After three decades of groundbreaking Hep C treatment in Australia, a new research project is focusing on ways of expanding Hep C care for Indigenous people. Andrew Binns explains.
In 1996 the then-Northern Rivers Division of General Practice received Federal government funding for a Hepatitis C shared care project. At the time there were 20 new notified cases of hepatitis C (Hep C) each month, according to a GPSpeak article by Dr Jane Barker, the Project Manager.
Interferon was one of the drugs used for Hep C treatment. It was given over a 6-12 months period and for some had unpleasant side effects. The waiting time to see a gastroenterologist for treatment was quite long and GPs were encouraged to share the care to reduce the workload of the specialists involved.
The Richmond area had the highest notification level on the North Coast, with 640 cases in 1995, the year before the project launched. It is believed this reflected the high use of intravenous drugs in this area, or the movement to this area of IV drug users from urban areas, e.g. Sydney, Brisbane, Gold Coast.
In 2003, after years of lobbying, the then-Northern Rivers Area Health Service secured funding to establish the area’s first Liver Clinic (in Lismore) for treatment of Hep C. This facilitated access to much-needed treatment for many patients, especially those on low incomes who were less able to travel for treatment.
The Liver Clinic provided a detailed assessment of the patient, including liver biopsy, education and treatment. Some GPs were trained to become S100 treatment prescribers for Hep C medications in a shared care model.
At the time the combination of pegylated interferon and ribavirin for Hep C patients (a once weekly injection) resulted in cure rates of at least 80% of patients with genotype 2 or 3 and about 50% for patients with genotype 1.
So where are we up to with Hep C treatment 16 years later?
Oral direct-acting antiviral (DAA) treatments introduced in 2016 have revolutionised the management of HCV infection and given rise to optimism about the potential for HCV elimination in Australia. With high cure rates (sustained virological response [SVR] >95%) after 8-12 weeks treatment, HCV DAAs provide the tools required to reverse the growing burden of liver disease and strive for HCV elimination.
The Hep C Virus (HCV) disproportionately impacts vulnerable populations, including Aboriginal and Torres Strait Islander people, injecting drug users, and people in custodial settings. In 2015, an estimated 227,306 Australians were living with chronic HCV, including over 22,000 Aboriginal people, with a growing burden of HCV infection and HCV-related liver disease. While Aboriginal people account for 2-3% of the national population, it is estimated that 8-10% of all Australians living with HCV infection are Aboriginal.
GPs play a vital role in identifying and managing those with chronic Hep C infection. Most of these regular patients have now been treated and the Liver Clinics around Australia are doing less initiating of Hep C treatment than in past years. GPs are now able to prescribe on authority script the DAA medications once the appropriate testing has been done.
The challenge in the attempt to eliminate Hep C is to access those people in the community who are maginalised, whether in the custodial system, experiencing homelessness or for whatever reason have not come forward for this lifesaving treatment. This may mean accessing those with Hep C infection through medical services for Aboriginal people, homeless people or those in custody.
One of the issues when working in these facilities is that, according to Hep C treatment protocols, there are many steps required during testing and follow up visits to a GP. As so often within an itinerant population, patients are lost to follow up. Compliance with a full course of treatment which lasts for 8-12 weeks can also be a problem for some of these people.
But what if there was a simple finger prick test that could enable diagnosis and treatment with a prescription in a matter of hours? This would certainly increase the chance of successfully treating a person with chronic Hep C infection.
The news on this front is encouraging, with such a test now being trialled at different sites around four of Australia’s Aboriginal Medical Services (AMSs). Jullums AMS, opposite Lismore Base Hospital, is one of those. It provides a primary care GP service to residents of Balund-a, a diversionary NSW Corrective Service facility. The residents are young men who have come through the custodial system. In addition testing at Jullums will be available for all patients who are at high risk of having acquired Hep C infection. This research project, known as Scale-C , commences in April 2019.
It is being run until 2022 by the Kirby Institute and the South Australian Health and Medical Research Institute, with funding from the National Health and Medical Research Council. The aim is to develop an integrated model of care that increases access to HCV testing and treatment for those who need it most.
According to Professor Gregory Dore, who leads the Hepatitis Clinical Research program at the UNSW Kirby institute, around 60,000 Australians have been treated since 2016 with the highly curative therapies and now for the first time we are seeing fewer people dying of hepatitis C- related causes.
Prof Dore’s data has also shown the prevalence of HCV among people who currently inject drugs had declined from 43% in 2015 to 25% in 2017.
Whilst this is an enormous advance in controlling the epidemic there are still 170,000 people in Australia living with chronic Hep C. Moreover, there has been a recent drop in treatment uptake that needs to be addressed in order to meet the WHO elimination targets of reducing deaths by 65% and new infections by 80% before 2030.
Encouragingly, Prof Dore believes Australia is in a good position to meet these targets, and if the experience of recent decades is anything to judge by, the prospects do look bright.