General Practitioner, NT
Viral Hepatitis Elimination: How and what are we achieving? Evaluation and Surveillance
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)