Other comorbidities and risk factors may contribute to the development of liver disease, such as excessive alcohol use and fatty liver disease/metabolic syndrome. These people should be encouraged to maintain a healthy lifestyle, including smoking cessation, safe alcohol consumption, maintaining a healthy weight, healthy diet and exercise. They should also be encouraged to avoid reinfection through harm reduction practices. Patients who have not received hepatitis A and hepatitis B vaccinations should be offered them.10
Patients without cirrhosis but with abnormal liver function results
Patients without cirrhosis who have abnormal liver function test results after treatment (alanine aminotransferase [ALT] ≥30 U/L [men] or ALT ≥19 U/L [women]) may have comorbid liver disease. Routine investigations for liver disease can be initiated by the GP. These patients should be referred to a gastroenterologist for further investigation and management.
Patients with cirrhosis
Patients who were diagnosed with cirrhosis before DAA treatment would usually have been referred to a specialist at that time. After DAA treatment, they will require ongoing management of their liver disease by a gastroenterologist and should be referred if not already receiving specialist care.
Patients who are not cured
About 5% of patients who complete a full treatment course do not achieve cure of hepatitis C with initial DAA therapy. Possible reasons include:
- viral resistance to the DAAs used
- presence of advanced liver disease.
Patients who are not cured should be referred to a gastroenterologist or infectious disease specialist who is experienced in the management of hepatitis C for further assessment and potential retreatment. Retreatment of a patient after DAA treatment failure may require a specific salvage regimen but generally has a good outcome.11
Hepatitis C virus reinfection
People with ongoing risk factors for infection are at risk of reinfection with HCV. The main risk groups in Australia are:
- people who inject drugs – most new HCV infections occur in this group6
- men who have sex with men, particularly those who are HIV-positive
- people in custodial settings
- people who have received a tattoo or body piercing in an unsterile setting.
Treatment of HCV reinfection
Patients with HCV reinfection should be retreated to prevent both progression of liver disease and transmission of HCV to others. Importantly, people with reinfection are eligible for PBS-subsidised DAA therapy. Those with clear reinfection – for example, HCV RNA detected after confirmed SVR12 or a different HCV genotype detected – can be treated as if they are treatment-naïve.6
Further, patients with HCV reinfection should be invited to bring in or refer their sexual or injecting partners (who may have been the reinfection source) for treatment. They should also be offered advice and support to reduce their infection risk.
Reducing risk of reinfection for people who inject drugs
People who inject drugs are at ongoing risk of HCV infection. Three simple hepatitis C harm reduction messages are:
- Use sterile injecting equipment and do not share any injecting equipment
- Encourage injecting partners to be tested and treated
- Remind people they can be retreated if they are reinfected.
Harm reduction is an effective approach to reduce hepatitis C risk. It includes providing access to clean needles, syringes and other injecting equipment and opioid substitution therapy (OST). Informative harm reduction resources for people who inject drugs are readily available on the internet and provide easily accessible information on topics such as safe injecting practices and OST (Box 2). GPs can play an active role in harm reduction by:
- offering OST within their practice or discussing pathways to access
- discussing safer injecting behaviours.
GPs are also recommended to offer HCV RNA PCR testing at least annually to people who inject drugs to screen for HCV reinfection, as previously discussed.
People who inject drugs may have other comorbidities requiring long-term care. A trusting and lasting relationship with a GP is very important for this patient group.12 People who inject drugs often report experiencing stigma and discrimination from healthcare providers, which can be a significant barrier to seeking health advice and treatment.13 Resources for primary care staff to help raise awareness about stigma and discrimination are available from the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (Box 2).14