The problem
The cure success rate of DAAs hepatitis C has transformed the therapeutic landscape for hepatitis C, with patients no longer needing to be afraid of a diagnosis. However, one of the biggest challenges facing hepatitis C treatment is the low uptake of treatment. Approximately 200,000 Australians diagnosed with hepatitis C are not receiving treatment, and an additional estimated 50,000 remain undiagnosed.
Dr. Wendy Lawrance, an addiction medicine advanced trainee, discussed the problem at the 7th Annual West Coast Liver Meeting in Western Australia 2016, and stated that “Just with increasing treatment efficacy we're not going to make a big impact on liver related deaths”.
The study this statement was based on explored three treatment scenarios incorporating different levels of DAA treatment efficacy, eligibility and eligibility. Scenario 1 evaluated increased treatment efficacy alone, scenario 2 evaluated the impact of increased efficacy and increased treatment uptake without restriction of treatment restriction, whilst scenario 3 considered the same increases as scenario 2 but also with fibrosis-restricted eligibility.
A combination of increased treatment efficacy and uptake was required in order to see a reduction in liver-related deaths (this was even more pronounced in scenario 3) compared to increasing treatment efficacy alone (scenario 1) which had very little impact.
Therefore it is essential that efforts are made to increase treatment uptake in hepatitis C patients. However, with the prevalence of hepatitis C in the Australian population (with ~23000 hepatitis C patients in WA), combined with the relative scarcity of specialists, there are too many patients to be managed solely by specialists and highlights the importance of GPs in hepatitis C care. Offering information, support, referrals and treatment options in the community, including avenues that the individual may already be engaged with (for example drug/alcohol treatment services), will improve access and uptake of treatment, especially for those patients unable to readily access specialist services.
How GPs can help manage hepatitis C treatment and care
HCV treatment is increasingly available in the community through primary care providers and GPs will be expected to be involved in all stages of care: prevention and education, testing and diagnosis, assessment, treatment and post treatment.
Hepatitis C is often asymptomatic so identifying people at risk and asking the important questions such as 'have you ever injected drugs?' in a non-judgemental way is essential in detecting those that may require testing. Once informed consent is obtained, testing for HCV is required to determine whether the patient has a current infection and whether follow up treatment is required, as explained in detail in ASHM's booklet Primary Care Prescribers and Hepatitis C.
Initial screening requires an HCV antibodies (anti-HCV) test to be performed. A negative anti-HCV result with normal liver function tests (LFT) indicates that the patient has not been exposed to the virus, or is in the window period of recent exposure. It is recommended to follow up the patient and repeat the anti-HCV and LFT if they have a recent or ongoing risk.
A positive anti-HCV test, or a negative HCV test plus an abnormal LFT, indicates exposure to HCV but does not prove current infection. To confirm current HCV infection a polymerase chain reaction (PCR) for HCV RNA is required. A negative result in spite of a positive indication with anti-HCV suggests that the patient has either spontaneously cleared the infection or has been successfully treated previously. A positive result for HCV RNA indicates viraemia/current infection and the need to initiate treatment.
In order to prescribe DAAs to treat hepatitis C the GP needs to be experienced in treating chronic hepatitis C or else in consultation with an experienced specialist. A consultation can be carried out remotely using the Remote Consultation Request Form for Initiation of Hepatitis C Treatment.
What DAAs should be prescribed depends on the HCV genotype, whether the patient has cirrhosis, and whether they have previously had treatment. For more information or a summary of clinical guidance for treating hepatitis C infection please visit the GESA website.
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