Open Access
Feature Article

Part 4. Ongoing care after hepatitis C treatment

KICO CHAN, * MICHELLE GOOEY, * MARGARET HELLARD, BELINDA GREENWOOD-SMITH, RICHARD CHANEY, David Baker, ALISA PEDRANA, JOSEPH DOYLE, Jessica Howell
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Abstract

Most patients who receive direct-acting antiviral treatment for hepatitis C are cured. The need for and nature of ongoing clinical care after treatment depends on whether cure has been achieved, the presence of cirrhosis or persistently abnormal liver function test results and ongoing risk of reinfection with hepatitis C virus.

Key Points

  • Over 95% of patients are cured after a full course of DAA treatment.
  • Patients with persistent liver function test abnormalities after DAA treatment need specialist referral for further investigation.
  • Patients with cirrhosis need specialist referral and lifelong monitoring for complications such as hepatocellular carcinoma.
  • Past infection does not result in immunity to hepatitis C, so patients should be counselled about the risk of reinfection and importance of harm reduction.
  • Harm reduction is an effective approach to reduce hepatitis C risk, including access to clean needles, syringes and other injecting equipment, and opioid substitution therapy.
  • Patients at risk of reinfection should be offered at least annual hepatitis C virus RNA PCR testing in the knowledge that they are eligible for retreatment if reinfected.

In Australia, over 70,000 people living with hepatitis C have received direct-acting antiviral (DAA) treatment, and GPs are writing an increasing proportion of all DAA prescriptions.1,2 Primary care is crucial to management of people after they have received DAA treatment for hepatitis C. 

This is the fourth article in a series about treatment of patients with hepatitis C in general practice. Previous articles outlined how to identify patients with hepatitis C, their assessment and treatment with DAAs.3-5 This article focuses on general practice care of patients after DAA treatment. This includes recommended care of those who have been cured of hepatitis C, the small proportion who are not cured, those with cirrhosis and those with ongoing risk factors for reinfection. 

Determining treatment outcome

Over 95% of patients with chronic hepatitis C are cured after a full course of DAA treatment. Hepatitis C virus (HCV) RNA testing is required to determine treat­ment success or failure (or subsequent reinfection). 

A patient is defined as cured of hepatitis C if HCV RNA is no longer detected by a PCR test on a blood sample taken at least 12 weeks after completing the DAA treatment course.6 Cure is also referred to as a sustained virological response at 12 weeks (SVR12). 

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Advice for patients who are cured

After successful treatment, it is important to inform patients of the following:

  • Antibodies against HCV will most likely remain detectable long term. These antibodies represent the body’s immune response to the virus and reflect exposure, not active infection. 
  • Past infection does not result in immunity and the presence of HCV antibodies does not prevent reinfection. People who continue to engage in behaviours that put them at risk can be reinfected with HCV. 

People who inject drugs should be reminded that practising harm reduction will help minimise the risk of reinfection (see below). Men who have sex with men should be reminded about safe sexual practices to minimise the risk of reinfection. It is also worth mentioning that HIV pre-exposure prophylaxis with tenofovir – emtricitabine does not protect against HCV infection. 

For people who continue to be at risk of HCV reinfection, HCV RNA testing by PCR should be offered at least annually (note that the MBS funds one HCV RNA PCR test per 12-month period).7 This is also an opportunity to discuss harm reduction measures. There is no indication for repeat hepatitis C antibody testing, as the result will most likely continue to be positive. It is important to let people know that they can be retreated if they are reinfected. 

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Clinical follow up 

The recommended follow up for patients after hepatitis C DAA treatment is shown in the Flowchart.8 The need for ongoing clinical follow up is determined by several factors:6

  • whether hepatitis C has been cured
  • the degree of liver fibrosis present before DAA treatment
  • liver function test results 12 weeks after treatment is completed
  • ongoing exposure to risk factors.

Follow up of a patient who is cured is described in Box 1

Patients who are cured

Patients without cirrhosis and with normal liver function 

Most people currently living with hepatitis C in Australia do not have cirrhosis.9 No further clinical follow up of hepatitis C is needed for those without cirrhosis who:

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  • achieve a cure
  • have normal liver function test results after treatment, and 
  • are not at risk of reinfection. 

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© FilippOBaCCi/istOCKphOtO.COm mODEls UsED FOr illUstratiVE pUrpOsEs OnlY
© FilippOBaCCi/istOCKphOtO.COm mODEls UsED FOr illUstratiVE pUrpOsEs OnlY
Ms Chan* is a Research Nurse in the EC Partnership, Disease Elimination, Burnet Institute, Melbourne. Dr Gooey* is a Public Health Registrar at the Burnet Institute. Professor Hellard is Deputy Director of the Burnet Institute; Consultant Physician in the Department of Infectious Diseases, Alfred Hospital; and Adjunct Professor in the School of Public Health and Preventive Medicine, Monash University, Doherty Institute and Melbourne School of Population and Global Health, University of Melbourne, Melbourne. Dr Greenwood-Smith is a Remote Medical Practitioner and Coordinator of the Centre for Disease Control, Alice Springs, NT. Dr Chaney is a GP Consultant in the Sexual Health Service of Royal Perth Hospital, the HepatitisWA Deen Clinic and General Practice in Perth, WA. Dr Baker is a GP at East Sydney Doctors; and Senior Lecturer at the University of Notre Dame Sydney, Sydney, NSW. Dr Pedrana is Senior Research Fellow in Disease Elimination, Burnet Institute; and Adjunct Research Fellow in the School of Population Health and Preventive Medicine, Monash University, Melbourne. Dr Doyle is Deputy Program Director of Disease Elimination, Burnet Institute; and Infectious Diseases Physician in the Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 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, Melbourne, Vic. * Equal first authors.