Hepatitis C virus (HCV) is an important cause of morbidity and mortality in Australia. More than 200 000 people are estimated to be living with chronic HCV infection, with over 80% of these infections resulting from unsafe injecting drug use. About 10 000 new infections occur annually, although incidence is thought to be declining.1 Following primary HCV infection, persistent viraemia and chronic hepatitis occurs in 50%–80% of patients; after 20 years approximately 7% develop cirrhosis, and a small proportion of these patients develop hepatocellular carcinoma.1

Treatment of HCV infection has advanced over the past 10 years, leading to improved outcomes; the most effective current treatment is pegylated interferon combined with ribavirin. The aim of treatment is viral eradication, and treatment is deemed successful if a patient has a sustained virological response (SVR).2 The subsequent reduction in liver disease progression in patients who obtain an SVR3 suggests that the burden of advanced liver disease could be reduced if more patients received treatment.

Treatment uptake has increased over the past 10 years, but has remained low. The removal of restrictions to prescribing for treatment — including the requirement for patients to have abnormal alanine aminotransferase levels or liver biopsy results (restrictions that were removed in 2005 and 2006, respectively) — has increased access,4 but the total number of individuals being treated for HCV infection in Australia remains low, at around 3500 individuals per year.5

Estimates vary, but recent modelling suggests that at least 6000, and closer to 10 000, people with chronic HCV infection need to be treated annually to reduce the burden of advanced liver disease in the future.1 While we acknowledge that not all people want or can have treatment for HCV infection, the number could be increased. HCV treatment can only be prescribed by certain medical practitioners or specialists, or at liver clinics, and cannot be prescribed by most general practitioners. Opportunities for treatment in tertiary hospitals and opioid pharmacotherapy clinic settings need to be expanded,6 but equally important is increasing GPs’ capacity to manage and treat patients living with HCV.

GPs are usually the initial point of contact for patients with or at risk of HCV. It is imperative that GPs provide clear, accurate and up-to-date advice on HCV risk, prognosis and management. Several surveys in the past 10 years have reported that most GPs want further education about treatment, interpretation of test results, pre- and post-test counselling, and referral information.7,8

Many GPs’ knowledge of HCV is limited. A study undertaken in the period 2005–2006 found that, although GPs were aware of which patients are at risk of HCV (injecting drug users in particular), many underestimated the large number of Australians infected with HCV.9 A 2002 study reported that 39% of surveyed GPs mistakenly believed that positive results from HCV serological testing, as opposed to positive results from HCV RNA testing, differentiated current and resolved infection.7 An anti-HCV antibody test only provides information on whether a patient has ever been exposed to HCV — a positive result does not necessarily indicate an ongoing infection. An HCV RNA test is required to determine whether a patient has an ongoing infection or has spontaneously cleared their infection. GPs’ awareness of HCV treatment was also limited. The 2005–2006 study showed that only 42% of surveyed GPs were aware of the effectiveness of current HCV treatment, and only 28% were aware of the eligibility criteria for access to subsidised treatment.9 The 2002 study showed that 52% of GPs were not aware that pegylated interferon–ribavirin combination therapy was the most effective HCV treatment.7

Other studies have shown that fewer than 52% of people living with HCV in Australia had ever been referred to a specialist liver clinic10,11 despite the general acceptance that this should occur for the vast majority of patients with HCV. In addition, many GPs have reported being uncertain about when to refer patients to hepatitis specialists.9

Ongoing education is vital if GPs are to remain up to date on the management of HCV infection. A range of options are required to meet the needs of different GPs and their patients. One option is training GPs to fully manage their own patients, including training to become accredited prescribers of pegylated interferon and ribavirin under the federal government’s Section 100 (s100) Highly Specialised Drugs Program. Currently, the availability of such training is limited and varies between states and territories.

A shared care model is a second option. Some GPs could be actively involved in the management and follow-up of patients without being an s100 prescriber. This model could suit GPs who manage only a few patients with HCV infection, as well as nurse practitioners and GPs in rural and regional areas. A specific training program could be developed to provide GPs and nurse practitioners with the necessary knowledge and skills, particularly for managing the side effects of HCV treatment.

A third option should be provided to potentially the largest group of GPs — those who have patients at risk of or infected with HCV, but who do not want to be directly involved in HCV management. Through ongoing and regularly updated training programs, these GPs need to stay up to date on who is at risk of HCV infection, what tests should be ordered to diagnose and monitor HCV infection, and when patients should be referred to a specialist. In addition, all GPs need to have a broad understanding of what HCV treatments are available, that current and recent injecting drug users are eligible for HCV treatment, and that a liver biopsy is no longer required for a patient to have access to treatment (Box).

Encouraging GPs to undertake HCV training in a setting of competing education priorities is a major challenge. Perhaps the first step should be to highlight that HCV occurs in about 1% of the population and that treatment options and outcomes for their patients have improved considerably during the past 5 years and are likely to continue to do so.