At the first day of the European AIDS Conference 2017, Sharon Walmsley (Senior Scientist at Toronto General Hospital Research Institute) spoke at the Women Against Viruses in Europe (WAVE) forum.  

When considering ART in women it is important to remember the following

• drug trials rarely include significant numbers of women
• Consider whether woman is planning pregnancy (remember safety of ART in pregnancy is generally based on expert opinion not on evidence)
• Consider drug interactions with contraception
• Stribild and Genvoya not recommended in pregnancy as elvitegravir and cobicistat do not cross placenta so baby is not getting adequate levels
• Consider co-morbidity in the older woman especially around menopause and cardiovascular risk
• HIV and/or ARTs seem to cause higher rates of early menopause
• Women living with HIV have higher rates of CVD AND women living with HIV have higher rates of osteoporotic fractures
• Therefore consider change of ART at menopause
• Women represent >50% of people living with HIV however studies of drugs for HIV rarely include significant numbers of women. 

 More to come...

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:

• The Rural Experience by Annie Balcomb (General Practitioner, Prince St Medical Practice Orange NSW)
• Bridging the Prescriber Divide – Treatment Made Easy by Alex Thompson(Director, St Vincent's Hospital And The University Of Melbourne)
• Eliminating Hepatitis C - The Cairns Experience by Darren Russell(Director, Cairns Sexual Health)

I attended the Australasian Viral Hepatitis Elimination Conference as a GP hepatitis B prescriber in an AMS (Aboriginal Medical Service), so my particular interest was to find out how we are doing in the rural and indigenous sectors and to get ideas as to how we might improve our services.

In this regard the Northern Territory is above the national average of treated Hep C patients at around 17%. My practice seems more inclined toward identification and adequate surveillance of hepatitis B (already a massive task). One factor in this is the medicare payment of only 3 hepatitis tests at any one time, leading to less than satisfactory levels of hepatitis C antibody checks. However, I suspect infection rates are low with respect to hepatitis B, due to lower use of IV drugs in the rural indigenous setting.

However, if the above holds, one wonders if rates of hepatitis C in indigenous communities may not be higher than the (rising) age standardised rates presented by Prof Rebecca Guy in her presentation.

If there is one thing I would hope to improve having attended this conference, is awareness and testing for hepatitis C in my AMS.

On a global front, it was disappointing to hear data from Homie Razavi (Managing Director of Center for Disease Analysis) that we [Australia] may be falling short of the 5 million hepatitis C treatments necessary annually to achieve elimination by 2030, even if total numbers of cases are declining.

Homie pointed out that shortcomings include restriction on treatment of young patients and (worldwide) lack of primary care involvement. However, a major factor is lack of political will, as evidenced by the failure – to date – of the pooled procurement initiative. While Homie pointed out that individual countries may negotiate their own prices on hepatitis treatments, it is unlikely that they could negotiate the prices achievable through large, multinational orders (with cash changing hands through secure banking transactions to ensure transparency).

Ed Gane (Heptatologist at Auckland City Hospital) presented a succinct account of the challenges NZ faces in eradicating hepatitis C and how it is going about it.

The challenges are:

• the still rising rates of infection (probably similar to rural NT)
• the numbers of still undiagnosed patients and treatment uptake already falling (pool of "accessible" patients running out).

Solutions proposed include increased GP prescribing (33% of scripts vs almost none in 2015), pangenotypic treatment régimes and targetted testing.

I suggest that GP prescribing for hepatitis (and other "shameful" diseases such as HIV) has benefits beyond than just "increasing coverage". Patients are more likely to come for, and accept testing. Treatment proposed by a trusted GP is more likely to be understood and followed, than if prescribed by a specialist that they meet on 1 or 2 occasions (Note: I don't wish to belittle highly-skilled and caring clinicians, who often understand very well the complexities of care in an indigenous setting). No doubt this applies in the general population – and maybe even in NZ.

See selected speaker presentations from this session, including:

• Global burden of hepatitis & use of pooled procurement to expand access by Homie Razavi (Managing Director, Center For Disease Analysis)
• Where is New Zealand in the race to eliminate Hepatitis C? by Ed Gane (Hepatologist, Auckland City Hospital)

In this presentation, Dr Nicole Allard describes a research project to examine whether an intensive follow-up and recall system improved liver cancer surveillance programs in patients with chronic hepatitis B.  On the basis of current recommendations for 6-8 monthly liver ultrasounds and AFPs, optimal screening was defined as having achieved 2 scans every 14 months, sub-optimal screening as one scan every 14 months and poor screening as less than one scan every 14 months.

The intervention consisted of nurses conducting an audit to detect patients requiring HCC surveillance within the clinic patient base, upskilling the healthcare workers in hepatitis B management, and establishing a proactive recall system consisting of a variety of strategies such as calling of patients, sending out of path forms by mail or sending out pre-appointment confirmation texts.

A participation rate of 75% was obtained in this patient cohort yet optimal screening was only achieved in 25% of patients. It was not clear what the baseline of adherence to screening schedules were like prior to the intervention, and thus it is difficult to interpret this result.

An important observation made during this study was that patients often had little understanding of their individual risk of HCC, and that this perhaps impacted on their adherence to screening schedules.

Recommendations included developing a low English literacy tool to help to explain this better to patients, implementing a community awareness program, considering the role of a liver cancer registry, and supporting the development of a more feasible method of screening.

See Nicole's presentation here.  

This session at the 2017 Australasian Viral Hepatitis Elimination Conference was a series of oral abstract presentations exploring a wide range of strategies in engaging marginalised populations, including persons incarcerated, people who inject drugs (PWID), Aboriginal and Torres Strait Islander populations/communities, and Culturally and Linguistically Diverse (CaLD) populations. Subsequently, various models-of-care adopted for each population in their respective studies and community settings.

Prof Andrew Lloyd provided an overview of the care for HCV affected people in prisons in Australia. Among the total of 230K living with chronic HCV in Australia, 65k of those are persons incarcerated, with many of this cohort being PWID and/or undertaking opioid substitution therapy (OST). Prof Lloyd spoke of the challenges of treatment adherence given the frequently movement of prisoners from one area of the prison to another (or movement to other facilities) and in some cases relatively short stays. The Surveillance and Treatment of Prisoners with Hepatitis C (STOP-C) study that he leads via the Kirby Institute throutout prisons in NSW is a nurse-led model of hepatitis care (NLMC) are appears to be very effective: a 95% of treated/assessed rate and currently 100 cases treated per month, despite barriers of pharmacy technology, challenges in drug procurement, etc. Future directions in this study include: establishing an Australian national prisons hepatitis network; to implement a practical strategies, such as, a one-stop shop for testing and treatment, and a 'treatment-as -prevention' approach aiming to eliminate hepatgitis C from the prison sector.

Dr Phillip Read of the Kirketon Road Centre (KRC) Sydney, presented a model-of-care for Alcohol and other Drugs (AoD) clients engaging with a huge diversity of care providers. There are numerous non-medical services ranging from government services to NGO and religious-organisations contributing to the complex care model for AOD clients, offering a range of services beyond clinical treatment, such as counselling. Currently, it is estimated that at least 25K PWID living with hepatitis C are still needed to be treated. The possible solution to engage PWID populations is to use an OST infrastructure. There is, however, a few challenge facing this strategy. For example: methamphetamine IV users have less medical contact, with only 10% of them are in care. Patients often had poor venous access, poor adherence and high risk for reinfections. Furthermore, many patient’s relationships with AoD services may not be always harmonious - with many experiencing stigma and discrimination in these settings. Nevertheless, many can be tackled in AoD-specialised setting. For example, HCV RNA testing using dried blood spot will be very practical for PWID with poor venous access. Overall, the HCV elimination campaign will be benefit from co-working with peers in the model of care for AOD. 

Ms Carla Gorton and Ms Kathy Clark from Cairns Sexual Health Service in Queensland shared a personal experience of approaching and engaging with HCV in a sexual health setting/context. Their key messages were very strong: Respect, dignity, individualised care were required in providing care according to the individual’s need. Ms Gorton shared strategies for providing care for the sensitive group of people, including sexual worker and transgendered persons. Ms Kathy Clark provided contact, encouragement and transport to care. Personal engagement also helps to address issues such as shame and guilt and life priority. To reach people’s heart and mind, the networking of Cairns community members has facilitated a friendly access for hepatitis C patient to reach treatment without restriction.

Dr Malcolm McDonald is a consultant physician serving in three Indigenous health services in Far North Queensland. He shared in his presentation his plentiful experiences and great insight in approaching indigenous people in rural and remote communities. Each community has a unique history and different setting. Health Service should be in the community. It is encouraging to see that readily in-community care is available, including testing and treatment, even the in-community Fibroscan.  

The end panel discussion of this session emphasised the need of continuing care and information should be transferred to primary carer, as well as, the barriers of providing continuing care for these populations.

Access speaker presentations mentioned via the AVHEC website