The National Hepatitis B and C Strategies set ambitious targets for 2022, aiming to make significant progress toward eliminating viral hepatitis as a public health concern and reducing attributable morbidity and mortality. Data newly released this week demonstrate that while some regions of Australia are on track to reach these targets, many are falling behind. Significant progress is still needed for us to meet our strategic goals and ensure equitable outcomes for people living with viral hepatitis across Australia.
The Viral Hepatitis Mapping Project, which maps the prevalence, diagnosis, monitoring and treatment of hepatitis B and C, is undertaken by the WHO Collaborating Centre for Viral Hepatitis (WHOCCVH) at the Doherty Institute, in partnership with the Australasian Society for HIV, Viral Hepatitis and Sexual Health (ASHM) and is funded by the Australian Government Department of Health using data from national communicable disease surveillance along with records available from Medicare Australia. It identifies priority regions for improving access to treatment and care and highlighting areas where profound progress has been made.
Treatment uptake for CHB in 2018 was 9.3% overall in Australia, well short of the National Strategy target of 20% by 2022. If current trends in uptake continue, Australia will not meet this target until 2044. Only the South Western Sydney Primary Health Network (PHN) is on track to reach the target, with treatment uptake already 18.3%. In more than one third of Australia’s PHNs, treatment uptake was less than 5%.
While all people living with CHB should be engaged in regular monitoring, the National Strategy target for the proportion of people receiving care is 50%. However in even the highest-achieving PHN (also South Western Sydney), less than 40% people living with CHB were in care. Further analysis of the cascade of care demonstrates that less than half of all people living with CHB have ever had a viral load test to assess their disease status and need for treatment, and only 11% had monitoring at the frequency recommended in clinical guidelines.
The lack of progress in access to treatment and care for CHB in Australia has serious health consequences. If we do not improve current care delivery, over 1,700 people will lose their lives due to preventable mortality from CHB between now and 2030.
CHB treatment and care uptake was generally lowest in rural and remote regions of Australia, highlighting the particular barriers for people located furthest from major cities, however some areas have achieved profoundly impressive results despite these challenges. In the Northern Territory, care uptake was higher than in any other state or territory in Australia, and antiviral treatment coverage has increased at a rate more than double the national average. In remote areas, many primary care practitioners have stepped up to provide hepatitis B treatment, and the PHNs with the highest rates of GP monitoring and treatment included the Northern Territory, Northern Queensland, and Country WA.
Dr Jane Davies, a senior clinical research fellow at the Menzies Institute and co-director of infectious diseases at Royal Darwin Hospital, emphasized the importance of localised data. "The Mapping Report has been and continues to be absolutely crucial to our work in the Northern Territory. As well as providing us with contemporary data around the cascade of care and so the ability to monitor our progress in a timely fashion, it has proved time and again to be an invaluable document to advocate for increased attention and resources for viral hepatitis in the rural and remote setting."
By June 2019, it was estimated than 40% of all Australians living with CHC had received treatment, reinforcing Australia’s position as leaders in the global hepatitis C response. However despite the very high uptake achieved when the new highly effective direct-acting antivirals (DAAs) were first listed on the PBS in March 2016, the number of people being treated for CHC has continued to decline over time. Even if current treatment levels do not decline any further, Australia is not projected to meet the 2022 National Strategy target of 65%.
Despite this decline, if current trends remain stable, 9 of Australia’s 31 PHNs are on track to meet the National Strategy target (Adelaide, Eastern Melbourne, North Western Melbourne, South Eastern Melbourne, Gippsland, Western Victoria, Hunter New England and Central Coast, North Coast NSW, and South Eastern NSW). These PHNs are all located in urban and inner regional locations, with more remote regions being those in greatest need of increased access to treatment.
Treatment of CHC by GPs increased as a proportion of total prescriptions from 10.1% in March 2016 to 49.3% in December 2018, making GPs now the most common prescribers of DAAs. Those PHNs where GP prescribing was highest were generally rural and regional, including Nepean Blue Mountains, North Coast NSW, and Murrumbidgee PHNs, as well as Western Queensland and Gold Coast PHNs, demonstrating the crucial role of primary care practitioners in increasing treatment access for those living outside major cities.
Despite the demonstrated high efficacy of DAA treatments in Australia, guidelines still recommend that all people who complete a course of CHC treatment receive a test to confirm that they have a sustained virological response (SVR), or cure. More than one-quarter of people treated for CHC in Australia did not have a test to confirm their treatment was successful, and this included a substantial number of people with liver disease or who had been treated previously, in whom follow-up testing is particularly crucial. There was an increasing frequency of GPs conducting SVR testing in people who had their treatment prescribed by a specialist. This finding highlights the utility of shared care arrangements in CHC management, and supports the participation of GPs in current and future models of care to improve follow-up for people who have been cured, particularly those with limited access to specialist services.
Professor Benjamin Cowie, Director of the WHO Collaborating Centre for Viral Hepatitis at the Doherty Institute, and one of the report’s authors, welcomed the report’s release. “For This Mapping Report demonstrates that in the 3 years following funded DAA access in Australia, four out of every ten people living with hepatitis C have been treated. While this is clearly a huge step forward, given reducing rates of treatment initiation, we must find ways to engage with people who have not yet accessed treatment. Furthermore, with 22 of Australia’s 31 PHNs not on track to achieve the National Strategy target of 65% treatment uptake, greater efforts in these areas are clearly needed. We must not allow place of residence to determine who can be cured of hepatitis C; no Australians should be left behind as we strive for the elimination of hepatitis C as a public health threat.
Professor Cowie also emphasised the urgent need to fundamentally shift Australia’s approach to providing care to people living with chronic hepatitis B. “We cannot allow ourselves to accept the current levels of diagnosis, monitoring and treatment of hepatitis B. While many lives have already been saved with current levels of treatment, so much more can, and must be done. Learning from the examples set in areas such as South Western Sydney and the Northern Territory, we must integrate existing public health and clinical responses to transform the way we address hepatitis B nation-wide”.
Access the reports here and explore the data on the online portal here.
Join the WHO Collaborating Centre for Viral Hepatitis at the Doherty Institute, in partnership with ASHM for the digital launch of the Viral Hepatitis Mapping Project.
Viral Hepatitis Mapping Project: National Report 2018-19 - Digital Launch Event.
Ms Jennifer MacLachlan
A/Prof Benjamin Cowie
WHO Collaborating Centre for Viral Hepatitis, VIDRL, The Doherty Institute
Time and date:
Friday, 31 July 2020
Sami Stewart, National Viral Hepatitis Program Manager - ASHM
Register HERE via Zoom
CHB treatment uptake in 2018 and projected uptake in 2022, ordered by 2022 uptake, by PHN.
MacLachlan JH, Smith C, Towell V, Cowie BC. Viral Hepatitis Mapping Project: National Report 2018–19. Darlinghurst, NSW, Australia: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), 2020.