effect.2 Therefore, the most effective way of reducing the endemic prevalence may be to treat those infected with pegylated interferon and ribavirin,2 in order to reduce the pool of infection that can be transmitted. Our model of care aims to transpose a hospital hepatitis C service directly into the heart of a community of vulnerable clients, by employing a nurse specialist to undertake caseload management. The three main elements are: to identify new cases of HCV infection by actively testing clients with risk factors; to offer pegylated interferon and ribavirin to clients who would not attend a hospital clinic; and to facilitate a consultant review of clients with obvious evidence of cirrhosis. In addition, the cohort provides real world data on the natural history of HCV infection in injecting drug users that is essential for decision making,3 and we can measure how the efficacy of pegylated interferon and ribavirin translates into successfully treating injecting drug users.3 Treating current injecting drug users may be controversial, but our goal is to facilitate equity of health care and improve the long-term public health of an impoverished and marginalised community.