Eliminating hepatitis C in Australia needs informed patients and enabled GPs

A national education program would facilitate achieving the full potential of highly effective curative therapies

Less than a decade ago, formidable obstacles challenged Australians hoping to be cured of chronic hepatitis C virus (HCV) infections. Treatment was publicly funded only after liver damage had been detected by liver biopsy. For most people, it consisted of a year‐long, arduous course of weekly injections with pegylated interferon, which frequently caused bone pain and cytopenia, thyroid disease, and, consequently, depression. Dozens of daily supplementary tablets elicited further side effects, including haemolytic anaemia and rash. The risk of death from decompensated liver disease precluded any treatment for many with cirrhosis. Despite the toxicity and difficulty of HCV treatment, the chance of cure (that is, sustained viral response) was only 50% for most patients.1

Given this complexity, treatment was predominantly provided by specialist clinics, usually in public hospitals. Many patients without symptoms elected to defer treatment, often at some cost to their health. Others were poorly engaged with a confusing health system that frequently stigmatised people with HCV infections, and responded with further disengagement or denial of their illness.2

Basic research revealed vulnerabilities in key viral enzymes and pathways that can be exploited as therapeutic targets for direct‐acting antiviral agents (DAAs).3 This now means that the vast majority of patients living with HCV infections, irrespective of whether they have cirrhosis, can be treated with a well tolerated DAA regimen of one to three tablets once a day for 8‒12 weeks. DAA treatment is highly effective for most patients, with sustained viral response rates of more than 90%.3

As a consequence, HCV treatment is no longer restricted to hospitals or specialists, but is increasingly provided by general practitioners. In this issue of the Journal, Stafford and colleagues report that their recent audit of Pharmaceutical Benefits Scheme (PBS) data for March 2016 ‒ March 2020 indicated that HCV treatment for 44% of patients had been prescribed by GPs.4 The proportion of HCV treatments initiated by specialists is declining as that of GP‐prescribed treatments increases, a watershed in treatment accessibility for patients with HCV infections.

Treatment is now better and more accessible than ever, but the annual number of HCV prescriptions has declined since DAA agents were added to the PBS in 2016, falling to 8100 prescriptions in 2020.4 A decline was inevitable following high early uptake by patients who had been “warehoused”, awaiting subsidies for the new treatments (33 203 prescriptions were written during March–December 2016). But, if estimates of HCV prevalence are correct, more than 100 000 people in Australia are still living with untreated HCV infections.5 Stafford and his colleagues found that only 10% of GP prescribers were frequent prescribers (ie, had written more than ten HCV therapy prescriptions).4 These GPs are probably working in high HCV caseload practices that care for people who inject drugs in opioid substitution clinics and prisons; that is, the coalface for preventing HCV transmission by treatment.6 Such efforts are probably explain the marked reduction in HCV prevalence in Australia among people using needle and syringe programs, from 51% in 2015 to 20% in 2018.5

Is there scope to expand the screening and treatment of hepatitis C by GPs? Increasing prescribing rates is critical for reducing HCV incidence. But in a time‐limited and cost‐constrained environment, is it feasible for a GP with a low HCV caseload to invest the money and time required to become an occasional HCV therapy prescriber? Stafford and his co‐authors report that 2986 GPs, about half the 6187 GPs who had prescribed DAA therapy, had each written scripts for only one patient.4 Further research is needed to better understand the enablers of and barriers to initiating and sustaining HCV prescribing by GPs.

Are people living with HCV infections in Australia not coming forward for treatment because they are not sufficiently informed to engage with therapy? Despite national and state government policy commitments to increasing HCV treatment rates, there is no nationally recognisable, funded education program to increase testing and treatment by improving patient awareness. In the United States, despite a national birth cohort screening policy for people born during 1945‒1965, the costs of healthcare in general and of HCV treatment in particular were major barriers to screening.7 These costs should not be barriers for people treated in the Australian universal health system.

Better therapy for people with HCV infections is only one part of the solution for the HCV elimination challenge. We need to enable GPs, particularly those in practices caring for people from groups with high HCV prevalence rates, to expand HCV management. People living with HCV need to be better informed so that they can navigate the pathways to cure. We need a national education program for GPs and the community. Hepatitis C should be de‐stigmatised and talked about in Australian living rooms so that it can be cured in GP consulting rooms. Taken together, we will not only be funding HCV treatment, but also enabling patients and prescribers to cure it. In doing so, we could achieve the full potential of HCV therapy and eliminate the virus in Australia.