Mixed-methods evaluation of point-of-care hepatitis C virus RNA testing in a Scottish prison

Abstract

Objectives: Hepatitis C virus (HCV) poses a global public health threat. Prisons are a focus of prevention efforts due to high infection burdens. Expedition of treatment for incarcerated people is critical, as many are short-term sentenced. We evaluated point-of-care (PoC) HCV RNA testing in a maximum-security Scottish prison and assessed its impact on transition to treatment. We also evaluated costs and determinants of implementation.

Design: Mixed-methods evaluation of a single-centre care pathway pilot using National Health Service (NHS) data from 2018 to 2021. Descriptive statistics and survival analysis were undertaken. Cost analysis was assessed from a provider perspective. Healthcare staff participated in semistructured interviews and thematic analysis with a deductive approach was undertaken to identify implementation determinants.

Setting: A large maximum-security Scottish prison health centre administered by the NHS.

Participants: 296 incarcerated NHS patients (all men) and six NHS staff members (two men and four women).

Interventions: HCV testing using the Cepheid GeneXpert platform with Xpert HCV VL Fingerstick assay.

Outcome measures: The main outcome was survival (in days) from HCV test to treatment initiation. Secondary outcomes were cost-per-cure obtained and implementation determinants.

Results: During the pilot, 167 Xpert tests were administered, with an 84% completion rate, and treatment transition was superior for those who received it (p=0.014). Where PoC tests were administered, shorter survival to treatment was observed (19 vs 33 days: adjusted HR (aHR) 1.91 (1.03-3.55), p=0.040; 19 vs 50 days; aHR 3.76 (1.67-8.46), p=0.001). PoC was costlier than conventional testing. In qualitative analysis, most facilitators were observed among characteristics of individual domain while most barriers were noted in the inner setting.

Conclusions: Integrating PoC HCV RNA diagnosis into nurse-led HCV care in a maximum-security prison health centre shortens survival to HCV treatment. However, there are cost implications to this approach and multiple determinants that impact on implementation should be addressed.

Keywords: Hepatology; INFECTIOUS DISEASES; Organisation of health services; PUBLIC HEALTH; Public health; QUALITATIVE RESEARCH.

Figure 1

Summary of observation dates and study activities. Conventional testing was by whole blood sent to a laboratory for analysis and dried blood spot methods.

Figure 2

Target cohort profile with related clinical outcomes and censoring. *Cases received treatment but excluded from cost and time-to-treatment analyses, as their testing data were unavailable or unverifiable. ^†All censored in survival analysis at relevant decease, liberation, transfer or follow-up censor dates. Group 1 are those tested conventionally from 2018 to 19 (reference period); group 2 are those conventionally tested during the pilot phase (2019–21); group 3 are those tested with the GeneXpert during the pilot phase (2019–21). LTFU, lost to follow-up; PoC, point of care; RNA, ribonucleic acid; RNA+, RNA positive (actively infected); SVR, sustained virologic response.