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Feature Article

Eliminating hepatitis C: Part 1. Finding your patients with hepatitis C

BRIDGET DRAPER, CHLOE LAYTON, JOSEPH DOYLE, Jessica Howell, David Baker, MARK STOOVÉ, ALISA PEDRANA
OPEN ACCESS

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© PHOTOGRAPHEE.EU/ DEPOSITPHOTOS MODELS USED FOR ILLUSTRATIVE PURPOSES ONLY

Abstract

Direct-acting antivirals (DAAs) can now cure almost all patients with chronic hepatitis C. This gives us the opportunity to eliminate hepatitis C from Australia. However, the number of people receiving DAA treatment is declining despite an estimated 165,000 people living with chronic hepatitis C. GPs have a key role in identifying and treating their patients living with hepatitis C if we are to reduce disease burden and achieve hepatitis C elimination.

Key Points

  • Direct-acting antiviral (DAA) treatments can cure almost all people with hepatitis C with only eight or 12 weeks of treatment.
  • Curing patients of hepatitis C not only reduces disease burden for the individuals but has the potential to eliminate hepatitis C in Australia.
  • GPs, nurse practitioners and specialists can all prescribe DAA treatments.
  • Of the estimated 165,000 people in Australia with chronic hepatitis C, about 20% are undiagnosed, and among those diagnosed more than half have not been treated.
  • GPs have a crucial role in identifying their patients living with hepatitis C through sensitively raising the topic of HCV infection and the availability of treatment and offering testing and treatment.

New curative treatments for hepatitis C, known as direct-acting antivirals (DAAs), have revolutionised the management of people living with hepatitis C virus (HCV) infection. The simplicity and tolerability of DAAs means it is now easy to cure hepatitis C in most patients, making possible the elimination of hepatitis C in Australia. However, major challenges remain in finding people with hepatitis C who have not been diagnosed, linking people who have been previously diagnosed into care, and supporting patients to complete treatment. GPs have a crucial role in identifying and treating their patients with hepatitis C to help achieve the goal of delivering treatment to everyone who is living with hepatitis C.

This article is the first in a series about hepatitis C in Australia. The series will guide GPs through testing, treating and curing hepatitis C in primary care. This article focuses on who to test and how to test. 

Hepatitis C virus infection 

HCV is a bloodborne virus that can cause liver inflammation and liver scarring and puts people at risk of liver cirrhosis, liver failure and hepatocellular carcinoma (HCC). There are six main genotypes of HCV; the most common in Australia are genotype 1 and genotype 3.1 

The natural history of HCV infection is summarised in Figure 1.2 Following acute HCV infection, 15 to 25% of people will spontaneously clear the infection, with the other 75 to 85% progressing to chronic infection. About 20 to 30% of people with chronic HCV infection develop cirrhosis after 20 to 30 years of infection.3 Hepatitis C is the most common cause of HCC in Australia. HCC is the fifth most common cause of cancer death among males and the eighth most common cause of cancer death among females in Australia.4 Incidence rates of HCC have increased more than those of any other cancer except thyroid cancer in Australia.4 

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What are the signs and symptoms of chronic hepatitis C?

Chronic HCV infection is usually asymptomatic. If symptoms are present, they are usually nonspecific, such as tiredness and lethargy. Serious symptoms occur when advanced liver disease develops, including confusion, jaundice, ascites, peripheral oedema, easy bruising and bleeding, haematemesis and muscle wasting. 

Investigation results such as raised alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels can indicate liver inflammation and warrant further investigation, including testing for viral hepatitis. 

What are the benefits of cure?

Curing hepatitis C reduces the risk of cirrhosis and HCC. During 2016-17, there was an estimated 20% decline in deaths from hepatitis C-related liver failure and HCC in Australia.5 

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Recent evidence suggests that people who achieve a sustained virological response or hepatitis C cure (defined as no detectable HCV RNA on a blood test 12 weeks after treatment completion) report improved quality of life. This includes physical health benefits, notably less fatigue, and an improved sense of psychological wellbeing related to less uncertainty about future health and no longer fearing infecting others.6 

Australia’s progress towards eliminating hepatitis C is shown in Box 1.7-9

How many people are living with hepatitis C?

Globally, an estimated 71.1 million people are living with chronic hepatitis C.10 In Australia, an estimated 165,000 people were living with chronic hepatitis C at the end of 2018 (projections from a model based on updated unpublished testing and treatment data that was originally published in Scott N, et al. Int J Drug Policy 2017; 47: 107-116).

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The hepatitis C cascade of care describes the recommended pathway through clinical care for people at risk of hepatitis C. Numbers of people at each stage of the cascade of care in Australia in 2017 are shown in Figure 2.11 An estimated 80% of people living with hepatitis C had a positive HCV antibody result (145,838), but only 47% of those people (68,544) had a positive HCV RNA result confirming chronic HCV infection (not shown). Of these, 31% (21,530) received hepatitis C DAA treatment in 2017, with 95% achieving cure.11 

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© PHOTOGRAPHEE.EU/ DEPOSITPHOTOS MODELS USED FOR ILLUSTRATIVE PURPOSES ONLY
© PHOTOGRAPHEE.EU/ DEPOSITPHOTOS MODELS USED FOR ILLUSTRATIVE PURPOSES ONLY
Ms Draper is a Research Assistant in Disease Elimination, Burnet Institute, Melbourne; and a PhD Student in the School of Population Health and Preventive Medicine, Monash University, Melbourne. Ms Layton is an EC Nurse Co-ordinator in Disease Elimination, Burnet Institute. Dr Doyle is Deputy Program Director of Disease Elimination, Burnet Institute; Adjunct Senior Lecturer in the School of Population Health and Preventive Medicine, Monash University; and Consultant Infectious Diseases Physician in the Department of Infectious Diseases, Alfred Hospital, Melbourne. Dr Howell is a Consultant Gastroenterologist at St Vincent’s Hospital, Melbourne; Postdoctoral Research Fellow in Disease Elimination, Burnet Institute; and Department of Medicine, University of Melbourne. Dr Baker is a GP at East Sydney Doctors; and Senior Lecturer at the University of Notre Dame Australia, Sydney, NSW. Professor Stoové is Head of the Public Health Discipline at the Burnet Institute; and Adjunct Research Fellow at the School of Population Health and Preventive Medicine, Monash University. Dr Pedrana is Postdoctoral Research Fellow in Disease Elimination, Burnet Institute; and Adjunct Research Fellow in the School of Population Health and Preventive Medicine, Monash University, Melbourne, Vic.