The last year or so, one particular virus has been at the forefront of our minds. Meanwhile, in the background, another virus – hepatitis C virus – was being successfully cured by an increasing number of people, as the nation chips away at reaching the 2030 target of eliminating hepatitis C from Australia.
By Dr Donna Mak
It has been just over five years since direct-acting antivirals (DAA) treatments were listed on the PBS. DAAs were a breakthrough in eliminating hepatitis C, curing 95% of individuals who complete treatment in a shorter time frame than previous treatments, with less side effects and taken orally.1
for the Department of Health, WA.
What progress has been made?
A total of 7,820 people, representing 41.9% of residents living with chronic hepatitis C virus (HCV) in WA, have initiated the new DAA treatment since it was introduced in March 2016.2
What can GPs do?
GPs are extremely well positioned in the community to be the champions of eliminating hepatitis C. Promisingly, DAA prescribing by GPs has been on an upward trend.2
While approximately equal proportions of WA residents were prescribed DAA treatment by a GP or a specialist in the period of March 2016 to September 2016 (first reporting period by the Department of Health WA), 79% of DAA treatment between October 2019 to March 2020 (latest published reporting period) were prescribed treatment by a GP.2
There was a 26% increase in the number of unique prescribers for DAA treatment in WA from the first reporting period to the latest published reporting period.2
This highlights the essential role of GPs in the elimination of hepatitis C, a role that is only increasing in importance. The skills that GPs use every day fits well with those needed to find and treat patients with chronic HCV.3
How can we effectively test?
As most people living with chronic HCV are asymptomatic, opportunistic identification of people at risk is vital.4
Routinely asking the question “Have you ever injected drugs?” or identifying if your patient’s country of origin is from a high HCV region may detect many of those who require testing for HCV due to being at risk of having acquired the virus.4
Once you have identified that your patient should be tested, to ensure complete and timely diagnosis of chronic HCV, reflex testing is recommended following a positive hepatitis C antibody (anti-HCV) screening test.1
Reflex testing involves requesting on the pathology form that a) if the blood sample is positive to hepatitis C antibody, to then test for HCV ribonucleic acid (RNA) and b) if the HCV RNA test is positive, that the pre-treatment virology assessment tests are also completed. A dedicated collection tube is required to undertake the HCV RNA.4
A good practice tip is to write on the pathology form: “If anti-HCV positive please perform a HCV RNA and genotype.” In this way, the HCV RNA and pre-treatment virology assessment tests can be collected at the same time as the initial screening.4 This will reduce the number of appointments and blood tests required for your patients and reduce the likelihood of patient attrition.1
PBS eligibility criterion for accessing DAA treatment requires documented chronic hepatitis C, that is, evidence of chronic hepatitis C infection (repeated HCV antibody positivity (anti-HCV) and HCV RNA positive).5
What resources and supports are available?
The WA Department of Health is committed to the goal of eliminating hepatitis C as a public health threat by 2030, so that the infection no longer impacts on the lives of people living with chronic hepatitis C and on the WA health system.
- The Department supports HepatitisWA to facilitate a project encouraging GPs to undertake a lookback for patients with hepatitis C and provide advice on treatment and monitoring.If you would like to speak to the hepatitis C GP Liaison Nurse at HepatitisWA, please call Kat on (08) 9227 9802 or email clinicnurse@hepatitiswa.com.au.
- The Burnet Institute Practice Support Toolkit WA1 provides information and resources promoting hepatitis C testing, treatment and patient support.
- The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) hepatitis C resources4 contains resources for general practitioners in eliminating hepatitis C and also hosts various training events.
- Further information about hepatitis C testing and treatment is also available in the ‘Silverbook’ (Guidelines for managing sexually transmitted infections and blood-borne viruses)6, and Healthpathways.7
References:
1. Burnet Institute Eliminate Hepatitis C Partnership. EC Partnership Practice Support Toolkit WA. Melbourne: Burnet Institute; 2018. Available online at: https://ecpartnership.org.au/ toolkit (accessed May 2021).
2. Mitchell K, Mak D, Bastian L, Giele C, Bevan J. Hepatitis C treatment uptake in WA Uptake of antiviral treatment for chronic hepatitis C, October 2019 to March 2020 [Internet]. Perth; 2020. Available from: https://ww2.health.wa.gov.au/Articles/A_E/Epidemiology-of-STIs-and-BBVs-in-Western-Australia
3. Baker D, Balcomb A, O’Loan J, Howell J. Eliminating hepatitis C Part 5. Practical steps in your practice. MedicineToday. 2019;20(9):36046.
4. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. Primary Care Providers and Hepatitis C [Internet]. Department of Health, Australian Government; 2016. Available from: https://www.ashm.org.au/resources/PCP_and_HCV_web_V10.pdf
5. The Pharmaceutical Benefits Scheme. General Statement for Drugs for the Treatment of Hepatitis C [Internet]. Australian Government Department of Health; 2021. Available from: https://www.pbs.gov.au/info/healthpro/explanatory-notes/general-statement-hep-c
6. Department of Health. Hepatitis C [Internet]. Department of Health, Government of Western Australia, 2021. Available from: https://ww2.health.wa.gov.au/Silver-book/Notifiable-infections/Hepatitis-C
7. WA Primary Health Alliance. Healthpathways [Internet]. 2021. Available from: https://wa.communityhealthpathways.org/13454.htm
Miracle of science
by Dr Ric Chaney
On a timescale that is little short of miraculous, managing hepatitis C in general practice has gone from being the province of the very brave GP to being simple, fail-safe and immensely professionally satisfying.
No longer the nightmare of prolonged injected interferon plus ribavirin therapy, which not only made patients very sick, but failed more often than it succeeded, hepatitis C treatment has been replaced by the new era of short-duration, non-toxic, all-oral medications, with cure rates approaching 100%.
It is difficult to imagine a more rewarding field of endeavour in general practice where, within a few short weeks, we can cure a disease that has blighted patients’ lives and damaged their self-esteem, often for decades.
We are not practising medicine primarily with the aim of gaining patients’ gratitude, but there are few fields where it is more manifest.
The Gastroenterological Society of Australia (GESA) has on its website a simple two-page guide to everything we need to know as GPs to manage hepatitis C. The key is to diagnose it in the first place: it really should be part of universal baseline screening in general practice, as there is a great pool of undiagnosed patients in the Australian community, many of whom do not have any of the traditional risk factors. Think hepatitis C!
Ric has worked in the field of blood-borne viruses for over 30 years, and now does regular sessional work at the Sexual Health Clinic at RPH and at HepatitisWA.
Consumer Perspective: Pete’s journey
Pete, with Dr Chaney, successfully completed hepatitis C DAA treatment in 2017.
What benefits have you experienced since being cured of hepatitis C?
In general, patients are more likely to seek appropriate GP care when required after they’ve been cured of hepatitis C, instead of ignoring problems because of shame or fear. Personally, my general health has improved immensely, both physically and mentally, since being cured of Hep C. Being co-infected with HIV, my symptoms from hepatitis C virus (HCV) were greatly exacerbated. I felt 30 years older than I am, but now my quality of life since HCV treatment/cure is hugely improved. I feel like myself again. I am optimistic again.
How did your relationship with your GP influence your treatment journey?
Because I have been living with HIV for over 35 years, my GP and I have forged a relationship built on mutual trust and respect. He knows my journey, particularly the difficulties regarding loss, trauma and stigma. I implicitly trust him. He always explained treatment regimes, outcomes and the like with me in ways I could easily comprehend. I was able to relay my fears and hopes. Our honest relationship was the foundation on which beginning DAA treatment for hepatitis C was based.
If you could give a message to GPs to encourage them to test and treat hepatitis C, what would you say?
The testing and treatment are easy and straightforward for both patient and doctor. Nothing is time-consuming. It also adds a tangible layer of trust between physician and patient. Open, non-judgmental discussion between both parties is the key. This again underscores the building of trust.
Questions? Contact the editor.
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