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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

It is worth noting that although an estimated 80% of people infected with hepatitis C in Australia have been diagnosed HCV antibody-positive, this refers to ‘lifetime diagnosed’. Many people with chronic hepatitis C are not currently linked to health services for their hepatitis C and are missing out on treatment and cure. This is a key driver of the drop-off in the cascade to treatment. GPs can help reverse this drop-off through identifying patients who have been previously diagnosed with hepatitis C and talking with them about the new treatment options. 

Who should be tested for hepatitis C?

HCV is spread through blood to blood contact, where the blood of one person enters the bloodstream of another. Key risk factors and populations to consider for HCV screening in Australia are shown in Box 2.3 Sometimes these risk factors may be difficult to identify during busy GP consultations, and they may have occurred in the distant past for many patients. 

People who have ever injected drugs (recently or at some time in their life) are at risk of having hepatitis C because of the risk of acquiring HCV through sharing injecting equipment. With an estimated 6000 to 8000 new HCV infections occurring each year, it is particularly important to test and treat people who currently inject drugs to reduce onward transmission of hepatitis C and prevent reinfections.

In 2017, a total of 10,537 hepatitis C notifications were made in Australia.11 Of the notified patients, 11% were Aboriginal or Torres Strait Islander people, 69% were male and more than half were aged 40 years and over. When classified by age, 11% of notified patients were under 25 years, 12% were between 25 and 29 years, 26% were between 30 and 39 years and 51% were 40 years and over.

The National HCV Testing Policy provides detailed information on who to test (http://testingportal.ashm.org.au/hcv). Apart from identifying risk factors for infection, an incidental finding suggestive of advanced liver disease or abnormal liver function test results warrant further investigation, including testing for viral hepatitis. All patients receiving opioid substitution therapy should be offered testing.

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Tips on starting the conversation about testing

GPs may find it challenging to ask patients about current or past risk practices related to hepatitis C. Most doctors take a social history from new patients, and this is an opportunity to enquire sensitively about risk factors for hepatitis C, such as current or past drug use, along with recording demographic variables such as country of birth and sexual behaviour. This information is also crucial for establishing whether there is a need to test for other bloodborne viruses, such as hepatitis B virus and HIV, which can all be undertaken as part of a ‘new patient screen’. 

Existing patients also need to be tested for hepatitis C. There are many opportunities for testing as part of general health checks, sexual health screens, pretravel check-ups and antenatal screening and as part of health promotion campaigns. 

Starting a conversation with a patient about hepatitis C is sometimes difficult, as discussing past or current drug use can be uncomfortable for both the patient and the GP. Patients may be unlikely to disclose injecting drug use, even to GPs with whom they have a good relationship. 

Having a focus on ‘liver health’ or ‘new hepatitis C treatments’ in the clinic as part of a targeted health promotion campaign can be a strategy to initiate a conversation about hepatitis C and to introduce testing to people who might be at risk. For example, a GP could explain ‘Now that we have new effective treatments for hepatitis C that are available on the PBS, we want to make sure we offer this treatment to all our patients who are eligible. Would you be interested in knowing about the ways people get hepatitis C and seeing if you think you should get tested?’ 

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Most people living with hepatitis C will have been previously diagnosed. This includes:

  • individuals who are fully diagnosed or partly diagnosed (HCV antibody test but no HCV RNA test) 
  • people who have previously been treated with older medications with treatment failure or who have been reinfected. 

This group also includes people who have not previously been offered treatment, those who declined treatment and those who are not engaged with regular care. Many people living with hepatitis C are members of marginalised populations and may have had negative experiences when accessing health care in the past or may have limited contact with the healthcare system. This is an important group to engage and to support into treatment. 

Trying to engage this group into treatment can be difficult. Offering testing in the context of a discussion about the new treatment options may be a good way to re-engage this group. 

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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.