Seek to Treat: Improving patient identification - part 1

Sammi: Good evening everybody and welcome to this evenings “Seek to Treat – Improving Patient Identification and Assessment of Hepatitis C webinar. We are joined tonight by our presenters, Dr Marie Healy and Dr Joseph Lawler. Before we get started, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work. I will just give you a bit of background on our presenters. Dr Joseph Lawler was awarded his Medical Degree from the University of Sydney in 2004. He completed his advanced training in gastroenterology in 2011, having trained at RPAH and Liverpool Hospital in Sydney. He completed a clinical fellowship in liver medicine and liver transplant medicine at Mount Sinai Hospital in New York City in 2014. He is now a consultant gastroenterologist and hepatologist in central Sydney and western New South Wales LHDs. Dr Marie Healy has been a GP in Redfern for more than 20 years with experience and interest in aged and chronic care and Aboriginal health. Marie has also been an RACGP examiner for 15 years. In saying that, I will hand over to Marie now to take us through the learning outcomes for this evening.

Marie: Good evening everyone. We are hoping that at the end of this activity, you will be able to discuss the epidemiology of hepatitis C in New South Wales and nationally, to be able to list the priority populations for hepatitis C testing and incorporate HCV screening into routine consultations, and a large part is identify patients at risk of hepatitis C and initiate discussions about testing using sensitive non-stigmatising language. So, look, testing really matters. Firstly identifying people with chronic hepatitis C infection has really important personal and public health benefits. Almost all people diagnosed with chronic hepatitis C can now be cured with current treatment. This will translate, as we know, to reduced morbidity and mortality in individuals, and reduce spread in the community. We are having a third webinar in this series which will cover treatment in more detail.

Looking at this slide. Hepatitis C tends to be a chronic and progressive disease, typically moving through the processes over 2-4 decades of chronic, active hepatitis, fibrosis and ultimately sclerosis which is advanced fibrosis with nodularity of the liver in the far right picture. As a general rule, this progression is silent for many years before the clinical manifestations of advanced liver disease become apparent. It is therefore really important to identify patients at risk of infection, because they may have absolutely no symptoms or few symptoms and they may not have any markers of infection, so offer them testing.

Now, a non-specialist can effectively treat hepatitis C virus HCV, and this does include GPs. DAAs are direct acting anti-virals, and from this slide you can see that GPs are increasingly prescribing treatment. For greater population benefits, it will be really important that we have got more GPs actively involved in recognising and treating hepatitis C.

Joe, from this slide, you can see here that really…

Joseph: By the end of 2016 around a third of all prescriptions were written by general practitioners, but we were discussing before we came on line, that more recent data shows that up to 54% prescription are coming from general practice.

Marie: Yes, and so it is really increasing all the time and that is what we are hoping. That black bar there is just going to increase and increase in frequency.

We will go on to hepatitis C in Australia now, Joe.

Joseph: Yes, so looking at the epidemiology of hepatitis C in Australia, there is estimated to be about 200, 000 people living with chronic hepatitis C in Australia. Of all the hepatitis C in Australia, there are up to seven structurally different genotypes with several sub-types being described. You can see from the graphic on the slide that the most common genotype is genotype 1 followed by genotype 3 and the remainder of the genotypes are lumped into that smaller group. So there might be geographic variations in the prevalence of the different types, depending on the locale. For example, some uncommon genotypes like genotype 4, might be common where you practice, so in areas where there is a large population of Egyptians genotype 4 might be more common.

Marie: So, in Australia, we have got a relatively high rate of hepatitis C diagnosis, but a low rate of treatment. That is improving. But GPs are well-placed to improve both testing and treatment to make a really positive contribution. So the next slide we will look at we will be able to see the potential benefits a bit more clearly.

Joseph: So on this slide you can see on the left-hand side the bar that represents the number of hepatitis C infections in Australia. The light purple is data from the beginning of 2016 and the darker purple represents by the end of 2016, acknowledging the numbers treated there. So, 200,000 people at the end of 2016 are living with hepatitis C. Of those, 81% have a diagnosis, which is great. But what is concerning, the population we are worried about and we really want to access is that 19% or nearly 20% that do not have a diagnosis. You can see right over to the right hand side, the proportion of patients that have been treated, in total numerical value we are looking at around just over 30,000 people. So it is really important that we work on finding those patients to get them on to treatment.

So drilling down into the New South Wales hepatitis C data, in late 2016 in New South Wales, there were just over 70, 000 people identified as having chronic hepatitis C infection with over 4,000 new cases diagnosed that year. So of that 71, 000 people the estimation, thinking back to the proportional graph before, so 19% of that 70, 000 are undiagnosed numbering just over 13,000 in terms of people that we have not yet identified with the infection. So these are the people that we really want to identify in New South Wales.

Marie: Alright, so look we have looked at the data, the epidemiology. We want to talk about how we identify the people who are not yet diagnosed so we can start treating them. So let us look at the priority populations and think about who might walk into your surgery that you might think about offering testing for. So there are some groups of individuals who are really at higher risk of acquiring hepatitis C and they really should be screened. All people who inject drugs or have ever injected drugs should be offered screening if they have not been tested, or should be offered screening if they have ongoing use. People who have ever been in custody, Aboriginal and Torres Strait Islander people with risk factors for HCV and other groups of people that you can see on the slide. A discussion around testing can also be triggered by possible markers of HCV infection such as abnormal liver function tests. It is important to be mindful of other medical and social problems that may co-exist in some populations. So you may need to make specific efforts to engage these groups of people who have been in custody. In addition, stigma and fear of discrimination may actually prevent some people from being tested, so look, it is important to be aware of all of these priority populations and you know, get comfortable with exploring the risk factors so that you can offer treatment. So about people coming from Egypt.

Joseph: Yes, look the prevalence of hepatitis C in anybody in Egypt is the highest anywhere in the world, so up to 10% of the Egyptian population test positive for the hepatitis C antibody. The explanation for this is and particularly of the one genotype was transmission through a mass treatment program for schistosomiasis from the 1950s to the 1980s. So that is why that is such a unique population in Australia.

Marie: There are other unique and specific populations aren’t there? The prevalence in Egypt is the highest in the world as you said. The hepatitis C notification rate for the Aboriginal and Torres Strait Islander population was also 3.8 times as high as the non-indigenous population in 2016. That might reflect differences in injector risk behaviours. Results from the Australian needle and syringe program showed that Aboriginal and Torres Strait Islander people are almost twice as likely to report recent receptive sharing of syringes in 2016. It could be accounted for by disproportionate rates of Aboriginal and Torres Strait Islander being in prison each year, a setting where hepatitis C screening is recommended on entry, so you are going to have higher diagnosis rates there. There is also a need for an increased focus on culturally appropriate harm reduction strategies for Aboriginal and Torres Strait Islander people in both community and prison settings. Behavioural factors have complex social determinants intertwined with poverty and discrimination faced by many Aboriginal and Torres Strait Islander people, so that is another specific population where you are going to need some sensitivity and awareness to engage that specific population and offer testing.

So we will talk about HCV case findings now. And think about when new patients come to your practice. It is good to set up systems so that you know, you can improve the diagnosis and testing of hepatitis C. So, you want to be able to identify people at risk of chronic hepatitis C and I think developing systems in your practice from the start will be really helpful. It is important to seek permission and provide a clear explanation when enquiring about risk factors for infection, remembering this can come out of the blue for some people who do not have symptoms. Make it a routine part of clinical information gathering. When raising the issue of testing for hepatitis C, note that it is curable and new treatments are available with minimal side effects. Consider testing in a range of people, those planning travel, starting a family, starting a new job for example for OH&S purposes, people who have a recent change in sexual partners, particularly gay and bisexual men, those newly single and for any new patient as part of base line check. You might even recommend it there. If your patient has risk factors, advise them that testing is important to confirm current infection and to assess for curative treatment. HCV testing should be discussed with people with a clinical indication such as jaundice, fatigue, unexplained abnormal liver function tests and known HIV or HBV infection.

So, we can discuss ways that you can also think about testing your existing patients in your practice. So, screen all patients with a known risk factor or clinical indication such as abnormal liver function tests. It would be great to do an audit or something like that to capture those people. Screen anyone who requests testing. Patients may not always feel comfortable remember providing their full history, so if somebody requests testing it is something that you really need to consider, that they may have a risk factor that they are not comfortable discussing. If a patient is infected with another blood-borne virus or falls into an at-risk group, regular HCV testing is recommended. Screen pregnant women and children born to mothers with hepatitis C virus, even though the risk of mother to child is less than 5%. It is still recommended that you do that. Also screen partners of people known to have hepatitis C virus. If injecting, they may share needles too. The risk of hepatitis C sexual transmission is low among monogamous heterosexual couples. Consider undertaking a retrospective case audit of patients in your practice, particularly those from priority populations or with abnormal LFTs. You can do that as part of a learning thing for your studies as well but I think that is an excellent idea. Case audits have several benefits in general practice. They can improve your skills at recognising risk factors and markers for HCV and they can assist in engaging the practice in increased HCV detection. You can develop them to earn CME points. Consider the following. Use the action box to trigger testing, you know write something like consider Hep C screening for patients when you come across abnormal liver function tests. Search for patients with conditions such as fatty liver, abnormal LFTs, cirrhosis, hepatitis B and past or current intravenous drug use, and recall them for review. Ensure ethnicity boxes are completed, especially for people who are Egyptian or Aboriginal or Torres Strait Islander.

Joseph: Marie, I was just going to point out a question that has come through on the dashboard, and it is interesting. The question is about prevalence of hepatitis C in Australia, and the question is stating that they thought the numbers were 230, 000 but we have just reported today that the prevalence was 200, 000. You know, that change in number reflects the success in treatment of hepatitis C in Australia. So the numbers, the often quoted prevalence of hepatitis C in Australia is coming down through treatment so that is good news.

Marie: And there is the how to Aboriginal and Torres Strait Islander people come across the hepatitis C virus. We did talk about the risk factors for being in custody.

Joseph: And the patterns of drug use and delivery in terms of needle sharing with receptive injections.

Marie: And low levels of diagnosis I suppose.

Joseph: And those other barriers to accessing health care and preventative health.

Marie: Okay. So when identifying people, how do we initiate discussion regarding testing? Look, the aim is to decrease the diagnostic and treatment gaps that currently exist, so we know that we are diagnosing a lot of people, but there is that gap so we want to capture those people and we know that treatment rates are still relatively low, so we want to really increase that. So it is important to obtain informed consent before testing, as chronic hepatitis C is often asymptomatic. So a diagnosis can carry significant stigma and fear, so you really need to let somebody know what test you are doing and why. Also, it is a relatively common condition. So some patients may not actually have an obvious cause. A careful and positive explanation is therefore required. On an individual and population, the benefits of diagnosis and treatment outweigh the negative aspects and this is something that you really need to stress with people especially in this era of the direct-acting anti-virals. Hepatitis C virus testing should be discussed in the context therefore of a high likelihood of cure with well-tolerated treatments. Even in the presence of liver damage, treatment can further reduce damage and disease progression along with the benefits of reduced disease transmission for the community. So, it is important that you provide the rationale that it is a common disease. With testing it is important to test because it is curable and obtaining consent is, “if it is okay with you, I would like to test you for hepatitis C today.” So, get comfortable with that because it is a really important public and individual health measure. So the more you do this, the more natural it will become. Normalise the procedure. We ask all new patients these questions, you might say. Ensure you check ethnicity and ask about risk factors.

So, how to initiate the discussions? Make it normal and then you can individualise it according to their particular risk factors. But look, I think you have a broad sweep and go “We ask all new patients these questions and can I ask you this and that?” So just get comfortable with asking those questions.

So, in terms of the tests. If they might have already had some tests, say they might have abnormal liver function tests. If you look at this slide here, you have just got, you know, the transaminase is slightly raised, a slightly raised gamma-GT. So that would be a trigger in a patient to offer them hepatitis C and hepatitis B testing. They might have low platelets on a blood count. That would be another indication for offering them testing.

Now informed consent will involve disclosure, and some people are going to be nervous about having a diagnosis of hepatitis C and you might be nervous about discussing the various issues that can come up with a positive diagnosis. So, I think it is important to discuss the potential downsides of testing with people. The positive upside of the fact that they are curable and the treatment is really well tolerated cannot be stressed enough, but for people to make an informed decision, even though some of the issues are academic, it is still important that the patient knows. So a positive diagnosis may need to be disclosed in certain circumstances such as on insurance applications, when donating sperm, applying for the Defence Force and in certain occupations. Discussion about disclosure to sexual partners, family and house mates should also precede testing. So these are all conversations that need to be had but the positive side of cure is really something that you need to stress.

So in that pre-test discussion, we have got here things that you can consider in the pre-test discussion. Look, it is a valuable educational opportunity as well to prevent hepatitis C virus transmission and disease progression in those infected. Giving them information regarding the risk of transmission and general risk factors can form part of the discussion in the pre-testing consultation. Provide follow up and gain informed consent from people so that you really engage them in the test and what is going to happen afterwards. Educate them on the available treatments and there is a greater than 90% chance of cure. Look, testing will also provide increased certainty to people with risk factors and give hope for those who can access treatment, because we really have entered a new era of treatment that really is curative. So, giving them written material and really discussing testing in a positive way with them is a really important and therapeutic strategy.

It is important that you have a good, positive and open discussion with people once they have been tested. Here are some guidelines on this slide about how to deal with a post-test consultation. Implications of results can be several. For example, a positive result can make the person feel very uneasy but they also will necessarily have to undergo further assessments to determine their stage of liver disease and to determine what treatment is available for them. There can be implications of negative results too, reassurance but also if they have ongoing risks, repeat testing. But look again at the post-test discussion reinforcing the positive benefits of treatment is one of the most important things you can do.

You know, people are going to be concerned about stigma and discrimination and hepatitis C is a highly stigmatised condition. We do know that, because so many people have contracted it through past and current intravenous drug use and that is its primary mode of transmission. This can cause feelings of shame and regret and people in the general community and in health care settings can create barriers to accessing hepatitis C services or to people discussing hepatitis C treatment or accessing the care that they need. So reducing and ultimately preventing hepatitis C discrimination remains a priority for action in the current national and state-based strategic response. And I think it is important for GPs to be aware that there is a lot of misinformation too that a lot of people were still using and that they should not be treated, and you know, that is not true. You know, we want to really treat all people with hepatitis C in the same way and offer them this really positive treatment that is curative. So it is important to be respectful, maintain confidentiality, be non-judgemental and non-discriminatory. So building up good relationships through your assessment and treatment is really, really important.

Joseph: So we are going to move forward into the discussion of how we test for hepatitis C and how we interpret those tests. Before I go on to that, I just want to point out another question that has come through, and it is does the Blood Bank test for hepatitis C on all samples every time? And the answer is yes, the Blood Bank will screen for all blood-borne viruses and notifications will be made on positive samples. So I think that is a really important point to make. We talk about transfusions being a risk, but that is before 1990, before the virus was identified and before screening began. So that is an important point to make.

So this is a bit of a repeat. So this slide is a recapping of when to test for hepatitis C. We have touched on this a few times. So, if a patient is to request hepatitis C testing, the clinician is prompted to order the test or screen for blood-borne viruses with abnormal liver function tests. That is another indication to test. If a patient has symptoms of signs of liver disease such as jaundice for example, or bruising or of course any other signs of liver disease. If your concerned as a treating clinician, that is reason enough to test for hepatitis C, and of course revisiting those really important risk factors, namely injecting drug use, sharing of snorting equipment which sometimes we do forget, that is an important mode of transmission, with blood to blood exposure. Those birth cohorts of people born in high prevalence countries, that transfusion risk factor before 1990 comes up there again for Australia. Unsterile tattooing and body piercing and unsterile medical and dental procedures can be risk factors. Incarceration as we have discussed, occupational health and safety issues with needle stick injuries in healthcare settings can be an indication. Screening for mother to child transmission is really important and we have highlighted that the transmission risk is low at about 5%, but remember that household transmission is very rare. It does take blood to blood exposure to transmit the virus and sexual transmission is rare but there are certain populations that are more at risk, in particular men who have sex with men or who have other sexually transmitted infections are at greater risk of transmitting the virus sexually.

Marie: So there is a question there just reinforcing of the stigma and saying some patients would rather not know but have a history of risk. Look, I think the answer to that really is that the treatments are good and the disease can be silent and they can go on to get cirrhosis, can’t they and not really know about it.

Joseph: Yes, and present later in life with liver cancer, so I think you should hopefully by the end of this talk feel confident to have discussions with your patients and be able to feed back to them the very positive situation that we have now in Australia in terms of access to treatment.

So, how do we test for hepatitis C? So you are all familiar with the hepatitis C antibody or the anti-HCV antibody. Now this is a screening test and if the test is positive, it can mean one of three things. It could represent an acute hepatitis C infection in the right circumstances, so a person with risk factors who might be jaundiced, might have so coagulopathy, elevated ALT and AST, that could trigger you to think about acute hepatitis C. Most commonly, chronic hepatitis C infection if you have got a positive test six months apart. And finally, and this is something we cannot forget, is hepatitis C infection that has cleared spontaneously. And remember that up to a third of people exposed to the virus will clear the virus spontaneously and will have that marker of infection. So the hepatitis C antibody is just the springboard. It is a screening test. It should prompt further testing to confirm a diagnosis of hepatitis C. So the antibody itself does not diagnose hepatitis C. So, if you do have a positive hepatitis C antibody, then that should prompt a clinician to send the HCV RNA test to look for the virus in the blood. Okay? And you will see references to the qualitative PCR and quantitative PCR. So the positive PCR actually counts the virus and quantifies the amount, and the quantitative PCR just tells you whether the virus is present or absent. Okay? And in terms of Medicare, you can order one PCR test a year if someone is not on treatment, but if they are undergoing assessment for treatment then on-treatment, you can order up to four per year.

Marie: Sorry Joe, there is a question related to this. You have to have the antibody test first before you can do the PCR?

Joseph: That is correct, but if you are doing a liver screen for somebody with acute hepatitis, then you can order the hepatitis C RNA. But you have to state your reason behind the test. So if a patient has chronic hepatitis C and you have confirmed that through a positive PCR, then the further tests that are key, are the hepatitis C genotype, because that can impact upon your treatment choice, even though we do have pangenotypic treatment regimens which we are going to through in a subsequent webinar. But at the moment it is still a PBS requirement to identify the hepatitis C genotype when you are calling for your prescription for treatment. And remember, and we will go through this again in the next webinar that there are particular patient populations such as those with renal failure that cannot use some of the treatments and there are limitations there and that will dictate your treatment choice. And finally, genotype can be really important too. If you have treated somebody and eradicated the hepatitis C and they have developed hepatitis C again, so someone infected with a different genotype can confirm that a different virus has been transmitted and this is a re-infection rather than a relapse which is very, very uncommon – the relapse I mean to say.

Marie: Do you see many equivocal hepatitis C antibody results and what is the cause of that, do you know?

Joseph: Look, any immune stimulation and whether it is an autoimmune disease or other viral infection, you might get a false positive test. Just re-test in that situation. Or, if it equivocal you can order the HCV RNA.

Marie: Okay.

Joseph: Okay. So it is a very simple testing sequence for identifying current hepatitis C infection, and this slide just summarises that. So you start with the antibody test. If that is non-reactive or negative, that is where you stop. If it is reactive, you send for the HCV RNA test. If that is not detected, there is no current hepatitis C infection. Okay? And if you are worried about abnormal liver tests, you have to find another answer for that. But if the HCV RNA is negative, there is no hepatitis C. Okay? But if that HCV RNA is positive, then you detect virus that does indicate current hepatitis C infection and that is the prompt to provide links to care and start considering treatment.

So again, revisiting that assessment algorithm, we will move on to the next slide and have a go at interpreting some test results. Now, you can see in the first column there we have got negative hepatitis C antibody and a negative HCV RNA. That typically represents absent infection.

Moving onto the second scenario where you have a negative HCV antibody but a positive RNA test, and this could represent acute hepatitis C infection. Okay? So again, a tricky little scenario, but this can evolve in practise.

Then onto the fourth row, we have got a positive hepatitis C antibody but a negative HCV RNA. Remember that situation. We have got cleared infection. So we have got the marker of exposure being the antibody, but absent virus, so it is resolved hepatitis C infection.

Marie: Or treated.

Joseph: Yes. That is correct. And then the final row is the positive hepatitis C antibody and the positive RNA, which of course represents acute or chronic hepatitis C infection and you have made your diagnosis.

Marie: So look, I just wanted to go back to one of those questions. So you cannot just add on hepatitis C without informing the patient. I would not.

Joseph: I would not either.

Marie: Because look, there is a burden on the doctor to do the right thing by the patient, but the patient also must know, that not out of the blue they have suddenly been tested, you know? Because we cannot presume that people will know that this or that was a risk factor can we?

Joseph: Yes, that is correct. And again, it is an opportunity for education and to sort of do your pre-test counselling and identify the responses to positive tests and already inform patients that if that test is positive, there are great solutions to treat hepatitis
C and to successfully eradicate it.

Marie: Yes. Definitely.

Joseph: So once you have confirmed a hepatitis C diagnosis, then what next? In patients that are at risk that have tested negative for hepatitis C, if they have ongoing at risk behaviours like injecting drug use or other exposures, these patients should be offered annual tests to pick up on new infections. And in those at risk patients within your own practice software, you can add in reminders and recalls to prompt you to do those screening tests annually.

Now there are a couple of things to remember too and it came up in those previous slides. So people who have cleared hepatitis C will remain hepatitis C antibody positive. They might lose the antibody titer and it might fall to undetectable levels, but it can persist life-long and it is really important that everyone understands that the antibody just means exposure, it does not mean active infection. You need the HCV RNA to diagnose that. So the patients in your practice that do inject drugs, if they do have the positive hepatitis C antibody, you are sending an RNA test, once a year.

Marie: Yes. Because they have already got the antibody there anyway.

Joseph: Yes. That is right. It is not a useful screening test in that population. That is correct. Okay. So then we are going to move on to, once a diagnosis is confirmed how to do you approach the provision of support and advice to your patients?

Marie: Well look, there are a number of important GP interventions that should be offered to patients to improve their liver and their general health. So look, in terms of general support, discussing the role of stigma and discrimination, and just having a really good therapeutic relationship with the patient is a really good start so that the practice, the doctors and the nurses, everybody. If you have got a good relationship with that patient, that is a really good start, and discussing ways that they can talk to partners and others if they need to about their health issues. Provide support for people who are living with hepatitis C. It can really help if you can provide access and links to information and peer support groups. Discussing legal issues such as disclosure, you know, doing role plays with them, just discussing how you know, you can invite them to bring family into another consultation. Discussing treatment options. Some patients will need specialist care, for example those with advanced liver disease and cirrhosis and I suppose making that clear for people who are looking like they are more complicated, and really engaging them in care for regular follow up and screening for complications such as liver cancer is something that they will need a specialty clinic for.

Preventing hepatitis C transmission is important, so discuss the risk factors such as sharing needles, syringes and other injecting drug use equipment, especially before they are cured. That is an important thing, but also so that they do not put themselves at risk again. That is a really important thing. So, sort of general support and lifestyle measures. Look, that is good general GP care just you know, giving them lifestyle advice about their diet and medications, smoking, alcohol, but also the medical things such as finding out what their comorbidities are. Updating vaccinations is really important and then obviously the public health benefit of preventing hepatitis C transmission.

Also, harm reduction stuff. You know, needle and syringe programs, opioid substitution programs. Helping them to access that sort of care is really important too.

Joseph: So I think now we are going to put on our acting hats and do a couple of role plays to kind of demonstrate how people may or may not discuss hepatitis C with their patients.

Marie: Yes. So we might go through and then there are some questions afterwards. So, first we will discuss the case of Vin, a 35-year-old man with a history of schizophrenia. So this could be one of our patients. He presents to the general practice for his annual anti-psychotic depot injection. Now, he is injecting methamphetamines occasionally with his partner and the practice record shows he has successfully been vaccinated for hepatitis B and regularly tested for HIV, but the general practitioner notes that he has not been screened for hepatitis C. So we will just do one role play first. So I am going to be the GP. Okay?

Vin, have you been injecting drugs?

Joseph: Ah, no.

Marie: Really? I can see marks on your arms.

Joseph: Oh yeah.

Marie: You should test for hepatitis C. Most drug users have it.

Joseph: I just came here for my injection and it is done, so I am out of here.

Marie: If the test comes back positive, we can get rid of it with treatment.

Joseph: I know people that went on treatment, and they had a really bad time. The treatment made them sick. I feel fine now and I want to stay that way.

Marie: Hm, so we are thinking what did the GP do well there?

Joseph: I think at least they asked and prompted a discussion about screening. I think that that is a positive thing. But it was a bit of a car crash.

Marie: Yes. Yes. Do you think Vin went away with a good understanding of hepatitis C and its treatment?

Joseph: No. I think he demonstrated some ill-informed knowledge or misinformed knowledge and it was a lost opportunity to explore that with Vin and provide a bit of education and we have lost a screening opportunity.

Marie: It was a little bit dismissive wasn’t it?

Joseph: Yes. Fairly judgemental language.

Marie: Yes. So how could the GP have really engaged him a bit more in that and how could they have improved?

Joseph: I think just a more gentle approach, you know, and I think particularly the language being used around people who do inject drugs. We have to acknowledge that is really quite a stigmatised discussion to have and it is going to put a lot of people off side if you are not careful about that conversation.

Marie: So sort of not so confrontational maybe.

Joseph: That’s correct. You really want those opportunities to discuss and educate.

Marie: So communication very robotic and not convincing. So we did not engage Vin then, so we will see if the GP has learnt from that experience. We will have another role play anyway and see if the GP can do a little bit better.

Vin, I have seen from your records that after your vaccinations you have protection against hepatitis B and you have tested for HIV many times, but I actually noticed we have not tested you for hepatitis C. I would really like to offer you that testing today.

Joseph: Why?

Marie: Oh well look, I understand you have been injecting ice occasionally with your partner. Now look, injecting ice does put you at risk of some viral infections. Now we know that you do not have hepatitis B or HIV but we do not really know about hepatitis C.

Joseph: But I get my needles from the needle exchange service and I do not share my needles.

Marie: Oh look, that is great to hear, but sharing needles is actually not the only way that the virus can be transmitted when you inject drugs. It is a really hardy virus and can live outside the body for a pretty long time. So it can be transmitted from one person to the other, even when sharing tourniquets and spoons for example.

Joseph: Wow, I did not know that. But I do not feel sick.

Marie: No. Look, hepatitis C is funny. It can cause sort of really gradual progressive liver damage and people can have the infection for many years, even decades without actually knowing it. So many people have no symptoms at all. So I reckon having the blood test is the only way you can really know if you have it. And we can do the test now.

Joseph: What happens if I have it?

Marie: Well, look the great news is there is really fantastic new medicines for hepatitis C now, Vin. And most people can get rid of the virus by taking tablets for only a few months. Getting rid of the virus with these treatments would prevent you from getting sick from liver damage.

Joseph: Well, that sounds pretty good to me. Let’s do it.

Marie: Yes. So we will talk about what sort of might have worked. What worked there?

Joseph: I think one of the big changes was that gentle sort of easing into the discussion in a far less judgemental approach and open discussion, and acknowledging the misbehaviour of injecting drug use. I think it was a very safe space for the patient or for Vin to be honest and engage in that discussion.

Marie: And I guess it fed back to Vin, just what was going on medically. It was more a medical discussion. Less about his drug use and more about the medical side of it.

Joseph: Or keeping him healthy.

Marie: Yes. And sort of did not treat him like an idiot. Talked about previous test results and then, but this is what we have not done.

Joseph: And also congratulating him on his great health care and his active health care and screening for HIV and having his vaccination peptides and acknowledging all those positive things and sort of putting hepatitis C in that bucket as well. So I think that is a great way of introducing discussions about hepatitis C in a non-stigmatising way.

Marie: Oh, good.

Joseph: So I think that did give Vin the opportunity to develop his understanding of hepatitis C. So he had some different beliefs about hepatitis C which he was taken through and challenged on, and he learned a lot.

Marie: Well, we have got another case history here. This is a bit longer, but it really talks to engaging somebody for testing.

Joseph: I think this time I am going to be the GP.

Marie: Yes, alright then. Yes. I am Angie.

Joseph: I think you make a far more convincing Angie than me. So Angie is a 32-year-old school teacher and she recently married and she is having a medical check-up before starting a family. She has got a past medical history of asthma and she uses a salbutamol puffer for that when she needs it. She drinks alcohol on the weekends, you know 4-6 drinks on those weekend days when she is out with friends. She has got a healthy BMI and a normal physical examination. She was born in Australia and is not Aboriginal. Angie has come back into the practice to discuss the blood test that you have done in your general health screen, and these have demonstrated some mildly abnormal liver function tests, and you can see there, the ALT and AST are slightly elevated alongside her GGT. But the rest of her liver function tests are normal. Her full blood count is normal. The kidney function is fine and her micronutrients are good as well with a normal TSH. So, here the GP wants to discuss the risk factors for hepatitis as part of the discussion that has been prompted by these abnormal liver function tests.

So Angie, most of your blood tests have come back normal, but there are some mild abnormalities in your liver tests that need further assessment. I would like to ask you some questions. Some of them are going to be pretty personal but I just want to work out what is going on.

Marie: What sort of abnormalities? What does it mean?

Joseph: Look, three liver enzymes are above normal levels and as you are basically healthy and do not drink a lot, I think it is really important to work out what might be irritating your liver. So, can I ask, have you, your partner or anyone in your family ever had liver problems or hepatitis?

Marie: No, not that I know of. No.

Joseph: Are you aware of any risk factors for hepatitis? These risk factors can include blood transfusions before 1990, body piercings, and even injecting drug use.

Marie: Oh, look I did inject with a boyfriend when I was 19, but it was only twice and I have never used again.

Joseph: Look Angie, it is really important to make sure you are healthy, and especially if you are planning a family. So I would really like to order some tests to check on your exposure to hepatitis B and hepatitis C with that distant history of injecting drug use.

Marie: I cannot really imagine I would have hepatitis as I am really healthy. I have never really told my husband or my family about that history and I really do not want them to know. I do not really want to know about it to tell you the truth.

Joseph: Look Angie, what we discuss and any testing we do, is confidential. Most cases of hepatitis C are diagnosed in people who inject or have ever injected drugs, okay? It is not unusual that people can be diagnosed years after that exposure, okay? Even though they feel well. You may not realise it, but if you were to fall pregnant, most hospitals will want hepatitis B results and will recommend hepatitis C testing for all mums in the antenatal clinic. So if we test now, we are going to have some certainty.

Marie: But what happens if I do have hepatitis? Would you have to tell work? I do not know whether I want to know.

Joseph: Look, those results will form part of your medical record and this stays confidential unless I am compelled to release these details for insurance or legal reasons. Hepatitis results are notified to the public health unit, but only for statistical purposes and your personal details are not attached to those results. And I do not have to tell your work. To be honest, it is better to know for a few more reasons. Chronic hepatitis can lead to liver disease, cirrhosis and even liver cancer, and the longer you have the virus the higher the risk of those complications. Remember that hepatitis can be passed from mother to baby and that is why they test in pregnancy. It is really important to know that there are really good treatments for hepatitis now.

Marie: Oh okay, well look I had better have the tests, but I am going to be really stressed. Will the test tell me if I have hepatitis or not?

Joseph: Look, the tests I would like to order are checks for past exposure to hepatitis B and hepatitis C. We will then move on, if those tests are positive to specific tests that will determine whether the virus is there or not. Would you like me to arrange any further testing if these screening tests turn out positive?

Marie: I would really like that because I want to know as soon as possible. So what tests will you order?

Joseph: Okay. Well first, we will order the hepatitis C antibody test to check for past exposure alongside those hepatitis B tests. If the hepatitis C antibody is positive, I will also ask the lab to check for the actual virus in the blood that they have already taken from you, so you will not get another stick. That way, I will be able to give you more information when I see you next week with the results. So we will go ahead with the tests?

Marie: Well I think we will.

So, what do I think you did well? Well look, I was obviously fairly nervous and wanted to make sure I was all okay before I had a baby. So I think that was really good of the GP to recognise that this was an opportunity for hepatitis C testing for a start. Those abnormal liver function tests, some people might ignore. But it was a really good opportunity and then that history came out, so look, I think that you have engaged the patient now. I felt that I was really well informed. I probably need you, there is a lot of information there and I think having you know, another discussion about the test and what the implications are would need to be done with a patient like that, because there was a lot of information there.

Joseph: But I think that rapport was really established wasn’t it, and you can tell that that GP, there is no judgement there and the patient was feeling pretty supported and was able to continue on that discussion.

Marie: I think the patient would trust the GP that they were being really upfront with them and that you know, that they would trust them with their care. I think that was certainly, you know, gave a lot of information, but I think it was needed because I think she was quite anxious.

Joseph: And also the really, really positive outcome that was stressed in terms of the ease of getting rid of the virus and I suppose something that could also be discussed is the ultimate prevention of the perinatal transmission if the maternal infection is eradicated before pregnancy is achieved, then that is a really positive outcome for this woman.

So I think that covers the acting bit.

Marie: Yes. Yes it does. So let us get back to reality folks. There is lots of learning that you can continue on with. Here are some places that you can go to for some more resources, so ASHM, NPS MedicineWise, MDBriefCase and hepatitis C web resources from GESA, ASHM and ASID. So they are all really good places for you to look.
And for patients support and resources, that you can refer patients to include, hepatitis – sorry folks, it is getting tired the computer at this hour – Hepatitis NSW, Hepatitis Information Line and for general practitioner support there is a directory of local doctors prescribing HCV and dispensing pharmacies. They are in the services directory and hepc.org.au, so they are all really useful resources that we can recommend.

Joseph: So before we go onto this slide, there are a few more comments and questions coming through. First of all, I think we are being congratulated on our acting skills. I think everyone has been pretty impressed with that. One question I wanted to bring up, somebody is asking about how do you confirm that a patient has cleared the virus after treatment, and this is something we will discuss in the third webinar coming up when we are addressing the specific treatments, but it is a really important question. But basically, in terms of testing people on treatment, you will have all your baseline pre-treatment assessments and then the most important test is the one three months after your treatment is completed. That is the SVR, which is the acronym that stands for sustained biological response and that is a 12 week test, and if the virus is absent 12 weeks post-treatment, that is considered a cure.

Marie: Hooray!

Joseph: Yes. So moving onto the summary slide, so you will be pleased to know that we are nearly done. So just remember to test and try to see testing as really simple. First you have to order the hepatitis C antibody, and remember that if this is positive, it just indicates that a patient has ever been exposed. I does not necessarily mean current infection. To confirm current infection, you need to detect the hepatitis C RNA in the blood. And of course moving on to genotyping the virus before you are thinking about treatment. And we discussed all those really important issues about pre- and post-test counselling. Now, in terms of your practice population, you want to evaluate which new patients and which existing patients are at risk of hepatitis C infection and test them. You want to keep in mind that you are going to screen all people with risk factors for hepatitis C and we have been through those a few times and incorporate routine hepatitis C screening for all new patients. And again, that is that familiarity with those discussions and being able to have an informed discussion with patients about the positives of making a diagnosis of hepatitis C and getting rid of it.

Marie: The labs will love us.

Joseph: They will, they will. And so case finding people with hepatitis C without obvious risk factors by offering testing as part of an annual check-up can be a good way to pick up on cases that might surprise you. And remember to test and treat hepatitis C if you have got evidence of hepatitis C infection, namely HCV RNA positive. So you know, all patients with hepatitis C do qualify for treatment.

Sammi: And Joe and Marie, before we move on to the next slide, a question came through before we did the role plays. When you treat hepatitis C, should you give hepatitis A and B vaccinations after treatment?

Joseph: Well, it can happen simultaneously. It is a really good question. It is a really positive, proactive thing you can do in terms of screening for vaccine preventable diseases. And you might think that hepatitis A has a different route of transmission so why would you bother? But if you have got chronic hepatitis C already and you add in the misfortune of having an acute hepatitis A infection, those patients are really susceptible to quite significant acute hepatitis A. So, testing and vaccinating for hepatitis A is really important.

Marie: So I think those vaccinations are very much part of the healthcare for somebody with liver disease or any risk of liver disease, regardless of treatment. They should really be offered those vaccinations if they are not immune.

Joseph: Absolutely. And we know that hepatitis B is part of the universal vaccination schedule, so since 2000 all people born in Australia will be vaccinated for hepatitis B. So this is about picking up people who would have escaped or missed that vaccination program in 2000.

Marie: The direct-acting antivirals, do they have any specific contraindications to the vaccines while you are on them?

Joseph: No.

Marie: So as early as possible vaccinate them if you know that they are not immune.

Joseph: And we all know that it takes time to get through all three vaccinations so there is no reason why you cannot do both simultaneously.

Marie: So acknowledgements. The presentation was developed by clinicians representing ASHM, ALA/GESA, RACGP and the Kirby Institute. ASHM is the Australian Society of HIV and Sexual Health Medicine, The Gastroenterological Society of Australia.

Joseph: The Australian Liver Organisation.

Marie: Yes, okay. ASID is…

Joseph: The Australian Society for Infectious Disease.

Marie: RACGP, I hope we know that one, and the Kirby Institute and the Department of Health NSW has provided funding too.

Joseph: Just before we summarise those learning outcomes, I think a question has come up again about disclosing hepatitis C status to your partner. So there is no legal obligation to tell your sexual partner or partners and we have had discussions around the sexual transmission of hepatitis C and I think having an informed discussion with patients about the absolute risk, so with vaginal penetrative sex, heterosexual sex, the risk is incredibly low, but it is really the population that are at slightly increased risk, and that is men who have sex with men. That is where I think it is a really important discussion to have. But you know as we said, there is no legal obligation but I think it is a really important public health message and a really important part of your patient education experience to compel them to have the confidence to have those discussions and as a clinician to be able to facilitate that in any way you can.

Marie: Yes. Yes. Look through role plays and just getting them used to, look it’s a disease, let’s reduce the stigma. Let’s treat it. Yes, that is it. So let’s hope these learning outcomes, I think we have addressed them all. We have discussed the epidemiology of hepatitis C, New South Wales and nationally, listing the priority populations for hepatitis C testing. We really want to pick up that 19%, incorporate screening into routine consultations. Let’s get comfortable with it. Let’s pick up those people. Identify the people at risk of hepatitis C and initiate discussions around testing using sensitive, non-stigmatising language and really keep it positive. Folks, we have got a great set of treatments here, great cure rates.

Joseph: Really well-tolerated.

Marie: Yes.

Joseph: We will talk more about that next time.

Sammi: That brings us to the end of this evening’s webinar. Thank you so much Joe and Marie for joining us tonight. I hope everybody on line this has really helped their ongoing education as a GP. In saying that, thank you all for attending and enjoy the rest of your evening.

Joseph: Good night everyone.

Marie: Good night.