Hepatitis C and ageing: a community brief

Executive summary: An estimated 226,700 people in Australia are living with chronic hepatitis C. While the numbers of people estimated to have been infected with hepatitis C has reduced over the past 15 years, the number of people with hepatitis C-related liver disease is increasing. Growing older and duration of infection are significant determinants in the progression to cirrhosis amongst people with hepatitis C. There is a lack of social research describing the experiences of people with hepatitis C as they grow older. Australia’s population is ageing with an increasing number and proportion of people over 65. Government programmatic responses to the ageing population are of a health promotion approach focussing on maintaining older people’s health and independence. Less than five percent of older people in Australia live or will live in aged care facilities with a greater emphasis from government policy on keeping people at home: home based aged care services will have an increasingly important role into the future. This qualitative, interview-based research conducted with key clinical, community and bureaucratic stakeholders in the Australian hepatitis C sector aimed to identify key issues and challenges relating to ageing and hepatitis C to inform future research directions. While all participants recognised ageing and hepatitis C as a significant issue for Australia, they acknowledged that there was a lack of specific services (clinical and/or community-based) targeting older people with hepatitis C. The lack of services resulted from the limited contact participants had with older people with hepatitis C, and participants expressed concern of their limited understanding of the needs of older people with hepatitis C. The lack of services is compounded by the variety of definitions of ageing between the research literature, national policy and stakeholder perspectives. For example, the Australia government considers people over 65 years to be “older”, whereas in the context of people with hepatitis C, participants described ageing as older than 55 years. An Australian Injecting & Illicit Drug Users League investigation into ageing in 2010 describes people who inject drugs who are over 40 years as ageing. During interviews, significant attention was directed towards discussing whether “age” is a proxy for “severity of liver disease” or whether there are specific-age related issues associated with mild liver disease. Participants acknowledged that older people with hepatitis C often experience co-morbidities related to ageing, in addition to extrahepatic manifestations of hepatitis C infection, which often complicate the management and treatment of hepatitis C. While the clinical management of hepatitis C is changing and new treatments promise a shorter treatment course with fewer side effects, several clinicians expressed guilt in advising older people to wait for interferon-free regimes because of concern about pre-existing comorbidities, while being concerned that advising older people to wait for three to five years for the new treatments may be too late. Older people with hepatitis C are not identified as a priority population nor are their needs discussed in the National Hepatitis C Strategy 2010-2013. Therefore, it is not surprising that hepatitis C and ageing are not identified as a priority in either the national or state health agenda of the aged care sector. In order to articulate the impact and issues associated with hepatitis C and ageing, the issue of ageing in Australia needs to be examined broadly and the impact of hepatitis C considered in the current context. Exploring the needs of people with hepatitis C as they age needs to occur as a matter of urgency, as older people with hepatitis C are a hidden population. A comprehensive, strategic approach to hepatitis C and ageing is needed to ensure that the needs of older people with hepatitis C do not continue to go unrecognised

Eliminating hepatitis C: Part 2. Assessing your patient for antiviral treatment

With the introduction of direct-acting antivirals (DAAs) in Australia in 2016, most people with chronic hepatitis C can be cured of this infection. GPs and suitably qualified nurse practitioners working in all areas of primary care have a key role in identifying, testing and treating their patients with hepatitis C. The previous article in this series discussed how to identify your patients with hepatitis C. This article provides practical advice on assessing a patient after diagnosis in preparation for DAA therapy. This includes determining whether they can be safely treated in general practice or require specialist referral

Viral hepatitis testing and treatment in community pharmacies:a systematic review and meta-analysis

Background: The World Health Organization seeks to eliminate viral hepatitis as a public health threat by 2030. This review and meta-analysis aims to evaluate the effectiveness of programs for hepatitis B and C testing and treatment in community pharmacies. Methods: Medline, Embase, Cochrane CENTRAL, and Global Health were searched from database inception until 12 November 2023. Comparative and single arm intervention studies were eligible for inclusion if they assessed delivery of any of the following interventions for hepatitis B or C in pharmacies: (1) pre-testing risk assessment, (2) testing, (3) pre-treatment assessment or (4) treatment. Primary outcomes were proportions testing positive and reaching each stage in the cascade. Random effects meta-analysis was used to estimate pooled proportions stratified by recruitment strategy and setting where possible; other results were synthesised narratively. This study was pre-registered (PROSPERO: CRD42022324218). Findings: Twenty-seven studies (4 comparative, 23 single arm) were included, of which 26 reported hepatitis C outcomes and four reported hepatitis B outcomes. History of injecting drug use was the most identified risk factor from pre-testing risk assessments. The pooled proportion hepatitis C antibody positive from of 19 studies testing 5096 participants was 16.6% (95% CI 11.0%–23.0%; heterogeneity I 2 = 96.6%). The pooled proportion antibody positive was significantly higher when testing targeted people with specified risk factors (32.5%, 95% CI 24.8%–40.6%; heterogeneity I 2 = 82.4%) compared with non-targeted or other recruitment methods 4.0% (95% CI 2.1%–6.5%; heterogeneity I 2 = 83.5%). Meta-analysis of 14 studies with 813 participants eligible for pre-treatment assessment showed pooled attendance rates were significantly higher in pharmacies (92.7%, 95% CI 79.1%–99.9%; heterogeneity I 2 = 72.4%) compared with referral to non-pharmacy settings (53.5%, 95% CI 36.5%–70.1%; heterogeneity I 2 = 92.3%). The pooled proportion initiating treatment was 85.6% (95% CI 74.8%–94.3%; heterogeneity I 2 = 75.1%). This did not differ significantly between pharmacy and non-pharmacy settings. Interpretation: These findings add pharmacies to the growing evidence supporting community-based testing and treatment for hepatitis C. Few comparative studies and high degrees of statistical heterogeneity were important limitations. Hepatitis B care in pharmacies presents an opportunity for future research. Funding: None.</p

Patients with chronic hepatitis C undergoing watchful waiting: Exploring trajectories of illness uncertainty and fatigue

We identified trajectories of illness uncertainty in chronic hepatitis C patients and examined their association with fatigue levels during 12 months of disease monitoring without treatment (watchful waiting). Sixty-two men and 63 women completed uncertainty and fatigue measures. Groups were formed by uncertainty scores (high, medium, low) at baseline. Baseline fatigue levels were higher in the high uncertainty group than in the medium and low groups. Over time, uncertainty levels did not change. Fatigue levels in the low uncertainty group remained constant, increased in the medium, and decreased in the high groups. Findings suggest that uncertainty and fatigue do not remit spontaneously. Being aware of this may help nurses identify those patients needing support for these two concerns

Managing chronic hepatitis B: A qualitative study exploring the perspectives of people living with chronic hepatitis B in Australia

<p>Abstract</p> <p>Background</p> <p>The implementation of a comprehensive public health response to hepatitis B in Australia is urgently required to reduce the increasing burden of hepatitis B infection on the health system and the community. A significant gap in the public health response to hepatitis B is an understanding of how people with chronic hepatitis B (CHB) respond to CHB.</p> <p>Findings</p> <p>A qualitative study involving semi-structured interviews and focus group discussions was conducted. Interviews were held with 20 people with CHB from three states of Australia. In addition, four focus group discussions were held with a total of 40 community and health workers from culturally and linguistically diverse communities in four Australian states.</p> <p>People with CHB reported no formal or informal pre or post test discussion with little information about hepatitis B provided at the point of diagnosis. Knowledge deficits about hepatitis B were found among most participants. Few resources are available for people with CHB or their families to assist them in understanding the infection and promoting their health and well-being. A lack of confidence in the professional knowledge of service providers was noted throughout interviews.</p> <p>Conclusions</p> <p>People with CHB need culturally and linguistically appropriate education and information, particularly at the point of diagnosis. Primary health care professionals need the knowledge, skills and motivation to provide appropriate information to people with CHB, to ensure they have the capacity to better manage their infection.</p

Perceptions of HIV cure research among people living with HIV in Australia

Participation in HIV cure-related clinical trials that involve antiretroviral treatment (ART) interruption may pose substantial individual risks for people living with HIV (PLHIV) without any therapeutic benefit. As such, it is important that the views of PLHIV are considered in the design of HIV cure research trials. Examining the lived experience of PLHIV provides unique and valuable perspectives on the risks and benefits of HIV cure research. In this study, we interviewed 20 PLHIV in Australia about their knowledge and attitudes toward clinical HIV cure research and explored their views regarding participation in HIV cure clinical trials, including those that involve ART interruption. Data were analysed thematically, using both inductive and deductive coding techniques, to identity themes related to perceptions of HIV cure research and PLHIV’s assessment of the possible risks and benefits of trial participation. Study findings revealed interviewees were willing to consider participation in HIV cure research for social reasons, most notably the opportunity to help others. Concerns raised about ART interruption related to the social and emotional impact of viral rebound, including fear of onward HIV transmission and anxiety about losing control. These findings reveal the ways in which PLHIV perspectives deepen our understanding of HIV cure research, moving beyond a purely clinical assessment of risks and benefits in order to consider the social context

National hepatitis B needs assessment

It is estimated that between 90,000 to 160,000 people live with chronic hepatitis B in Australia, yet no nationally coordinated public health response exists. A significant gap in the national response is the documentation of the specific needs of people with chronic hepatitis B and service providers, which this report aims to do. It is estimated that between 90,000 to 160,000 people live with chronic hepatitis B in Australia. More than half of these were born in highly endemic countries of the Asia-Pacific region. Other high-risk groups include people born in other highly endemic regions, and Indigenous people, while a minority of people with chronic hepatitis B are men who have sex with men, and people who inject drugs. The number of people dying as a result of chronic hepatitis B, and the number of cases of hepatitis B-related liver cancer in Australia are increasing despite improvements in antiviral therapy. The hepatitis B virus is difficult to eradicate and while only a small proportion of people with chronic hepatitis B receive treatment, these treatments are increasingly able to control replication of the virus and reduce liver disease progression. Unlike the Australian national public health response to reducing the impact of human immunodeficiency virus (HIV) and hepatitis C upon the community, no nationally coordinated public health response to chronic hepatitis B exists. A significant gap in the national response is the documentation of the specific needs of people with chronic hepatitis B and service providers

Challenges in managing patients in Australia with chronic hepatitis B: the General Practitioners’ perspective

Abstract Objective: General Practitioners (GPs) are essential to reducing the impact of chronic hepatitis B (CHB) given their clinical management role where only 56% of people with the infection in Australia have been diagnosed. This qualitative study aimed to identify the challenges GPs face in effectively responding to CHB. Methods: Semi‐structured interviews were conducted with 26 GPs self‐identifying as having a ‘high caseload’ of patients and/or a particular interest in CHB. Participants were recruited from five jurisdictions and came from diverse ethnicities, clinical experience and practice profile. Interview data were analysed according to the principles of grounded theory. Results: Patient and GP knowledge, a lack of community awareness, and language and cultural diversity impeded the GP response to CHB. Communication with specialists was reported as challenging with unclear referral pathways, limited feedback from specialists after referral, and poor liaison and support for managing people living with CHB. Regulations restricting GPs capacity to respond included the lack of prescribing opportunities, fear of Medicare auditing for screening the populations most at risk, and inadequate financial support given the complexity of CHB and the communities most affected by the infection. Conclusions: General Practitioners require additional skills and resources to support the effective management of people with CHB. These include improved awareness and knowledge about the infection, adequate financial resources to support patient management, and effective referral pathways and support