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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

When discussing the new treatment options, GPs should cover the following:

  • new treatments cure 95% of people with hepatitis C
  • treatment lasts only eight or 12 weeks
  • all treatments are oral (no injections)
  • side effects, if any, are mild, such as fatigue, nausea and headaches;  these generally subside after the first four weeks.

GPs can identify patients with hepatitis C or requiring testing by searching their practice management system. Third-party tools such as POLAR or Pencat can help identify patients with potential risk factors and indicators (e.g. abnormal liver function test results) for testing. 

Points to discuss with patients before testing are shown in Box 3. Informed consent to testing is also required. Positive results need to be conveyed in a sensitive manner. 

What tests are needed? 

Two tests are required to diagnose HCV infection: 

  • an antibody test to screen for anti-HCV antibodies (indicating past exposure to HCV)
  • a polymerase chain reaction (PCR) test for the presence of HCV RNA (indicating current HCV infection).

To reduce the number of appointments, blood draws and time to diagnosis, we recommend reflexive hepatitis C testing. Both the anti-HCV antibody test and the PCR test for HCV RNA can be ordered on the same pathology order form by writing ‘Please order hepatitis C PCR only if anti-HCV is detected’ or ‘HCV antibody +/- HCV RNA, if Ab positive’. The Medicare Benefits Schedule covers an HCV RNA PCR test only in the case of a positive HCV antibody result, and therefore it is recommended to add the above phrase in the clinical notes of the pathology request form to avoid an out-of-pocket cost for the patient.

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A comprehensive bloodborne virus screen, including testing for hepatitis B and HIV infection, is also recommended for patients at risk of hepatitis C. This is because of the shared risk factors across all three infections and the availability of highly effective treatments for both hepatitis B and HIV infection. 

Interpretation of HCV test results is shown in Figure 3. Documented chronic hepatitis C (duration of current HCV infection six months or longer) is a PBS eligibility criterion for accessing treatment. Test results in acute hepatitis C are discussed in Box 4.

If HCV RNA is not detected after a positive anti-HCV antibody test then the patient has either spontaneously cleared HCV or been successfully treated in the past. The presence of HCV antibodies will remain but does not provide immunity to future infection, and there is currently no effective vaccine for hepatitis C. 

Hepatitis C is a notifiable condition (HCV antibody positive and/or RNA positive) by the laboratory or medical practitioner, depending on the jurisdiction. If results indicate current HCV infection, patients should consider recommending to their sexual or injecting partners to be tested also.

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The diagnosis of hepatitis C can be distressing for patients. The support of a knowledgeable, caring GP is crucial. Patient support organisations such as Hepatitis Australia can be helpful in providing support by phone or in person. Useful resources on hepatitis C for GPs and patients are shown in Box 5

Conclusion

An estimated 165,000 people are living with chronic HCV infection in Australia; however, the number of people being treated is declining. Renewed efforts are needed to reach everyone living with hepatitis C to offer testing and treatment. GPs are well placed to identify people at risk of hepatitis C and to offer testing and DAA therapy. Curing a patient of chronic hepatitis C is easier than ever before. It has the potential not only to benefit the individual by reducing their risk of liver disease and HCC and preventing transmission but also to eliminate HCV from Australia.     MT

 

COMPETING INTERESTS: Ms Draper has an NHMRC Postgraduate Scholarship and receives investigator-initiated funding from AbbVie. Dr Doyle receives funding for investigator-initiated research or consulting from AbbVie, Bristol-Myers Squibb, Gilead and MSD. Dr Baker has received clinical trial funding and conference sponsorship and serves on the advisory Board for AbbVie, Gilead and MSD. Professor Stoové has an NHMRC Senior Research Fellowship and has received funding for investigator-initiated research from AbbVie, Bristol-Myers Squibb and Gilead. Dr Pedrana receives funding for investigator-initiated research from AbbVie, Gilead and MSD.
 

References

1.    Bowden DS, Berzsenyi MD. Chronic hepatitis C virus infection: genotyping and its clinical role. Future Microbiol 2006; 1: 103-112. 
2.    Chen SL, Morgan TR. The natural history of hepatitis C virus (HCV) infection. Int J Med Sci 2006; 3: 47-52. 
3.    Hepatitis C Virus Infection Consensus Statement Working Group. Australian recommendations for the management of hepatitis C virus infection: a consensus statement (September 2018). Melbourne: Gastroenterological Society of Australia; 2018. Available online at: www.gesa.org.au/resources/hepatitis-c-treatment (accessed June 2019).

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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.