In day one of AVHEC17, we had been hearing presentations on how important the role of primary care workers would be in achieving the goal of elimination of viral hepatitis. Day two sessions gave us the opportunity to hear the stories of those who were leading the way.
The Rural Experience
First up was Dr Annie Balcomb, a rural GP based in Orange, NSW, who has been involved in Chronic hepatitis C treatment since 2008, and presented on The Rural Experience. Dr Balcomb described the structure around the Chronic hepatitis clinic she has run in recent years - a model working closely with gastroenterologists in a shared-case arrangement, that takes referrals from local GP's, nurses, health workers, drug and alcohol services, mental health services, forensics, hospital inpatients, gastroenterologists, and importantly patient self-referrals. The model has seen her successfully treat over 100 patients since the introduction of DAA's in March 2016.
Over this time, Dr Balcomb has observed frequently the stigma and shame felt by many patients with chronic hepatitis C - some driving hundreds of kilometres to obtain their medications from a pharmacy where they could enjoy anonymity, others describing that some of the worst judgement and stigma they faced was within our own health-care systems. On the back of this, one of the central tenants to her ongoing work is the education and upskilling of GP's and other health professionals in her region, to optimise patient access to information and effective treatment.
Dr Balcomb is also committed to being a voice that identifies and challenges some other barriers to access of care. She proposed a number of "ways forward" (see page 10 of Speaker Presentation PDF from her talk) to maintain patient safety while optimising access through primary care. Most exciting for me, were the use APRI<1 and FIB4 >2 as a fibroscan triage tool that has allowed some 60% of her cohort to proceed to treatment as non-cirrhotic without the need to obtain pre-treatment fibroscan; the hope of exploring options of shared GP care with gastroenterology input for some cirrhotic patients, using tools such as telehealth to improve rural access; and the excitement of pan-genotypic DAAs simplifying the treatment landscape for newcomers to the game. She instils the excitement of being involved in this area of medicine, and encourages us all to pass it along to our GP colleagues back home.
Challenges Ahead in Primary Care on the Path to Elimination
Next up, Dr Nicole Allard, a GP with special interest in hepatitis B and refugee health (who must be secretly cloning herself in order to continue her work as a medical epidemiologist at VIDRL, Melbourne health at the Doherty institute and PhD student at Melbourne University). She spoke on the Challenges ahead in primary care, and made a statement early in her talk that drew a few puzzled looks, and a lot of smiling nods - that "GP's are specialists - they specialise in primary care and in looking after people from marginalised populations". Recognising this, and both the challenges and advantages it presents, will go a long way towards engaging those Primary Care Specialists across Australia. When your speciality is primary care, the breadth of knowledge required is vast, so the message of who needs testing must be simplified - inclusion of screening messages in the RACGP Red Book will help this, as well as automatic cascade testing of HCV RNA and HBV DNA as indicated based on initial screening bloods, without the need for a specific request or re-bleed. She spoke of the power of creating a testing demand from patients, of reducing the stigma to allow these conversations to take place more readily in families, communities and consult rooms, and in providing support to GP's on the ground to best equip them to carry out testing and ongoing management effectively. She also raised the valuable tool of GP-to-GP referrals for those with colleagues with a special interest in viral hepatitis management. She addressed the tertiary specialists on the importance of good quality communication back to the GP, to enable effective ongoing monitoring in primary care and highlighting the role that a well written and relevant letter has in GP education (and as a heads up in case any non-GP specialists missed the memo: good communication including letters = more referrals + better overall care for your patients. Just thought that was worth repeating!)
Bridging the Prescriber Divide – Treatment Made Easy
Off the back of those two powerhouse primary care presentations, Professor Alex Thompson, the Director of Gastroenterology at St Vincent's Hospital, spoke on Bridging the Prescriber Divide: Treatment Made Easy, and the models being utilised in Victoria to achieve just this. He highlighted that Australia is among the first countries allowing and actively encouraging the treatment of hepatitis C by primary care doctors, and the responsibility we have to demonstrate that it is a safe and effective approach. He highlighted that the DAA treatments are generally well tolerated, but that practitioners need to recognise that symptoms such as fatigue, headache, insomnia and GI side effects can and do occur, and that despite these being far more acceptable compared to those suffered during previous treatment eras, we still need to counsel our patients in this regard. His "5 key questions" in the approach to treatment work-up, represent a straightforward approach that is easy to follow (See: Speaker Presentation PDF page 9: The KISS principle; Is Cirrhosis Present; Who needs to see a specialist on page 13).
Prof Thompson also spend some time discussing the approach undertaken by the Eliminate Hepatitis C (EC) Partnership, which aims to "support and enhance programs to increase HCV treatment update among people who inject drugs, using nurse-led models of care in community and prison settings" and to "assess the feasibility and impact of treating high enough proportions of PWID to reduce new infections and inform HCV elimination models in Australia and globally". It's great to see the diversity of approaches being undertaken in trying to engage at-risk communities. See their implementation plan via page 16 on the Speaker Presentation PDF.
Eliminating Hepatitis C - The Cairns Experience
The final speaker for the morning, Associate Professor Darren Russell, is a sexual health physician and the Director of the Cairns Sexual Health service who spoke passionately about Eliminating Hepatitis C - The Cairns Experience. He recalls a meeting held in their department, the morning after the initial DAA's were PBS-listed in March 2016. The strategy was to identify and work with priority groups, with the plan to "Hit 'em hard, hit 'em early", ramp up quickly and clear the warehouse. Local liver clinics triaged back to GP's, with waitlists then cleared in just a few months. The Sexual Health Service adopted a same-day assessment and treatment clinic, that utilised on-site pathology and fibroscan with links to local pharmacies to ensure medications were kept on the shelves and therefore available for supply without delay. By working with community groups including Cairns Hepatitis Action Team (CHAT), media interest was stoked, prompting a dialogue in the community and firing up demand for testing and treatment in at-risk groups. Health professionals in prisons, ATODS, Aboriginal Medical Services, Rural and remote, and General Practice settings were supported with onsite ASHM training to equip them to respond to this demand, with liver and sexual health clinic support via phone/email/fax, and "academic detailing" where GP clinics who were interested but not yet prescribing received outreach support and training. This multi-pronged approach has led to the enviable situation, where Cairns can say that "virtually all the people in Cairns and surrounds - and further North - who know they have hepatitis C and want treatment, have been treated" with the focus now on increasing testing, finding the undiagnosed cases especially in those clients connected with mental health services and young injectors, and watching for incident cases in particular in prisons and Indigenous communities. It was an exciting demonstration of how a concerted whole of system approach, utilising resources including primary care and community groups, can lead to impressive results.
The Panel Discussion
The follow-up panel discussion was engaging and energising - it left me with a number of messages, first and foremost that Peer-to-peer GP education is key to getting the message out there. So I'll start with this blog, my local practice and GP and nursing colleagues, the Australia and NZ-wide community of GP's DownUnder and my at-risk patients. I'd encourage you to start a conversation too - with friends, family, colleagues - stamp the stigma and get word out that treatment is available... or better yet, sign up for some ASHM training and get testing and prescribing. It's not often in GP you get to say "You're cured" - let's give as many people as possible the opportunity!
See selected speaker presentations from this session, including: