The little community clinic that could
Hepatitis C has been called a silent killer. An individual can have the insidious virus for years without realising, until it starts to attack their liver with potentially deadly consequences. An estimated 50,000 people in New Zealand have hepatitis C, and the numbers are expected to increase dramatically. A community clinic has been set up Christchurch as a pilot programme with the aim of tackling the disease head on. Kelly Andrew takes a look at its novel approach.
A small yellow sign with CLINIC written in black type is the only clue to the new location of the Christchurch Hepatitis C Community Clinic. Uprooted from its former home in the central city by the February 2011 earthquake, the centre has been forced to set up in a temporary site in an industrial area on the city fringe where factories, panel beaters and fledgling businesses are the more usual tenants.
The front door is painted lilac, and inside, the waiting room comprises an old brown couch and a desk. A narrow stairwell leads to an office and small clinic room upstairs where blood tests can be taken. The basic surroundings, stocked with second-hand furniture found on Trade Me, have not stopped the clinic enrolling more than 530 clients since it opened its doors in January 2009. In fact, its laid-back informality, approachable staff and accessible community setting have been key components in its success.
Clinical Nurse Manager Jenny Bourke believes the unique Christchurch service represents a benchmark model that could be adapted to suit other cities around the country to improve management of what is a highly debilitating and increasingly prevalent disease.
“It’s the only clinic of its kind in the country and the only one internationally that’s focused solely on management of hepatitis C. It integrates primary healthcare with secondary healthcare,and I think it has the potential to be transferred in some form to other regions. It could devolve some of the antiviral treatment from hospitals into the community setting, allowing better use of our health dollars.”
It’s estimated 50,000 New Zealanders are currently living with the hepatitis C virus, and this is predicted to increase by 50 percent in the next 10 years. What makes these figures of greater concern is that, because it can be symptomless for many years, only about a quarter of people with hepatitis C are aware they are carrying the virus, with 20 percent diagnosed and only 5 percent accessing treatment. The estimated cost to New Zealand if those infected do not receive treatment is $400 million annually by 2020.
While HIV and AIDS have had a much higher public profile than hepatitis C, internationally, there are about 200 million people with the disease and only 40 million with HIV. There is undoubtedly a need to ensure early diagnosis and improved access to treatment for people with hepatitis C. The vast majority of sufferers are either past or current injecting drug users, and Bourke says this group often feels stigmatised and discriminated against, making them difficult for mainstream health workers to reach.
Establishing a community-based clinic to provide testing, support and information to people with hepatitis C was first mooted back in 2002 by a group that included Charles Henderson, now National Director of the New Zealand Needle Exchange Programme. Locating such a clinic near a needle exchange and establishing a close relationship between the two organisations seemed like a “no brainer” to him, considering up to 90 percent of intravenous drug users will contract the disease through infected needles or syringes. Christchurch has the largest population of injecting drug users in the country, with an estimated 10,000 currently in the Canterbury region.
A proposal for a community clinic was presented to the Hepatitis C Treatment Advisory Group by Bourke as a result of a collaboration between three Christchurch-based organisations – the New Zealand Needle Exchange, the Rodger Wright Centre Needle Exchange and the Hepatitis C Resource Centre – and in 2008, the government gave the go-ahead for Health Ministry funding. The 3-year pilot was part of a package of funding for treatment programmes designed to help resolve the so-called bad blood scandal of the 1990s, which stemmed from delays in donated blood being screened for hepatitis C.
Sharing governance with the nearby Rodger Wright Centre, the Hepatitis C Community Clinic opened with the aim of increasing access to diagnosis and treatment, improving monitoring and prevention of the disease and helping people with the virus have a better quality of life. Bourke says it has quickly built a good rapport with its clients.
“The thing we’ve managed to do well is to get on side with the community we serve – they wouldn’t come if we didn’t serve them well.”
In a pioneering approach to a major public health issue, the clinic liaises with other local health agencies such as general practices, the Community Alcohol and Drug Service, the Christchurch Methadone Programme and Christchurch Hospital as well as needle exchange staff.
The clinic’s 3-year pilot ended in October, and an evaluation has been carried out by the National Centre in HIV Social Research at the University of New South Wales. The results back up Bourke’s pride in the project. The report says the clinic’s model provides a continuum of care that improves the health of people with hepatitis C.
Clients expressed a high level of confidence in and satisfaction with the clinic – with 95 percent giving positive feedback. It was described as nonjudgemental, non-threatening and holistic, with clients saying they felt more supported and less discriminated against by staff at the clinic compared with mainstream healthcare workers. The report says, overall, the centre is meeting its objectives in increasing knowledge of hepatitis C, enabling lifestyle modifications and increasing access to treatment for what can be a marginalised group.
A feedback form asking clients where they would go for help if the clinic was not available found 50 percent ticked “nowhere”, suggesting these people would not have received testing and management without its help. Through the clinic, 71 clients have so far been referred and supported through to antiviral therapy at Christchurch Hospital.
The evaluation also praises the clinic’s integrated model, saying that, by working in partnership with other agencies, it was able to act as a point of entry for people unwilling to directly access conventional healthcare providers. However, it recommends clinic staff work harder on improving their relationship and collaboration with PHOs and GPs.
Bourke, who has a friendly but firm manner, spent time training in Australia and New Zealand to become a specialist hepatitis C nurse in 2006 after developing an interest in the disease while working in Christchurch as a
home detox nurse – visiting people who had been through detoxification from alcohol or other drugs. She enjoys working with her clients, and she finds the hepatitis C virus fascinating, despite its highly damaging effects.
“The more you know, the less you know; that’s what I find. I learn something new about it every week, and I tell that to my patients. There are new inroads into treatment and new clinical trials all the time, things are always changing.”
Clinic data shows 22 percent of its clients are Mäori and most are aged 35 to 49. Nearly three-quarters are on Work and Income benefits, a group most in need of more equitable access to healthcare.
Bourke says the clinic’s approach is non-judgemental and based around asking each client what they want to do and then helping them achieve it. It provides completely free access to testing, social work and on-going
information. It refers some patients to hospital-based treatment services, but others may choose not to have antiviral treatment, and they are offered information on ways to prevent their disease progressing, including healthy eating, quitting smoking and referral to the Community Alcohol and Drug Service. While the centre is nurse led, it also has a part-time GP, Mike Thwaites, to help with hepatitis C-related health concerns, and a part-time social worker, Marilyn Brown.
The clinic is open to anyone who believes they may have been exposed to hepatitis C, but with its close ties to the Rodger Wright Centre and an outreach clinic Bourke runs every Thursday at the Christchurch Methadone Programme, it particularly targets injecting drug users who are at highest risk.
“The affiliation with the Rodger Wright Centre and the Methadone Programme helps us find a great niche, because that is our target population,” Bourke says.
“But it’s really important that those who are not on methadone or are no longer using drugs also feel comfortable accessing the clinic.”
Proposed new premises in Cashel Street will see the community clinic sharing a building with the Rodger Wright Centre, but Bourke says separate access will be available for clinic clients.
People who are currently injecting drugs are generally excluded from treatment but Bourke says it is still important for them to be tested and find out their hepatitis C status so they can get information on the disease and their options for management and the treatment process.
“To be open to anybody who has concerns I think is really important, and sowing the seeds early on is good for harm reduction and self-management.”
Charles Henderson says hepatitis C is at “absolutely epidemic” levels and the situation is likely to get worse. Advanced drug treatment means people with HIV can maintain their quality of life for many years. But with hepatitis C, there’s a 50 to 80 percent chance that antiviral therapy will be a ‘cure’, preventing a patient’s progression to chronic liver disease. The success rate depends on what genotype (or strain) of the virus they have.
“The stats are clear; there are currently 32 liver transplants in New Zealand each year. That’s going to increase to 250 by 2030, and it will be predominantly due to hepatitis C infection. It’s such a nasty, pernicious virus. You might be largely asymptomatic, but a few years down the line, you could be cirrhotic and eventually need a liver transplant.”
Henderson strongly believes the Christchurch Hepatitis C Community Clinic is delivering a valuable service and says the trial has been a success despite huge disruption caused by two major earthquakes and the loss of its original building.
“By attaching a health clinic to a needle exchange and working with other agencies like GPs, the Community Alcohol and Drug Service and the hospital, you’re doing a lot of good for a reasonable amount of dollars, so it’s
a good investment.”
However, the clinic – which won a second runner-up award in the community-based section of the Canterbury District Health Board’s (CDHB’s) Quality Improvement and Innovation Awards last year – is only assured of CDHB funding for 1 more year, and its long-term future is unclear.
The Ministry of Health is currently investigating ways of improving hepatitis C services around the country, with a summary report due from the Hepatitis Foundation of New Zealand in March next year covering a wide range
of hepatitis C issues. A Ministry spokesperson says it is reviewing the evaluation report of the Christchurch clinic by the National Centre in HIV Social Research, and the findings will feed into future planning for the provision of hepatitis C services.
But he says there is no expectation the hepatitis C clinic model piloted in Christchurch will be rolled out as a national solution for hepatitis C services in New Zealand.
Bourke says providing early diagnosis, management and the option for antiviral therapy is paramount in order to make headway in tackling this disease. She believes the community clinic provides the most effective model for Christchurch, but other centres may need to adapt to local circumstances.
“We’ve set up a benchmark model that can provide a framework for future improvements in hepatitis C services.”
- Kelly Andrew is a writer based in Christchurch.