It is hard to think of a more significant medical advance in recent years than in the field of hepatitis C treatment (answers on a postcard). In the space of less than 10 years, management of the condition has progressed from offering patients a treatment which lasted one year, was associated with major side effects (suicidal depression was not uncommon) and with just a 30% success rate, to single tablet regimens for 8 weeks with almost no side effects and >90% cure rates. It really has been a revolution.
The result of this phenomenal success is that treating the condition is no longer a complex process requiring detailed diagnostic workup and intensive monitoring. With advances in simple non-invasive tests for liver fibrosis and excellent safety profiles, the rate-limiting step to achieving cure is no longer technology or expertise; rather, it is diagnosis, linkage to care, and funding to supply the expensive (~£30K per person) drugs.
Two recent papers published by Frontline Gastroenterology helpfully outline the current landscape. First, Mendizabel and colleagues details very succinctly the current barriers to achieving hepatitis C elimination, which the WHO aims to achieve by 2030. Patient barriers arise as the nature of transmission means there are a disproportional number of patients with hepatitis C who are injecting drug users, prisoners, refugees, or living in resource-poor settings for whom traditional service delivery models, such as outpatient clinics in secondary care settings, are just not fit for purpose. Educational programmes and community- based services are therefore essential to reach out to these patients, instead of waiting for them to come to us. Provider barriers include limited knowledge and misconceptions among healthcare workers, and solutions include training up primary care workers to provide treatment locally. Finally, structural barriers are systems in place that are either poorly designed or inadequately funded to provide the coverage of treatment required.
To that end, James O’Beirne’s team from the Sunshine Coast University Hospital have conducted a nice study retrospectively analysing a prospectively collected clinical database from their programme for HCV treatment, in a country which has led the way in HCV treatment by making the drugs freely available for all. Their approach included novel strategies to move treatment away from specialist centres into the community to address some of these barriers discussed in the Mendizabel paper. They outline two models: first, a rapid access hepatitis clinic to which GPs could refer in patients with prior HCV genotyping and liver biochemistry and following transient elastography (TE) a DAA regimen would be recommended, which would then be fully provided in primary care except for complex patients e.g. suspected cirrhosis, who would be seen in secondary care. The second model involved a specialist nurse using portable Fibroscan machines to evaluate patients in community settings, up to 800km away from the regional centre. Following assessment and remote review at a multidisciplinary meeting, a treatment regimen is again recommended and provided locally. Importantly, in both models monitoring was kept to a minimum, and just included a 12-week SVR test. Through these novel models of service delivery, O’Beirne and colleagues successfully increased the proportion of patients treated in primary care from 13% to 80% while maintaining excellent SVR rates (95%).
There is a long way to go to achieve the Who targets but changing our treatment paradigms like in this paper will surely play a significant part.