Providing treatment for hepatitis C in an Australian district centre

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.

Preventing, identifying and treating hepatitis C

Hepatitis C is a blood-borne virus that, if left untreated, can result in significant liver damage and cancer. Most individuals are unaware that they have been infected with the hepatitis C virus and remain asymptomatic, which makes early diagnosis challenging. While the virus will spontaneously clear in some individuals, the majority will develop chronic hepatitis C. This article provides nurses with an overview of hepatitis C and how it is transmitted. It details the available treatments, and examines the challenges involved in early identification and access to treatment, as well as outlining the barriers to treatment and how these can be overcome. This article also discusses the role of the nurse in the management of people with hepatitis C and in addressing their complex needs.

Instrumental support to facilitate hepatitis C treatment adherence: working around shortfalls in shared-care

Adherence to treatment for hepatitis C virus (HCV) infection is associated with the successful eradication of infection. However, patients often have difficulty adhering to HCV treatment because of factors such as the psychiatric side effects of regimens and social disadvantage. Commonly, health professionals including specialist physicians, nurses, social workers and psychologists work together under a multidisciplinary model of shared-care to support patients' adherence to HCV treatment. In some HCV treatment clinics, shared-care is not always available, or only partially implemented and this has implications for patient adherence. To explore the facilitators of adherence, an interview-based study was conducted in 2012 with a purposive sample of Australian physicians and nurses (N = 20). The findings reveal that when comprehensive shared-care was limited or unavailable, physicians and nurses filled in the gaps by assuming roles outside of their expertise to help patients adhere to HCV treatment. Physicians and nurses applied instrumental support strategies based on psychosocial interventions, namely patient advocacy, pragmatic problem-solving, treatment engagement and emotional support. These strategies were provided by dedicated physicians and nurses to address shortfalls in multidisciplinary shared-care. Although these interventions were reported to assist adherence, there is an increased risk of complications when physicians and nurses move beyond the bounds of their disciplinary training, for example, to assess and manage patients' psychiatric side effects or advocate on their behalf for social services. Future research should measure the effectiveness of instrumental support strategies on HCV treatment adherence, and explore the costs associated with physicians and nurses providing instrumental support in the absence of comprehensive multidisciplinary shared-care.

Treatment of chronic hepatitis C infection among current and former injection drug users within a multidisciplinary treatment model at a community health centre

The aim of the present prospective observational study was to assess uptake and success of hepatitis C virus (HCV) treatment among a group of former and current injection drug users with chronic HCV infection at the Street Health Centre in Kingston, Ontario. The Street Health Centre offers hepatitis C education, assessment and treatment within a multidisciplinary, integrated and collaborative treatment model of care delivered by primary care professionals. The study enrolled a convenience sample of 34 patients. Seventy per cent of study patients had no postsecondary education, 85% were unemployed and one-third were unstably housed. A majority of study patients self-reported mental health problems. Of the 14 patients who initiated antiviral treatment in the study period, eight (57%) achieved sustained virological response. Regardless of virological outcome, patients who initiated treatment showed positive trends toward increased social and psychiatric stability, and decreases in high-risk behaviours. These results suggest that not only is successful treatment of chronic HCV infection in current and former injection drug users with concurrent psychiatric disorders possible, but the benefits of such treatment delivered in a community-based, multidisciplinary, primary care model may extend beyond narrowly defined virological outcomes.

General practitioner attitudes to prescribing hepatitis C antiviral therapy in a community setting

There is a growing debate about the prescription of hepatitis C virus (HCV) antiviral therapies within a community setting in Australia. This study aimed to identify interest and confidence among general practitioners (GPs) in prescribing HCV antiviral therapy in a community setting. Data from 580 GPs who responded to a cross-sectional population-based survey were analysed to measure: self-reported interest and confidence in initiating HCV antiviral therapy; and/or prescribing maintenance antiviral therapy; and self-perceived education needs about HCV antiviral therapy. Forty-two percent of respondents indicated they would be interested in prescribing HCV antiviral therapy. Most were not confident to initiate therapy (80%). Higher proportions indicated that they would be more confident in prescribing maintenance therapy (35%) rather than initiating (7%) therapy (z = 10.5, P < 0.001). Confidence in prescribing was related to a higher caseload of patients with HCV (P = 0.001) and being a HIV community-based prescriber (P = 0.002). Fifty-three percent of respondents expressed an interest in education about HCV antiviral therapy. The initial step to recruit potential primary care prescribers of HCV antiviral therapies should be to develop an integrated education program. Recruitment to this program might be most efficient from GPs with a high caseload of patients with HCV.

Patients' perceptions of information and support received from the nurse specialist during HCV treatment

AIM

To identify patients' perceptions of support received from the nurse specialist during Hepatitis C virus (HCV) treatment.

BACKGROUND

HCV is a worldwide health problem. However, it is a treatable disease and treatment success rates are high. Unfortunately, treatment comes with a multitude of adverse side effects and patients require informational and psychological support from specialist nurses while on treatment. To date, there is little nursing research on support received from this specialist nursing care.

DESIGN

This study used a quantitative descriptive design.

METHOD

A 59-item questionnaire collected data from 106 patients with a diagnosis of HCV attending a HCV outpatient clinic.

RESULTS

Overall, patients were very satisfied with support received. Advice on contraception was well received. However, many patients did not feel supported with regard to advice on sleep management. There were no statistically significant differences between overall satisfaction and gender, age, genotype and risk factor. However, there were significant correlations found between support received and reported genotype. Those patients presenting with genotype 1, who are mostly infected through blood or blood products, indicated that they require more support in relation to information on side effects of treatment, quality of life and support groups. Specific approaches to support and advice for this cohort may need to be incorporated into current services.

CONCLUSION

Results of this study reinforce the need for the ongoing use of specialist nurse services and development of this service where no such facilities exist. In addition, the service may need to further recognise and support the information and psychological needs of patients with differing modes of HCV infection.

RELEVANCE TO CLINICAL PRACTICE

Findings provide information to practising nurse specialists about patient's views of information and support received from nurse specialists in HCV treatment centres and identify where deficits exist.

Treatment of hepatitis C infection for current or former substance abusers in a community setting

Substance abusers account for the largest number of hepatitis C infected cases in developed countries. We describe a care model for treating current or former substance abusers with antiviral therapy for hepatitis C virus (HCV) infection. The care model involved hepatitis nurses, a psychologist, infectious disease specialist and primary care physicians. Clients met selection criteria including regular attendance at clinic appointments and social stability. Use of alcohol and illicit substances was monitored with urine toxicology screens. The association between substance use, rates of completion of therapy and rates of response were assessed using multivariable regression analyses. A total of 109 clients (75 with genotype 1/4 and 34 with genotype 2/3) received at least one injection with pegylated interferon between November 2002 and January 2006. Treatment completion rates of 61 and 74% were achieved for genotypes 1/4 and 2/3, respectively. Treatment response rates in an intention to treat analysis were 51% for genotypes 1/4 and 68% for genotypes 2/3. A positive urine toxicology screen indicating use of illicit substances 6 months prior to initiating therapy was significantly associated with lower rates of treatment completion but not lower rates of sustained virological response. A positive urine screen indicating use of alcohol prior to therapy was significantly associated with lower rates of completion and lower rates of response. Rates of completion and response are comparable to non-substance abusing populations. Antiviral therapy for HCV infection can be successful within the context of ongoing care for substance abuse for carefully selected patients.

Hepatitis C Videoconferencing: The Impact on Continuing Medical Education for Rural Healthcare Providers

This study compared the impact of multipoint videoconferencing (VC) versus standard lecturing (ST) on primary care providers' (MDs, NPs/PAs, and RNs) education regarding hepatitis C virus (HCV). The hypothesis was that the educational impact of teaching through telemedicine is comparable to the traditional method. The aim was to provide participants clinically relevant information and knowledge about the natural history, diagnosis, and management of HCV. Improved knowledge was scored from a 10-item quiz administered before and after the educational intervention. Comparison of the pretest knowledge scores within provider groups showed no statistically significant difference in baseline knowledge for the ST versus VC method. However, for all practitioners combined, the VC group scored significantly lower on the pretest than the ST group (p < 0.05). All three types of learners improved their knowledge scores following intervention. On average, MDs and NP/PAs correctly answered two to 3.5 more questions in the posttest. RNs showed the greatest improvements, correctly answering an average of four to five more questions following intervention. Improvement in knowledge scores between the two methods was statistically significant in favor of VC for the MDs (VC = 3.56 +/- 1.92 vs. ST = 2.13 +/- 1.89, p < 0.001) and all groups combined (VC 4.37 +/- 1.92 vs ST 3.06 +/- 1.89, p < 0.001). The results of this study indicate that VC is equivalent, if not better, than standard continuing medical education (CME). VC can potentially improve clinician education regarding the history, diagnosis, and management of HCV, thereby making a substantial impact on the clinical course of patients with this condition. In addition, VC has the potential to eliminate the financial and geographic barriers to professional education for rural practitioners.

Physicians, Nonphysician Healthcare Providers, and Patients Communicating in Hepatitis C

In-office conversations about hepatitis C can impact patients' perceptions of outcomes, as well as medication adherence. This study analyzed interactions between physicians, nonphysician healthcare providers (including nurses), and patients with hepatitis C virus infection in order to examine differences based on number and type of providers participating. Gastroenterologists, nonphysician healthcare providers, and patients with hepatitis C virus infection were video- and audio-recorded during regularly scheduled visits. Recordings were transcribed and analyzed using validated sociolinguistic techniques. Thirty-four visits took place with a physician only, 4 with a nonphysician healthcare provider only, and 25 with both providers (9 concurrent and 16 consecutive). Differences among the participant schema included visit length, patient "talk-time," and motivation provided. When providers saw patients consecutively, differing information was sometimes provided. In visits where providers saw the patient concurrently, competing authority between providers and exclusion of the patient through use of medical jargon were obstacles to ideal communication. Differences in hepatitis C-related interactions based on the number and type of participants suggest opportunities for improved communication. In visits with multiple providers, physicians and nurses should attempt to ensure that they (a) avoid supplying differing information, (b) present a "unified front" to avoid competing authority, and (c) minimize the use of medical jargon, which excludes patients from participating in their own healthcare.