Great strides have been made in treating and managing blood borne viruses such as hepatitis B, C and HIV in recent times, meaning people living with these conditions can lead full, healthy lives. But is the promise of these treatments being fulfilled for patients, asks North Western Melbourne PHN CEO Adj/Associate Professor Christopher Carter?
Reproduced from VICDOC — Magazine of the Australian Medical Association Victoria
April/May 2017 edition (p. 22-23)
Up until recently attempts to cure hepatitis C involved lengthy interferon-based treatments, along with which came serious side effects and relatively poor success rates. Newly available hepatitis C treatments have significantly more efficacy with up to 90% clearance rates for patients with minimal side effects.
HIV treatment and care has made huge strides since the advent of highly active antiretroviral therapy (HAART) which became available in the late 1990s. HIV is now, in the main, a manageable chronic condition with a current strong community debate focusing on potential HIV eradication through the combined effects of undetectable viral load (UVL), pre-exposure prophylaxis (PrEP), and post exposure prophylaxis (PEP).
While there is no cure for hepatitis B, there is strong evidence showing that early detection, follow-up and treatment of chronic hepatitis B can slow the progression to liver failure and the development of liver cancer. A very effective vaccine against hepatitis B also exists with over 90% of Australian children fully immunised.
Despite these advances, many people living with these conditions are not receiving treatment, even once they have been diagnosed. Nearly half of the approximately 219,000 people in Australia living with chronic hepatitis B (CHB) infection remain undiagnosed, and of those with a diagnosis, 87% are not receiving adequate care. Without access to appropriate care, up to a quarter of people living with CHB will die from their condition.
Treatment rates are even lower for hepatitis C. More than 70,000 Victorians currently live with the hepatitis C virus, and before the release of new treatments only 1.3% of them received treatment; left untreated, chronic hepatitis C can lead to cirrhosis, liver cancer and death.
There has been a substantial boost in treatment rates since new treatments were listed on the Pharmaceutical Benefit Scheme in March 2016, with some figures suggesting as many as 13% of people living with hepatitis C received treatment in the first few months of the program. The boost in treatment rates are an encouraging start – however as many as eight in every 10 people with hepatitis C are still not being treated.
Why people are not receiving treatment is a question with many potential answers. All three conditions may be present with no or minimal symptoms, especially in the early stages of infection, meaning many people simply do not know they have the condition.
Levinia Crooks, CEO of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) says that there is a range of systemic barriers to healthcare for people living with viral hepatitis or HIV.
“Widespread hepatitis C-related stigma and discrimination in the healthcare sector – mostly directed towards injecting drug use – impedes access to services and impairs the quality of healthcare delivery for people living with hepatitis C and other key populations,” Ms Crooks said. “It directly undermines efforts to eliminate the disease.”
ASHM is working on a two-year project to address stigma, discrimination and structural barriers to accessing healthcare and prevention services.
Training programs and policies designed to be taken up across different health services and settings aim to provide clinicians in training with the skills to identify and address stigma and discrimination in their own practices and in the systems in which they work.
It’s not only stigma that is holding people back from treatment. A lack of access to services, especially outside of metropolitan Melbourne, and the serious side effects associated with some older treatments may also be putting patients off seeking care.
While the challenges are significant, the example of HIV in Melbourne shows they can be overcome through a coordinated approach between governments, service providers, health professionals and the community.
Melbourne became a Fast Track City in 2016, joining a global network of cities committed to ending the global AIDS epidemic by 2030 through better awareness, prevention and access to treatment. Early results are encouraging, showing Melbourne is meeting or exceeding Fast Track Targets in all areas:
- 90% of people living with HIV know their HIV status
- 94% of people with diagnosed HIV infection are receiving sustained antiretroviral therapy
- 93% of people receiving antiretroviral therapy have viral suppression
Extending this success to the treatment of other blood borne viruses is the aim of the newly launched Victorian HIV Hepatitis Integrated Training and Learning (VHHITAL) program. VHHITAL provides s100 prescriber training to GPs for both HIV and hepatitis B drugs, as well as education, training and support for all primary health professionals to take an active role in BBV care.
Currently there are only 60 HIV and 10 hepatitis B s100 prescribing GPs in Victoria, the vast majority of whom are based in Melbourne. Boosting these numbers will mean more people will be able to access the care they need, at a location and environment they are comfortable in.
Increasing prescriber numbers is even more of an issue in regional and rural areas of Victoria, with very few GP prescribers of either HIV or hepatitis B drugs located outside of Melbourne. Country regions rely on visiting specialists who don’t always have the capacity to see all potential patients in their limited time in each location. Patients may also be less comfortable seeking treatment with a visiting specialist than with a trusted local GP.
While the program only officially began late last year, it is already having an impact at community level. An excellent example is in the Murray River town of Mildura, where VHHITAL recently held an information session on viral hepatitis for local health professionals.
Inspired by the session, a local GP has set up a dedicated hepatitis clinic in the town, giving residents with hepatitis the chance to receive ongoing treatment without having to wait for infrequent specialist visits. As well as providing the initial inspiration, VHHITAL is also delivering practical support, helping the new clinic source a fibroscan machine and assisting GPs from Mildura to attend s100 hepatitis B prescriber training in Melbourne.
This is just the beginning. Supported by partners including North Western Melbourne PHN (program lead), ASHM, Peter Doherty Institute for Infection and Immunity, Alfred Health and the Victorian PHN Alliance, VHHITAL is rapidly rolling out information sessions and organising prescriber training across Victoria.
It’s not just about boosting GP prescriber numbers, though of course that is a key goal. It’s about supporting all GPs, and primary care professionals in general, to take on a greater role providing care for people living with BBVs.
There is an enormous opportunity to eliminate hepatitis C, prevent new transmissions of HIV and limit the impact and spread of hepatitis B – and general practice has a huge part to play in turning these opportunities into reality.
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VICDOC - April/May 2017 Edition - Improving access to treatment for blood borne viruses (p. 22-23)