Issue 11 / 29 March 2016

NEW guidelines and newly accessible drugs are an exciting step forward for hepatitis C virus (HCV) management, but experts say much more needs to be done to address the disproportionate burden of disease in Indigenous communities.

Associate Professor James Ward, head of the infectious diseases research program – Aboriginal health at the South Australian Health and Medical Research Institute, told MJA InSight that “the approval of these new drugs that have fewer side effects has really opened up a new opportunity to improve how we treat HCV”.

“But Aboriginal and Torres Strait Islander people have less access to health services, so they may not be coming through the door to get these new drugs,” he said.

Professor Ward was commenting on an article published online today by the MJA which summarised a consensus statement on HCV management prepared by an expert panel from the Gastroenterological Society of Australia, the Australasian Society for Infectious Diseases, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, the Australasian Hepatology Association, Hepatitis Australia and the Royal Australian College of General Practitioners.

Interferon-free regimes, involving combinations of sofosbuvir, ledipasvir, daclatasvir and/or ribavirin, are now listed on the Pharmaceutical Benefits Scheme (PBS) for treating people with HCV genotypes 1–3.

The statement said that this PBS listing would now allow these therapies to be prescribed by specialists experienced in treating chronic HCV infections, or by a GP in consultation with a specialists.

The recommendations advised that people with cirrhosis and other special populations, including those with decompensated liver disease or renal impairment, should be referred for specialist care.

Key issues during pre-treatment assessment include identifying HCV genotype, evaluating for cirrhosis and considering concomitant medications, such as over-the-counter and illicit drugs, to prevent adverse drug interactions.

Dr Emma Miller, epidemiologist on hepatitis C infection at Flinders University, welcomed the consensus statement, saying that “up until very recently, the only treatments available have been quite toxic in terms of side effects, difficult to take and quite extended – up to a year for many patients”.

“These treatments have also not been very effective for many of the genotypes of hep C virus currently circulating,” she told MJA InSight.

Dr Miller said that tor this reason, treatment uptake has been very low in Australia and this has kept the national prevalence of HCV high.

Professor Ward told MJA InSight that while the new recommendations would help address HCV rates overall, there is still serious concern about how to address the high prevalence rates in Indigenous communities.

“Over the last 5 years, there has been a 40% increase in the number of HCV notifications and 10% of the people currently living with HCV identify as Aboriginal or Torres Strait Islander.

“That’s a fairly disproportionate representation.”

Professor Ward said that special attention must now be paid to ensuring that every community in Australia is able to benefit from the new guidelines.

“GPs are diagnosing HCV, so there is awareness. But we need to look at how to best roll out these changes.

“In particular, we have to make sure that [Indigenous people] can access the health services providing this treatment in the first place.”

Dr Miller agreed, saying that while the new range of antiviral drugs were now affordably available, it was going to be a real challenge to make people aware that the new treatments are highly effective and have very few side effects. 

“[This] will be critical and will require a concerted effort to challenge widespread beliefs about hepatitis C treatment,” she said.

Professor Ward said that a way to improve awareness and access to care would be to integrate nurse-led models of care with HCV management.

Dr Miller said that public health strategies at the population health would also have a key role to play.

“The most effective transmission reduction strategy to date has been the wide-scale provision of clean injecting equipment.

“Efforts to reduce stigma and a gradual movement towards managing drug use as primarily a health issue, rather than a criminal issue, will greatly increase access to prevention resources in injectors and other highly marginalised groups.”

Dr Miller added that these awareness initiatives would not just be targeted at the general public.

“Upskilling GPs to prescribe the new treatments and to confidently and sensitively manage hepatitis C patients will greatly increase the accessibility to treatment.”

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