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THERE is an ever-increasing range of health priorities Australian doctors are expected to be aware of, and consider in their day-to-day practice.
Sometimes the evidence underlying these priorities can be limited, as can practical guidance on how to incorporate them into routine clinical care.
This did apply to chronic hepatitis B — a condition which affects more than 210 000 Australians — but no longer. A range of resources and guidelines has become available to guide testing, assessment and management in primary care. Some of these were discussed recently in MJA InSight, and we provide some examples at the end of this article.
Without access to care, up to a quarter of people living with chronic hepatitis B will develop advanced liver disease and/or liver cancer. Chronic viral hepatitis is the leading cause of primary liver cancer, the fastest increasing cause of cancer death in Australia.
Access to appropriate care is effective at preventing these outcomes, and has been found to be cost-effective in Australia.
However, two recent publications, with which we were involved, show that the current level of care is far from adequate.
The first of these publications explores the “cascade of care” for chronic hepatitis B in Australia.
Diagnosis is naturally the first step in providing care, but it is estimated that only just over half of all people living with chronic hepatitis B have been diagnosed. Only 13% of those living with hepatitis B received an annual viral load test to monitor their disease activity in 2013, despite recommendations that this should occur for all patients.
Australia’s National Hepatitis B Strategy sets a treatment target of 15% coverage of all people living with chronic hepatitis B with antiviral therapy, yet current uptake is only 5%.
The other recent publication exploring this issue is the Second National Hepatitis B Mapping Report, which examines these and other indicators at a local level. It helps explain why access is so low, and where the need is greatest. For example, in rural areas antiviral treatment coverage is even lower than the national average, in some areas less than 2%.
However, even in communities with the highest coverage — largely in urban areas of Sydney and Melbourne — less than a third of those living with chronic hepatitis B are receiving guideline-based care. Another key factor in the response to chronic hepatitis B is the high concentration of the burden in these communities, with more than half of those diagnosed with chronic hepatitis B in the past 15 years living in just 10 of the 61 Medicare Locals areas in Australia.
Why is access to care so low and what can be done about it?
Improving awareness is a key priority. The groups with the greatest burden of hepatitis B in Australia are migrants from endemic areas and Aboriginal and Torres Strait Islander people. These communities often experience lower health care access, face ongoing stigma and discrimination, may have reduced health literacy, and experience other barriers to engagement with preventive health care.
As for clinicians, it has been demonstrated that the level of awareness regarding the natural history and availability of treatment for chronic hepatitis B could be improved.
Hepatitis B serology can be confusing. While there are now clear guidelines regarding who to test and how to do so, these could be incorporated into practice management software or clinical resources to maximise their utility for clinicians.
Even when a patient is diagnosed, GPs (including those who have undertaken additional training) are currently not permitted to initiate antiviral treatment when required. This restriction is clearly a barrier to care, and in many cases forces patients with straightforward treatment requirements onto lengthy waiting lists to attend public hospital clinics.
This can also delay specialist review for those with advanced disease or complex needs who do require specialist care.
The majority of deaths due to hepatitis B are avoidable, mandating that we address this deficit in access to care.
The gap between high-level strategies on one side, and actual resources and programs on the other, is large and steadily growing. We cannot allow this gap to widen further as the number of deaths attributable to hepatitis B rises.
Using the new evidence and the tools already available, we must act now.
List of Resources
• B Positive: All you wanted to know about hepatitis B: a guide for primary care providers
• The National Hepatitis B Testing Policy
• The Hepatitis B Decision Making Algorithm
• ASHM training for management of chronic hepatitis B
• Australian Family Physician – Hepatitis B serology and Chronic hepatitis B: What’s new?
Dr Jennifer MacLachlan is an epidemiologist at the Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital.
Associate Professor Benjamin Cowie is an infectious diseases physician with the Victorian Infectious Diseases Service and an epidemiologist at the WHO Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory, The Doherty Institute.