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Hepatitis C in Primary Care (QLD)

Good evening.  I would like to welcome you to this evening's webinar on hepatitis C and primary care.  This is the fourth of five webinars in this series sponsored by the Australasian Society for HIV, viral hepatitis, and sexual health medicine.  My name is Michael Burke and I will be your host for the evening.  To start tonight's webinar, I would like to make an acknowledgement of country.  We recognise and acknowledge the traditional custodians of the land and sea, on which we live and work.  We pay our respect to elders, past, present, and emerging.  Okay.  I will now run through a few housekeeping notes.  This webinar is being recorded and will be made available for you in the coming week.  To interact with us today, you will need to use the zoom control panel.  If you cannot see a panel like the image on the slide, hover your cursor over the bottom section of the shared presentation screen, and the panel will appear.  The control panel allows you to select your preferred audio settings, and it is where you can ask questions by the Q&A module.  We have put all attendees on mute tonight to ensure learning will not be disrupted by background noise.  As this is a webinar, we are unable to see you as participants.  If you need assistance, please use the Q&A feature to raise any technical issues, and to submit your questions throughout the presentation.  Please do not enter any personal information outside your name and question, as other attendees will be able to see this.  We will be addressing questions throughout, and after the presentation, in the dedicated question-and-answer time.  You can upvote questions by selecting the tick icon on a question.  This will assist in reducing the amount of same or similar questions being submitted.  Tonight's webinar is proudly supported by ASHM, and our presenter this evening is Dr Jodi Stevenson.  Jodi is a GP, who has worked in Indigenous Health for the last 20 years.  She has been working at Inala Indigenous Health in Brisbane since 2014.  As liver disease and hepatitis C is overrepresented in this community, she has pursued a specialist interest in prescribing this.  Before we start, we will play a video from Hepatitis Queensland.  A great video resource, which provides insight from various lived experience stories to what living with hepatitis C is like, and their journey to being cured.  After the video, Jodi will commence her presentation.
(Transcripts from the video)
My name is Grant.  I am a Gadigal man from the Eora Nation.  I was diagnosed with hep C when I was in prison.  I was told that basically there was nothing I could do about it.
I contracted hep C from injecting drugs in 1998.  I wasn’t told anything about the virus, I wasn’t given any treatment options.  I have definitely felt judgement from healthcare workers.  I felt shame because of the way I contracted it.  I always felt like I was doomed.
When I disclose my diagnosis to some friends, they are a bit scared, and so I think it’s around educating.  When people know more, they are more understanding.
I was always concerned about infecting somebody else.
It was a constant worry and now I don’t have that worry anymore.
The treatment was really easy to get on.  I had no side-effects.  It was amazing.
Now that the GPs can prescribe, it’s one tablet a day for 12 weeks, and you can get rid of the virus.  When I was cured, I felt I had lost something, I had been carrying it around for so long, but now I can just get on with my life.
I feel like I am better now, I am free from substance abuse, I have got heaps of more energy, I am enjoying my life now.
Liver health is important.  Just go and get tested.  If you get a positive result, there is a cure, and you can beat the virus.
I am just sharing my screen.  Hello everybody.  My name is Jodi, a GP as Michael said, that works in Inala, servicing the Jagera, Ugarapul, and Turrbal people.  I would like to extend a special  welcome to the people from Sydney.  We are thinking of you and hoping that you have been safe in this lockdown.  I would really like to start this webinar by reflecting on the video because it’s really the hope stories in these stories that the patients are telling us.  It’s a very moving and powerful set of stories and it really hurts to see the stigma and the suffering of people living with hepatitis C.  It’s these stories, similar stories to these, that my patients were telling me that motivated me to do more in this field.  I undertook training with ASHM, and as Michael has already discussed, ASHM is a marvellous educational organisation.  I recommend that you go to their website, that you look at the courses that they have available.  They have courses with infectious diseases specialists and gastroenterologists etc., half-day, full-day courses in hepatitis C, and in specific populations, that can answer every educational need you might have very comprehensively.  So, I recommend looking at those courses.  I also am aware that you should have been sent a link to the decision-making guide on hepatitis C from ASHM and essentially this answers all your questions in practice, say that’s a golden thing to have available.  In addition, the video was actually put together by Hepatitis Queensland, and they are another organisation that I think are golden, that support patients and support doctors wanting to treat people with hepatitis C.  So, in contrast to the ASHM courses, I think it is important to note that this is more of a K Star webinar, where I see myself as your colleague, encouraging you that this is great medicine, you should get into this, you should do this.  For starters, the hepatitis C is a chronic infection that causes significant morbidity and mortality, and the treatments that have become available are extremely effective, they are essentially a cure, they are well-tolerated, safe, and short courses.  So, it seems like a no-brainer, serious disease, awesome treatment options, and really, we as primary care physicians are in the perfect position to be offering this.  In the healthcare system, we are like the most ideal people.  We are screening people all the time, we see all kinds of people through our practices, so it is one more thing that can be thinking about, as you see people, because essentially this is the message I want to give you.  It’s easy medicine for us, basically we screen people all the time, we will screen them, then we can offer them a treatment that works, essentially, we can cure a terrible infection.  It makes so much difference to the patients’ lives, it saves lives, and it actually makes you feel good, so in the course of my day, I actually get a bit excited, going awesome, I get to treat somebody, I am going to make something go… some bad part of their life eliminated, so it’s wonderful.  Okay.  So, I just want to let you know that this is my first webinar, and I am learning the language of _____ and _____, and I am going to give it my best shot today.  So, this is the presentation put together by ASHM, the slides have been put together by ASHM.  Thank you for that.  Okay.  So, I have changed the screen.  I just want to figure out _____ I have done something, but I don’t know what I have done.  So, hepatitis C affects millions of people around the world and is estimated to cause around 4000 deaths in a year, so it’s a massive problem for the world.  It is an RNA virus and it uses the mechanisms in the cell to replicate in the nucleus.  The body's reaction to the virus causes inflammation and this damages the liver cells.  The inflammations in the sinusoids, you get back up with the blood, and all the collateral damage from there.  This virus is transmitted via blood to blood contact.  It causes liver fibrosis, it can lead to cirrhosis and to liver cancer.  So, it’s a really nasty chronic infection.  Now, this is the picture of hepatitis C in Australia and that shot taken in 2019.  There is thought to be 1,21,000 people still living in Australia with hepatitis C.  80% of people have been infected through injecting drug use, and our problem is that one in five people don’t know that they have it.  Over here, the genotypes ____ that hepatitis C genotype 1 is the predominant genotype in Australia 1/3.  Historically, we used to have to genotype this for …. we chose our treatment and this is not as relevant now with the treatment regimens available.  As most of you are in Queensland, the statistics in Queensland are that there are 43,000 people living with hepatitis C, so it’s a big job, and we need all of you to help.  It would be great.  So, the main question is what do you think your role will be in this hepatitis C response, and I don’t need to tell you what you do every day, but I would say it’s just, it’s _____ perfectly to primary practice.  We have a viral load screening and management and treatment.  Importantly, a lot of us already manage comorbidities in high-risk people.  We manage people who use drugs, people with significant mental illness etc., and we don’t wait to prevent transmission, we can educate people and minimise harm.  Essentially, we are reducing morbidity and mortality in our patients’ lives all the time, and we can help to reach the WHO target.  So, _____ organisation has a goal to eliminate hepatitis C as a public health threat by 2030.  This goal breaks down to 90% less new infections by 2030, and two-thirds less mortality related to hepatitis C.  So, it’s a large goal, and we are really fortunate to work in Australia because our government decided to fund the medication and open it up to primary practice, which I believe is golden for the people of Australia, who are suffering with hepatitis C, and it is a marvellous opportunity for us and for them.  Okay.  This slide is detailing essentially the change over time, so the direct-acting anti-viral medications that treat hepatitis C were launched and we were given access to them in March 2016.  And at that time, you can see that the majority of prescriptions were with the gastroenterologist and Infectious Diseases.  As we moved through the years, we see that primary care physicians and general practitioners are taking the lion’s share of this work.  I have heard, however, that over time, the pace is slowing, so it’s a huge job, and we need to make it a part of our treatment tool, so that all of us can offer this to patients to be able to eliminate hepatitis C.  I think it’s a pretty exciting goal to eliminate an infectious disease and we have got the tools to do it, so I just think why not be involved, and we definitely have the skills for this.  So, ASHM has broken it down into six simple steps, and really everything or part of this is easy.  First question is, when do we test.  Alright.  So, when we are looking at people's results, there are clinical indications.  If you saw abnormal liver function tests, hopefully, you would think what would this be, what else things this patient has going on, but we want you to think could this be hepatitis C.  It is important to note that the abnormal limit that you want to start thinking about hepatitis C is lower than the normal ranges than the laboratory list.  In men, it’s an ALP of greater than 30, in women it’s an ALP of greater than 19.  If you saw, on physical examination, the stigmata of chronic liver disease or jaundice, that would be another ideal time to test.  The crux of the matter really is recognising the risk factors and offering the test to people who have risks, that we already know this is an RNA virus, but it is transmitted blood to blood.  So, injecting drug use is 80% of the population, so when we come across the people, who have admitted to injecting drug use, the best thing I think is, oh, I feel having them test for hepatitis C.  In my role, I see people coming to me from _____, for mental health plan, because of the drug conviction, letters for the courts, all kinds of things that involve drug use, and these other complaints, I will hopefully address, that in the end I am thinking, this is a young person, who has got a disease from doing something that he is anticipating now, 20 years from now, he might end up with fibrosis, cirrhosis, and hepatocellular carcinoma, or she might end up with these things and that’s quite a legacy from the youth, so I would like to talk to them and introduce them on getting tested and undertaking treatment.  So, the other things that present risk are sharing of smoking equipment, being born in a high prevalent country, so that will be relevant to other practitioners, especially Egypt, you probably have heard, had a public health campaign from 1950, I think into 1980, where they are trying to control schistosomiasis with IV medications and that was before hepatitis C was known about and they had a seroprevalence in the 90s, I think of 40%, and it’s down to 7% now.  They have quite a legacy from hepatitis C and with liver disease and cirrhosis _____, before 1990, in Australia, if you would speak about transfusion of blood products, these things were not known about, and you could be at risk of having hepatitis C.  Another mode is home tattoo or backyard body piercing.  In my population, once again, I see heaps of this, and I bring this up if I come across a person who is telling me what they have done or how they got this or that.  I think you can read the rest of the list, another really important one is time in prison, so, it is thought that 30% of people, the seroprevalence of hepatitis C in prisons in Australia is 30%, so that is absolute tragedy that a person would be incarcerated, and with their time in prison maybe… obviously some people get it before then, but then they may have much greater likelihood of getting this disease.  Another mode of transmission that we all think about is healthcare workers when they have a needle prick injury, and importantly mother-to-child transmission, we have got to think about that, 50% happens in-utero before delivery, so really we want to be treating the mother before she falls pregnant.  If you see a fertile woman who has hepatitis C, I talk to them about this risk because it changes her life and it changes her baby’s life.  Sexual transmission is also important and because it is blood-to-blood transmission, it’s more prevalent in sexual practices that are traumatic, and that’s more in men who have sex with men and especially in men who are HIV positive or people who are HIV positive.  Other reasons to test for hepatitis C include when you are initiating prep and when someone requests a test.  This slide is talking about how to find and diagnose patients, how above and beyond screening to find and diagnose patients, and it is making the point that when someone asks for a test, they may not be comfortable raising the injecting drug use history, but they think they are at risk and they deserve a test.  When I see a new patient that I have never seen before, who is new to the practice, we all I am sure do the same thing, take a history, see what medications they are on, and what past medical problems they have etc., and I take a drug, alcohol, smoking history, and I go into that drug history and normalise what they might be taking, and how they take it, and who they take it with, and do they use clean needles.  So, I think it’s a part of every new patient I am screening and existing patients, you should be screening pregnant women and partners of people with known hepatitis C.  Smarter people than me can do _____ or use medical software ordered as well looking for specific markers such as abnormal LFTs.  If you did that in my work, you would find that most people do have abnormal LFTs and it wouldn’t be _____, but you can retrospectively search for patients and see if they can be not with hepatitis C.  And the important thing may be that _____ are important to consider and that’s because they are now in their 60s and 70s and in their youths, in the 1970s etc, they may have used drugs and do not consider themselves anymore a drug user.  They may have abnormal LFTs, and hepatitis C wasn’t even named at that time, yet it can silently go on in their lives, cause fibrosis, cirrhosis, and hepatocellular carcinoma, and liver failure.  So, they are a special category that we have to consider testing for hepatitis C.  This last little box here is fairly obvious, is somebody who is jaundiced, had unexplained abnormal LFTs or known HIV or hep B or any stigmata of liver disease, which should be testing for hepatitis C.  And importantly, 15% of people have no identifiable risk factors, so that’s why we should broadly be thinking about it.  Okay.  So, to say you all that this is easy and rewarding and saving people’s lives, this is the case of Tom.  Tom is a 42-year-old office manager, he is new to your practice after moving into the area.  He is experiencing extreme tiredness lately.  He is otherwise well, he is on no regular medications, he drinks 30-40g of alcohol a day, and during history taking, he tells you he briefly injected drugs in 1990.  On physical examination, he has no stigmata of chronic liver disease, no signs of cirrhosis.  So, question number 1.  If you can refer to your lovely decision-making tool in hepatitis C from ASHM, we are asking you, would you test for hepatitis C in Tom?  (Long pause).  It’s an incredibly good result, yes, we should be testing for hepatitis C in Tom, you have all got that message basically.  You can see that the majority of us would test Tom and I will go on to tell you if you are unsure, why will you test Tom _____.
You can just press the cross in the top right corner.
I don’t get a cross.  Anyway….
You can just try ____ get a cross, so, sorry.
Ah… thank you.  I am _____, I wish you would be able to train.  So, if you look at the decision-making tool on hepatitis C, the first thing that we are looking at is when to test.  This is what we are able to find those undiagnosed people, and for Tom, he has a history of injecting drug use in 1990, so this indicates that we should test for hepatitis C.  The next part of our job is to audit it and interpret it around hepatitis C.  Once again, I think this is pretty easy and we can all do this.  So, we go back to our decision-making tool in hepatitis C, we look at the second tab, and the first part of it is ordering a hepatitis C antibody.  Okay.  And Tom’s test results have come back, he is hepatitis C antibody positive.  Question 2.  Tom’s positive hepatitis C antibody result could be consistent with.  A.  Current hepatitis C infection.  B.  No prior exposure to hep C.  C.  Past infection that has resolved.  (Long pause).  Awesome.  So, so the answers were, both current infection and past infection that has resolved…. and you guys have done really well.  Okay.  So, the next test that we are organising is the hepatitis C RNA.  When we look at this, the hepatitis C antibody tells us that the adaptive immune system has seen this virus before, has created an antibody, and it is going to be there for life, so that is has he ever been in contact with hepatitis C.  The RNA is the viral RNA, so it’s telling us that this person is infected with hepatitis C now.  If they are antibody positive and RNA negative, it’s telling us that there is no virus, so they have been infected in the past.  If they are antibody negative, they have never been infected with hepatitis C, which is _____.  So, what do we also order if we are suspecting hepatitis C, so if I am suspecting that a patient has hepatitis C, I often write them a pathology form, hepatitis C antibody or hepatitis C serology, and in brackets write if positive for HCV RNA, and plus or minus a genotype at that stage, and I would always organise LFTs, because this is the disease of the liver.  Okay, so, we are going back to the decision-making tool from ASHM again, it has everything we need.  We know he is antibody positive, we are looking now at his RNA and his LFTs, and his result is that he is HCV RNA positive.  Does Tom have current hepatitis C infection?  This is the question we need to answer.  One more, _____ doing really well.  (Long pause).  Okay.  So, the majority of you chose that Tom does have current hepatitis C infection, which is wonderful.  I think that may be the presentation is and I speak fast, so I am not quite sure, when you are contemplating these questions, sometimes you don’t have the slides you need in front of you tonight.  Okay.  So, regarding back to our ASHM decision-making tool, we know that he is RNA positive.  This is the next step.  What do we do, when we have a diagnosed infection, hopefully he should have been counselled when you are ordering the test, he may have contemplated that he has this disease, but also some people are quite shocked and in ____ video, the first thing people say is often about friends and family and who I have infected and it’s quite tragic to see that pain, and it is important to address transmission and how to avoid transmission because it’s so important to the people who have been recently diagnosed.  And, as this is a blood-to-blood transmission, the main modes of transmission are drug use 80%, as we know.  The transmission rate of hepatitis C from drug use and shared needles is thought to be 40%.  I was told that the average user infects 10 people, so if we can find people who are using IV drugs and offer them treatment, if they have hepatitis C, that will multiplicatively help us to get out of the situation that we have with hepatitis C.  It is important to note that it’s not just sharing the needle and the syringe, but also the drug paraphernalia, so people who share tourniquets or share the bandage or the cotton that they are trying to tamponade the bleeding with, and they share syringes, that anything what you are sharing with blood obviously is a risk factor for hepatitis C.  There’s also risks when you share, I don’t know, snorting equipment, they must be mixing needles and a lot of syringes as well etc.  So, obviously, we would advise using clean needles and syringes, and in Australia, we are very fortunate to have a needle and syringe exchange program that are hopefully dotted in in the suburbs and places that need them.  And ____ obviously a fantastic ____.  It’s also a great time to talk about the life-changing therapy with opioid substance use.  Often, I find that when someone has been diagnosed with hepatitis C, you are giving this an opportunity to get rid of the virus that had terrible consequences and it can stay with them for life, and they feel with renewed energy to change their lives and get on the bandwagon and do other awesome things for themselves, and opiate addiction is another sentience, the ills and harms of which can be reduced without the opiate substance use and therapy, and these two things go together extremely well, so I recommend putting these two things together.  So, another important consideration is household risks.  We know as doctors, that blood-to-blood transmissions means that you have to have blood, so you have to have cut yourself and somebody else must have cut themselves to have transmission.  So, we would understand that sharing razors, toothbrushes, and nail clippers, contact with bleeding wounds would be risk factors.  Patients often don’t understand that and it is tragic to hear of what patients will do thinking that they are a risk to everybody around them.  There’s shame and fear and it is worse addressing the normal activities such as sharing knives and forks and plates and glassware, touching, hugging, kissing, sneezing, coughing, so, it liberates people to know that these things are not ways that they can transmit hepatitis C.  Another important mode of transmission is sexual activity, and once again, knowing it’s a blood-to-blood route of transmission, this is more likely in traumatic sexual practices and the transmission rate is thought to be about2-5% in monogamous couples, but it’s higher with unprotected anal intercourse, co-infection with HIV, and coincident ulcerative sexually transmitted diseases like ____ and syphilis.  We would be doing this all the time, I do this day in day out, encourage using condoms, especially though for HIV positive people and men who have sex with men, and those people who have multiple sexual partners or recurrent STIs.  And the last category does not pertain to Tom, but once again it’s important, there’s a 5% transmission rate from _____ infected mothers to infants and breast-feeding ____.  And like I said, we can do something during delivery to reduce the risk of transmission, but there is an in-utero transmission that we cannot stop, so it is much better to offer treatment to fertile women before they fall pregnant, and when I come across a young woman who is an injecting drug user, one of the first things I want to talk about is long-acting contraception, so that she doesn’t unexpectedly fall pregnant or unwantedly fall pregnant and we can offer treatment for hepatitis C.  Okay.  So, this slide is offering a comprehensive look at the diagnosis of hepatitis C and what the patient will need.  So, they need general support and understanding as the video said, when you no know more, people are more understanding, and you have less fears.  This is where Hepatitis Queensland and ASHM have very good resources and they are designed for different patient populations and I will usually print them out and give them to patients.  It is important to consider the impacts of stigma as the story in the video, one of the people who suffered with hepatitis C talked about even feeling judged by the doctor, which I feel is a very sad situation, and I would like to take the stigma or pain out of this consult by likening the hepatitis C infection to tonsillitis or some other more routine infection.  I would say, this is an infection of the liver, and we have got this awesome set of treatments that we can offer you, that can take it away, it is short, it is safe.  If you had tonsillitis, I would give you penicillin and you take it _____, I will try and decrease the pain by likening it to more simple infections.  If there is more fear, stigma, shame, trouble with this diagnosis, obviously you can refer to counselling and peer support organisations.  So, in Queensland, and I believe the majority of you are in Queensland, there is Queensland Injecting Health Network, they are extremely helpful, awesome organisation and they have peer support workers, who have been through treatment with hepatitis C, they have been injecting drug users, and I think when they are paired up with patients, they offer a level of support that middle-class doctors don’t, so I can’t recommend them enough either.  The next point is referring to lifestyle measures and essentially we want to offer the best opportunity for this person’s health from this point onwards.  Treating hepatitis C will take chronic inflammation out of their liver, but if they are engaging in other activity that damage their liver, it is wise to tackle more at the same time.  This is ____, we all know that alcohol and tobacco use are bad for the liver, and fatty liver ____ this problem, diabetes, and dyslipidaemia.  So, we will be thinking about all these things and talking about all these things.  I have practiced also with a hepatologist and doing FibroScans and many things like that.  In that role, I have heard him liken the liver to our patients as state of origin pain, and I think it is pertinent because it is state of origin _____.  I don’t speak the language of football very well, but some of my patients do, and he talks about hepatitis C as being all the substitutes.  So, you have got your liver and you have got your 13 men on the field and all of your substitutes are out because they have got hepatitis C.  They are not going to come back on the field, they are injured.  If you start drinking, binging etc., you are going to take men off the field, and there’s no way you are going to win.  So, it’s an analogy that worked in my patients’ world.  I am not sure what would work in yours, but essentially, we have got to address all of these things, could be given the best chance.  Medically, we also want to avoid hepatotoxic medications.  Once again, this is not _____.  For me, my medical software program obviously will do that if I code that this patient has hepatitis C infection in their past medical history, or if I prescribe one of the medicines that treats hepatitis C.  We should also be offering immunisation for hepatitis A and hepatitis B.  Once again, it is state of origin team, we don’t want to take out more players.  With these diseases, if you catch them, your liver will be you know stuffed kind of thing.  So, the next one is, it is important role for us to check for fibrosis.  This is because it pertains to the treatment of hepatitis C, but also because cirrhosis is a pre-cancerous state, so if we are looking at a person who has liver disease that progresses towards cirrhosis, we want to establish that they are cirrhotic because for the rest of their lives, they will need six-monthly ultrasounds and AFPs to make sure that they haven’t developed hepatocellular carcinoma, so that’s an important role.  I think it’s the second take-home message.  The first one is, it’s easy, its’ lifesaving, let’s do it; the second one is don’t miss cirrhosis and the monitoring that it requires.  So, we are up to pre-treatment assessment.  I think of this step as, is this person suitable for general practice prescribing for hepatitis C or does this person need to see a specialist, this is what this step is all about.  Sometimes, they don’t need to see a specialist, but you definitely need to talk to a specialist.  I think it’s pretty easy, the patients that can’t be treated in general practice are people who have cirrhosis, people who have co-infection with HIV or hep B and people who have significant comorbidities.  Also people who have failed previous treatment will have treatment with the assistance of the treatment-experienced people.  To be honest, that is the minority of the people I see and the majority of the people are suitable for general practice treatment, so you just have to go through these steps and say this is somebody I can treat.  Okay.  So, this is the pre-treatment assessment recommended.  A full blood count and liver function tests and kidney function test.  Hepatitis B, HIV, and hepatitis A serology, and a pregnancy test for childbearing women.  So, with a full blood count, we are looking for sequelae of liver disease with thrombocytopenia and platelets under 150 to 100, which would prompt you to do an INR and _____ fibrosis.  As I said, we don’t want a patient to have hepatitis B and treat hepatitis C.  This is because the treatment for hepatitis C can cause a flare in hepatitis B, that can cause a fulminant hepatitis and has led to death.  So, you don’t want to prescribe direct-acting antivirals for hepatitis C in a patient who has hepatitis B, it’s a really important message, and what we are looking for is the hepatitis B surface antigen, it tells you that the person has the virus now.  So, if they are hepatitis B surface antigen positive, you need to refer to a specialist.  The value in the hepatitis A antibody is just in whether you will offer them immunisation.  Okay.  So, the next slide is referring to whether genotype testing might be useful.  This is historically very important, because historically, there are multiple regimens that could treat hepatitis C, and they are dependent on the genotype that the patient had.  So, you have to look it up, this one goes with this one etc. etc., it’s a little bit hard.  Now, it is all easy, there are two main treatments, they are pangenotypic, that means that they treat all genotypes 1 to 6, you don’t have to do anything tricky anymore and you don’t need to genotype that taking that away from the criteria for authority prescribing in 2020.  The genotype is still relevant, however, in decision-making for people with cirrhosis and people who are treatment-experienced.  Really, that’s the realm of the specialist, however, so you can add that thing if you have got hepatitis C RNA performed on all blood, if the laboratory is keeping the bloods.  In the end, there’s a value to doing the genotype because in people who continue to use IV drugs, if they subsequently are hepatitis C RNA positive, you then want to know if this is a re-infection or relapse and having the genotype helps with that, so at this stage, I am still doing it a lot, and you can do it on the Medicare once a year.  A person who actively uses IV drugs should be tested once a year for hepatitis C and RNA.  Okay.  So, these are Tom’s results.  Tom’s full blood count looks normal.  His platelets are reassuring at 320.  His kidney function is normal, so that he doesn’t have the significant comorbidity of kidney disease.  His liver function tests are abnormal, so his ALT is 59, which is above that upper limit that we are concerned about, 30.  His AST and gamma GT are also elevated.  Now, Tom has not got hepatitis B surface antigen, so he does not have this virus, hasn’t got the core antibody, so he has never had this virus.  He does have the surface antibody, so he is immune to hepatitis B, and we do not need to immunise Tom.  He is HIV negative and he is hep A IgG positive, which means he is immune by immunisation to this disease.  So, I will just put a little note in there.  ASHM also does hepatitis C prescribing courses and I recommend those, they are fantastic, and sometimes the interpretations of those tests are difficult.  It’s not the purpose of this webinar, but you can do other courses if you wanted to do.  So, what else should we consider?  So, we have considered the virus and the hepatitis C antibody and PCR test, we should really consider his liver and the fibrosis staging, as I said before, and then there’s some individual factors that are important.  His use of alcohol and drugs, pregnancy, which is not relevant to Tom, other medications that might interact with the treatment regimens we are considering ____ and significant comorbidities.  Essentially, as I said, we are just trying to figure out if this person is safe for us to treat or if they should see a specialist.  Okay.  So, the importance of liver fibrosis assessment.  I have said it before, and I think it’s a really important take-home message.  It is an important one for the appropriate hepatitis C treatment measurement.  It informs when you should refer to a specialist, but once again, it can save lives.  So, I think the progression of hepatitis C is thought to be at 20 years, 20% of people have cirrhosis.  So, in the long term, the fibrosis leads to scarring and nodularity and cirrhosis, and all of the sequelae of that.  When a patient has been diagnosed with cirrhosis, it is considered a precancerous condition, and we are thinking that this person has a 1-2% annual risk of hepatocellular carcinoma, and to me, it’s quite tragic that somebody will be getting a cancer from something they did in their youth 20 years ago, and in my experience, we have had a lot of young people have hepatocellular carcinoma in Inala and it is a burgeoning cancer in Australia in every region.  So, I don’t want to miss that, because by the time these people are getting their cancers, they have got families and jobs, and it’s a tragedy to the community and the families of course.  And cirrhotic status is still currently required for PBS approval.  So, how do we assess the liver fibrosis?  Now, we are not, that this is a really simple answer, but it’s a picture, you are putting together a picture and really that’s general practice or primary practice every single day.  We are putting together information from different areas and deciding does this person need a fibrosis testing.  The first thing that we are considering is the history, we are considering the length of time of the infection.  So, for instance, if I saw a 20-year-old, who tested negative when they are 19, but is positive when they are 20, I don’t think they are going to have cirrhosis, but if I am looking at a ____ or a 40-year-old, and they were using in 17, I will be thinking this person is really likely to have cirrhosis.  You are also thinking about those comorbidities, so if they are drinking a carton a day, and they have had hepatitis B since they were 17, then the two things act synergistically and accelerate the damage and then fibrosis of liver.  So, I will be thinking, yeah, this person could have cirrhosis.  On examination, any stigmata of chronic liver disease, jaundice, ascites, varices, encephalopathy, I will be thinking despite any test that this person probably has cirrhosis ____ any previous tests or blood tests.  On the blood tests, of course, we are looking at the liver function test, we are looking at the synthetic part of that, we are looking at the coagulation profile and the platelet count.  These things are telling us about the severity of liver disease.  And ultimately, there’s this awesome thing called serum biomarkers, and with hepatitis C, the one that is promoted is the APRI score.  The APRI score, we will go through in the next slide, if it is less than 1, cirrhosis is considered unlikely, if it is more than 1, cirrhosis is considered likely, and we need to assess with a FibroScan or shear wave elastography in the least.  If that’s unavailable, you can use other things and add to this picture, but really this doesn’t need to be seen with a specialist.  Okay.  So, this is the APRI score.  It is the AST-platelet ratio index score and on this awesome ASHM decision-making tool, you will find a link to the tool.  I have that saved as a favorite on my browser, I never have to look for it, so that makes it really easy, and we put Tom’s results in there, his AST is 56, the upper limit of normal is 40, his platelet count was 320, and his APRI score is 0.437.  So, with Tom’s APRI score of 0.437, is it likely Tom has cirrhosis?  (Long pause).  Okay.  We can see the _____ results _____, so, it is not likely he has cirrhosis, the cutoff of above 1 makes it more likely he has cirrhosis from the APRI score.  So, if we look at the ASHM decision-making tool again, we have used our APRI score.  We have decided that he is probably not likely, but if he was, we would be seeking a FibroScan, and if a FibroScan is available, like it is at my workplace, I will do a FibroScan, because this is another part of the picture that you put together.  Essentially, the stiffer the liver is, the greater the degree of fibrosis, and the FibroScan is pictured in the picture there.  It’s simple, quick, painless examination that the patient has, basically a pulse goes through the liver and it times its movement through the liver and tells you how hard it is.  So, I think it was initially made to assess the hardness of cheese, but that’s an interesting trivia fact.  Anyway, the importance of this score is that a score over 12.5 kPa indicates cirrhosis and that’s lifelong.  Okay.  Michael _____.  Not sure what to do with that.  Michael, do you want to talk?  I can’t hear anything.
Please go on.
Oh Sorry.  Okay.  With the FibroScan results, a score over 12.5 signifies cirrhosis, and that relegates that person to a high risk of hepatocellular carcinoma and other liver failure issues.  So, they need close surveillance with ultrasound of those and AFPs.  A low score is telling you that this liver is normal.  So, the scan is good at discriminating cirrhosis, it’s good at discriminating normal, but in between those two cutoffs, it’s most specific and sensitive, and it can be affected by things such as diet and alcoholic binge that you know in recent times, a current infection, so it has to be considered in context to the part of the feature that you are considering in context, and it is not perfect, but it is a very good tool.  So, some notes about anatomic imaging.  These are not adequate for staging, but once again, they just add to the picture.  If you have a nodular liver or an enlarged cordate lobe or an enlarged spleen or the vessel of flow in the portal vein or the presence of portal vein collaterals, all of this is telling that this patient has cirrhosis, and I will be referring them to a specialist, and I will be organising hepatocellular carcinoma monitoring.  Okay.  So, we know when to test because we are primary care physicians, and we are thinking about risks all the time.  We can interpret the test _____ antibody in the RNA test, and we have just gone through which patients can we treat, which is the majority of people.  We don’t want to treat cirrhotic patients, so we have got to assess that, we don’t want to be treating people with co-infections, so we are going to assess that, and significant comorbidities or people who have treatment experience or have had treatment failure, they will be going to the specialist, and now we are looking at treatment.  And surprisingly, treatment is the easiest part in my opinion.  Question.  I should have gone the other ____, it’s your turn.  Should Tom be treated now?  A.  No.  He doesn’t have any significant symptoms.  No, he doesn’t have advanced liver disease.  Yes indeed.  Unsure.  (Long pause).  Excellent.  You have got that right.  So, all of you said Tom should be treated, this is it, you’ve got it.  Okay.  So, the benefits of treating are for the individual, reducing liver disease progression and improving his clinical outcome.  He will be less tired, he would incur less shame and stigma, he will enjoy his life, hepatitis C, he won’t get fibrosis, cirrhosis, and hopefully _____.  And on the population level, yeah, we are reducing transmission to 10 of his friends and we are eliminating hepatitis C and we are feeling good about ourselves as doctors and primary care physicians.  So, this is my favourite favourite slide, because everything on it is good.  First of all, we can compare the treatments available today, the direct-acting antiviral, the pangenotypic regimen, so there’s only two that you have to choose between, and they are both awesome.  If we compare them to the historical options that a person had with hepatitis C, they absolutely shine.  So, just for starters, they are all oral options, which is fantastic, because the old regimen included injections, which nobody likes.  They have a few side effects, they are minor, they don’t stop people from completing the treatment in general, and they are very well tolerated.  That is very different to the historic picture of treatment with hepatitis C, where people had significant side effects with fatigue, psychological distress, depression, and psychosis, and things like that with interferon, and it was scary for people.  They are short courses of treatment, so, it’s 8 weeks on one of the regimens, and it’s 12 weeks on another one.  So, that is 2 months or 3 months of your life to clear chronic infections that cause a serious morbidity versus previously the treatments would go for 6 months to a year or longer.  Another golden thing is you need a little monitoring while on these treatments, they are considered safe, and greater than 95% cure rate, just phenomenal.  If we had these kind of treatment for multitudes of things, we will be rushing at them to use as treatment.  This is an amazing set of therapies that we have got available to us, and we can improve the quality of life of our patients by treating the hepatitis C, so everybody who has hepatitis C should be offered treatment for hepatitis B.  It is easy and effective.  So, we are going back to our ASHM decision-making tool.  What treatments are available for Tom?  We will look at section 4 and we come down, we see the table and we have two medications on that table.  And this is what they are.  We have glecaprevir and pibrentasvir, which is commercially known as Mavyret.  That regimen is three pills once a day.  You take them at the same time.  You take this medication for 8 weeks and you take it with food.  The second one on this table is sofosbuvir and velpatasvir, which commercially is known as Epclusa.  It is one pill a day for 12 weeks.  So, I am going to from here, use the names Mavyret and Epclusa because they are easier for me.  I have not got any affiliations with any drug company and even we have some sort of policy at our workplace where drug companies can’t come in.  Nonetheless, it is easier to say Mavyret and Epclusa.  So, Mavyret is three pills once a day 8 weeks with food and Epclusa is one tablet for 12 weeks.  Pretty awesome choice.  Okay.  So, the next question is, what side effects can Tom get?  (Long pause).  Excellent.  So, really, these medicines have side effects such as headache, nausea, and fatigue.  There are numbers that are similar to placebo and the majority of people don’t have any side effects, so you have done really well again with this prompt.  Okay.  Deciding which pangenotypic measurement to use.  I said it was the easiest thing, because it’s only two medicines, but then when they are both awesome, it’s also a little bit tricky.  I generally use the medications that a patient is already on, to see if they will interact with one or the other, but otherwise this is the story.  So, this is Mavyret, three tablets with food once a day, eight weeks of treatment, and it has drug interactions with statins, which is something we can stop for a short period of time.  It has interactions with ethinyl estradiol, which is an oral contraceptive pill combined, which is important in some situations, and you would prefer to put them on lock if you can of progesterone-based medications.  And you need to avoid Mavyret in decompensated cirrhosis, but as general practitioners or primary care physicians, we are not prescribing to that group of people as best as we _____ anyway to them because of this is an extremely good option, and it can be used in all levels of renal impairment, and that is a very exciting fact, and when that became available, that was a big selling point for this medication.  Now, similarities.  So, they are very similar, they are both pangenotypic, so they are awesome.  They both have a risk of reactivating hepatitis B, which we discussed, so we need to test for hepatitis B, and we need to not treat the person and send them to a specialist.  And, they have the similar level of minor side effects, headache, nausea, and fatigue.  And then this is the story with Epclusa.  It’s one tablet with or without food, it’s 12 weeks of treatment, and it has drug interactions also with some statins, and importantly, for this medication is acid suppression, which has to do with the absorption of the medication, so that is your PPIs and things like that and amiodarone.  This is another important drug interaction.  It can be used as medicine all levels of cirrhosis, but once again, this is both for patients _____ specialist, and now, I ____ recommendation for the management of hepatitis C consensus statement from June 2020 is letting us know that the US Food and Drug Administration has approved Epclusa for chronic kidney disease, including severe chronic kidney disease, and most people on dialysis.  So, that’s a bit of good news for Epclusa.  So, how do I choose between them?  Like I said, I will look at whether the medications interact with one or the other, but I give the choice to the patient generally.  I say, what would you prefer, three tablets a day for eight weeks or one tablet a day for 12 weeks.  And ____ where patients would choose different regimens.  A lot of people choose the shorter course because that’s exciting for them.  They also choose it because it can be cheaper with the co-payment.  However, some people do not like swallowing tablets, even though they can tolerate injecting drugs, and they will want one tablet a day.  In addition, the Mavyret has three tablets in each blister pack, seven in a box, so you have quite a big box for one week of treatment, and Epclusa has a month’s supply in a bottle.  So, people make different choices based on that.  However, most people prefer the Epclusa, and people who want to keep their treatment discrete, safe, or hidden, are those ones who will prefer that.  _____ will prefer one or the other, but I give the choice to the patients.  Okay.  So, which treatment measurement would you recommend for Tom?  Select the best answer.  They have given you the different options and A is 1 or 2, B is 1 or 3, and C is 2 or 3?  (Long Pause).  Awesome.  Yep.  So, the only wrong answer there was the glecaprevir and pibrentasvir, which is Mavyret, for 12 weeks, because Mavyret is an 8-week regimen.  So, the first answer is sofosbuvir-velpatasvir, which is Epclusa for 12 weeks, which is how long Epclusa takes, and glecaprevir and pibrentasvir, Mavyret, for eight weeks, and both of them are good options.  Okay.  So, this is looking at that table.  He is not a cirrhotic person.  If we use Epclusa, it would be for 12 weeks.  Assess for potential drug interactions.  So, this is what I was talking about.  This part of the job has been made easy for us as well, nothing is difficult.  The ASHM hepatitis C decision-making tool, if you look at it, when you are looking at the treatment section, and under the table with Epclusa and Mavyret, there is a check for drug-to-drug interactions, and there is a site, which you can see on the slide, that I have saved in my favourites on my browser again, and it comes up.  You put the medications that the patient is already on into the calculator, and then you choose the direct-acting antiviral that you would like, and the calculator is awesome, it prints out all the medications, and it has a traffic light system, it has a red colour over the medicines that are contraindicated and should not be covered medicines, and it has an amber colour and underneath there are the medicines that need additional monitoring or alteration of drug dosing or timing and then it has a green category, where the medicines don’t interact.  So, I essentially put in all the medicines that the patient is on, I tick both medications, I look at the calculator, I print it out, and I decide which one is going to be more doable, which one does not have any med contraindication and I look at the ones that need monitoring, can I stop the statin for two months, can I change the dosing of the PPI, or the timing of the PPI, and that’s how I do it, so that’s a brilliant brilliant website.  And I also print out the interactions and I scan it into the patient notes just to say that I have thought about it, and I tell the patient that every time you see a doctor you need to tell them you are on this medicine, and we need to talk about all the medicines they are on, including herbal and over-the-counter medicines.  They are on the calculator, and also illicit drugs are on the calculator.  So, it’s an incredible result.  So, are there any drug-drug interactions relevant for Tom?  No, Tom is not on any other medications, which is absolutely awesome, so we don’t have to do any hard work at all.  Okay.  So, here are some extra dots to consider.  Are there any consequences if Tom misses a few doses and what strategies can be recommended to Tom with support at your end?  We know as primary care physicians and general practitioners that it’s human to miss doses, and trial situations incorporate humans, and these things have been considered.  We have to recommend a 100% adherence, but when someone misses a dose, if it is on the same day, they can take a tablet within 18 hours when they were meant to take the tablet, but they shouldn’t double-dose the next day.  So, we have got to recommend a 100% adherence.  With respect to adherence, when we worry why would this person take the medicines, I find the easiest way to figure that out is to ask him, or say what can be a problem for you with this medication, what can be hard about taking this or remembering this, and they can often tell you and you can help them with that.  Sometimes, it’s for side effects, if you are seeing them when they are on therapy, or if you had booked an appointment to do that, but really it is not the end of the world if they miss a dose, these medicines are so good, they can handle that.  I have heard some horrific stories of people instead of taking three Mavyrets a day, taking three a week and still clearing it.  And I don’t think that should be advertised, but occasional missed doses are okay.  So, we need to involve and empower our patients in decisions about treatment and _____.  Strategies.  This is the same for every medication that a patient takes and we will be talking about this often for other diseases.  Pill boxes, linking the dosing time to a routine, to something they do every day that they are not going to forget, put a reminder there or the tablets there.  Any side-on medication, I put it near my coffee in my fridge because I never walk out of the house without a coffee, so something like that.  And you can help them with mobile phone alarm, marking calendars, which we still gauge, because they know more, I should have finished this medicine and what’s going on there.  Peer support workers.  They help with all of this and this is an incredible part of their role.  The last point was dosing with opiate substitution.  Obviously, that is a brilliant idea, because they would definitely get that medication.  So, the next thing we are going to do, so, we have decided we want to treat, we have checked our drug interactions, he hasn’t got any, the next thing is we are going to gain the specialist’s approval to treat.  So, it’s recommended that you seek at least for the first 10 patients that you prescribe for specialist approval and this part gives you two different options.  There is a REACH-C form, that’s an ASHM setup.  You get specialist approval within 24 hours and they evaluate the real-world outcomes with direct antiviral therapy.  This is also I believe on the ASHM, yeah it is, decision-making tool, there’s a link there, so you can save that in your favourites.  Another alternative is GESA, the Gastroenterological Society of Australia, they have an approval form that you can get approval with.  What I find is that it is not until you start prescribing that you really have questions, so this is the value of the specialists, they can answer those questions.  You won’t encounter these real-world difficulties until you encounter them and then that’s when you really learn, so I recommend getting specialist approval and using one of these setups.  As you know, I work in Brisbane, and I work for Metro Health Staff.  Metro Health Staff has an awesome setup, where you get your approval through the CNC and the liver specialist team at the PA Hospital, and they are extremely responsive and they will speak to you about any concerns you have got.  So, once again they are amazing people working on hepatitis C, there’s CNCs in every hospital that are more experienced than myself and can help me with all the worries that I have got, so reach out to them and ask your questions and learn from them.  Okay.  So, how do we obtain our PBS authority script?  We all know that.  We ring that number and we have to answer three questions.  So, we have to say how many weeks of treatment this person needs to undertake, which as you may remember is, Mavyret is 8 weeks and Epclusa is 12, so it’s fairly simple.  You have to say that the person makes the general statement and whether they have cirrhosis or no cirrhosis.  And remember that there’s a copayment for each individual script up to 60 for healthcare cardholders and 41 for those without a concession card, and scripts are dispensed monthly.  With the CGG for indigenous patients, it is free.  Okay.  So, hopefully, you will remember this, but when do you consult with or refer to a specialist?  These are the three Cs, cirrhosis, co-infection, and complex comorbidities, and then treatment-experienced people because they are worried that they may have a distance and that the smart doctors have to think about that.  In addition, they have put on this slide, extrahepatic manifestations, which I would only rarely refer to a specialist anyway, and acute hepatitis C is their _____.  Okay.  So, we are learning that these six steps are easy.  We know when to test, we are good at ruling out risks, it’s a blood-to-blood transmission, we know how to interpret the tests, as long as we do the tests, we know who we want to send to the specialist and the majority of people we can treat, and we know that there’s only two treatments and we can sort that out pretty easily.  So, then we are talking about monitoring.  So, this is another piece of good news, it feels blessedly easy.  When you initiate treatment and when you are diagnosing hepatitis C, you have your full blood counts, kidney and liver functions and hep C RNA, and they don’t really need any monitoring until 12 weeks after the end of treatment.  We are looking for sustained virological response at 12 weeks after the end of treatment, and we are doing LFTs and an HCV RNA.  We are checking that there is no more virus left in the patient’s bloods, and if we are seeing them in the interim, which hopefully we are, we are talking about adherence, side effects, and drug-drug interactions.  The bottom of that slide referred to interact receiving more close monitoring, which is true basically, as I said specialist’s condition may usually outline that.  When you become more experienced, you can talk to the specialist and definitely treat people with Child Pugh A cirrhosis, probably in primary practice, but you need that approval.  So, Tom commences on direct-acting antiviral treatment.  He is reviewed at week 4.  He had a slight headache that didn’t require any treatment and he didn’t miss any doses, which is fantastic, I don’t know this man.  Anyway, seen at 12 weeks at the end of treatment, he had normal liver function tests, which is fantastic, and he was hepatitis C RNA negative, SVR 12.  So, question 8.  Is Tom cured of hepatitis C?  (Long Pause).  Great work.  So, yes, SVR 12 is considered a cure.  So, that means that there is no RNA virus in his blood, he does not have this infection any longer.  He has been cured.  So, SVR 12 undetectable hep C RNA post treatment, he doesn’t need another SVR unless his risk of reinfection is high because he is an ongoing user, he should be tested yearly.  Note that hepatitis C antibody test remains positive after cure and it should not be repeated, so that I tell the patient that if you ever have a hepatitis C serology done or hepatitis C antibody test done, you will always be positive on the antibody test because your body has created an immune response to this virus and it never goes away.  It is the RNA test or the virus test that you need.  I try and speak to them since they understand there’s a difference, so that when they see another doctor and need another test that they get the correct test from the beginning.  So, importantly, virological cure does not protect against reinfection.  So, if you have had treatment and you had SVR 12 and it was negative and then you use again and you come across the same genotype of hepatitis C, it doesn’t protect against reinfection.  And treatment failure is on the converse, detectable HCV RNA 12 weeks post the treatment completed.  Okay.  So, what followup does Tom need, does he need any followup?  That’s question number 9.  (Long Pause).  Awesome.  So, he has been cleared of hepatitis C, has normal LFTs, he doesn’t need further followup, he is not an ongoing user.  I can see an argument for testing liver function tests again if he continues with the heavy drinking, however.  Okay.  We are now talking about determining post-treatment followup with no cirrhosis.  No cirrhosis, normal LFTs, do not require followup for hepatitis C.  They can move around as hepatitis C-free; however, they need ongoing monitoring if there is a potential risk of re-exposure.  So, people who inject drugs, HIV positive people, and men who have sex with men.  If Tom had abnormal LFTs and SVR 12, I wouldn’t be happy and thinking what else is going on with this man, what is contributing to the damage to his liver and I will be thinking of his other risk factors of alcoholic liver disease.  We know that he drank too much, that could be it, and does he have diabetes, does he have an autoimmune disease etc.  And then I will be considering a specialist review.  In Tom’s case, he doesn’t need any further followup.  So, determining post-treatment followup for advanced fibrosis and cirrhosis.  So, when a patient has been diagnosed with advanced fibrosis and cirrhosis, as I have said many times and I think it’s an important take-home message, it is a pre-cancerous state, the person needs routine followup two times a year six-monthly with ultrasounds abdo looking for hepatocellular carcinoma and AFPs.  In addition, as we know, sequelae of chronic liver disease in some patients with cirrhosis, is that patients can get an oesophageal varices, and that can be deadly.  So, we need to organise endoscopy at least three-yearly or as per the recommendations of the gastroenterologist.  And we need to organise a bone mineral density scan for osteoarthritis, so when I diagnose somebody with cirrhosis, I automatically organise an ultrasound and AFP and put in reminders in my software system for every six months to do this, and I tell them for the rest of your life you are going to do this, you have got a 1-2% risk of a liver cancer and if you want to get that if it does happen early, because we can take it out and it doesn’t affect you.  If you wait longer, even miss one, and you go to a yearly screening, the situation will be very different.  And then I would organise endoscopy and then I would organise a bone mineral density testing.  Okay.  So, and then you are also monitoring for progression of liver disease and contacting your hepatologist when you are worried about that.  Okay.  We have been through this.  Say, there’s another examination investigation that’s available privately in radiology practices called a shear wave and they get a METAVIR score, F3 or F4.  So, the F3 or F4 in that situation as well should be getting hepatocellular carcinoma surveillance.  And, so if you have got the scores which you are worried about getting this so or you are going to get this surveillance sorted out, but if you are thinking this person with the picture that you put together might have fibrosis, but they have diagnosed you to have a lower level of fibrosis, but they have got significant comorbidities such as diabetes or alcohol abuse, it’s also reasonable to institute closer surveillance for them.  And if the person’s AFP or ultrasound is abnormal, refer them to a specialist obviously, usually a multidisciplinary team for hepatocellular carcinoma, and they will discuss the ways that they want to deal with that.  Other management issues.  Tom is 80% of people.  Tom is the 80% of the easy medicine that we have _____.  There are treatment-experienced patients, there’s treatment failure, and there is pregnancy that we need to consider.  So, we would direct you to these statements, and they have a different genotype-specific regimen.  This is for the treatment-experienced people, so they may fail the one DAA, so you want to use different components in the next treatment, and that’s once again for the smart doctors to look out really.  So, then, hepatitis C treatment in pregnancy.  So, women of reproductive age with known hepatitis C infection should be counselled about the benefit of DAA therapy prior to pregnancy.  Of course, it will improve the health of the mother, but it eliminates that low risk of 5% risk of mother-to-child transmission.  And antiviral therapy is recommended usually before pregnancy because it is contraindicated in pregnancy.  There are no large-scale trials in the use of DAAs in pregnancy, but sadly if a child acquires hepatitis C from his/her mother, there is a 3-5% chance that it will become a chronic disease in them, so it’s actually less than the adult chronic rate, but it’s a sad legacy from the mother and we should be thinking to test these babies nine months after delivery.  They have their mother’s antibody still for six months and at nine months we can determine if they have this infection, and of course it is extremely important because then we would have a 20-year-old getting hepatocellular carcinoma, if we missed that.  Okay.  So, this is just making it clear, the use of DAA’s in pregnancy is contraindicated.  You need to screen for pregnancy pre-treatment and periodically during treatment.  I usually am very strong on recommending contraception, so you don’t want to do this when you are pregnant, leaving that till don’t fall pregnant, this is so worth it, _____ contraception for some reasons, and a lot of people don’t want it.  And you have to avoid therapy during pregnancy and lactation and recommend contraception during therapy and the washout period for DAA’s is four weeks.  Okay.  So, this is more information about vertical transmission, the overall rate is low, if I could point out again, but I think that’s not acceptable, and I would really rather that that woman didn’t pose a risk to her baby, and we can offer treatment.  This is increased risk in mothers with HIV and a higher HCV RNA levels and poses risk, and like I said, the mother-to-child infection rate that progresses to chronic hepatitis B is 3-5%.  Okay.  Something we are expert at, maintaining liver wellness after hepatitis C cure.  We are holistic practitioners, so we are _____ harm-minimisation strategies.  We are talking about how not to get hepatitis C again.  We have talked about needle and syringe program, we are talking about Queensland Injecting Health Network, which we can use hepatitis queries, and we can use ASHM, and want to give them information about this disease and how not to get it again.  We want to recommend not taking alcohol at unhealthy levels, and if there is any liver fibrosis or cirrhosis, you want to abstain from alcohol, and with obesity, I think this is the major accelerator that our society is suffering with liver disease and it is common having hepatocellular liver disease.  So, once again, the energy in, energy out, lifestyle modifications, diet and exercise are a part of the complication about liver wellness.  So, in summary, I am trying to remind you that I want you to do this, you can do this, it is really easy, it is good medicine, it saves people’s lives, it’s going to make you feel good when you cure someone with hepatitis C.  So, you are going to diagnose a patient with hepatitis C, if they have hepatitis C RNA positive and antibody positive.  So, they need that RNA and know they have got that virus.  Then we are going to asses them to see if they need to be seen by a specialist or if they are the majority and can be seen by a primary practitioner.  You are going to test them with a blood test, a full blood count, kidney and liver functions, a HIV, a hep B, a hepatitis A serology, and an INR.  Personally, I also do syphilis and a HbA1c, but mandatory, we need to do these things that are on the decision-making tool for ASHM.  We need to know if this person has had treatment before, because this is somebody who will likely need to see a specialist, and we want to assess for cirrhosis, because it’s a pre-cancerous state, and we should be sending those patients to a specialist.  We want to check for drug-to-drug interactions, which is an awesome tool, it tells you what to do, it’s really not rocket science, and then we are going to assess for adherence and we are going to support our patients, which is something we do all the time.  Okay.  Then, we are going to choose between two awesome therapies that cure hepatitis C.  We are going to write our authority script.  Actually, before we do that, we are going to get our specialist approval, if we are not experienced prescribers.  We have got the REACH-C form, which is on the decision-making tool, or we could use the DHM mobile consultation form or depending on your health service, you could use your local hospital, then you are going to write the authority script and you are going to counsel the patient about the minimal minor short-term side effects that they might experience, and you can organise followup.  Importantly, you are going to a blood test or try to do a blood test 12 weeks after the end of treatment, that can be very difficult to get people back for, and followup is recommended.  Okay.  So, every step of that I believe, primary care physicians will find easy, and I encourage you to getting there and prescribe treatment for your patients that are at risk and have hepatitis C.  Okay.  I think it’s time for questions.  Does anybody have any?
Oops.  Thanks so much, Jodi.  I have got one question for you.  If I was to be working in Western Queensland, where would I find an opportunity to organise a FibroScan?
Ha, ha.  I don’t know the resources that are available in Western Queensland.  I am trying to think ….  you could call Hepatitis Queensland.  They have programs that rent out the FibroScan remotely, that’s how we have access to the FibroScan, and they go to specific communities that can’t afford or don’t have a FibroScan.  They are an incredible organisation, and if they can’t hopefully tell you where that resource might be, I am sure they can direct you to one.  Yeah.
Thank you so much, Jodi.  We don’t seem to have any other questions.
So, I am afraid that’s all we have time for this evening.  On behalf of webinar partner, ASHM, thank you very much to everyone for attending, and we hope you enjoyed the webinar.  Also, a big thank you to our presenter, Jodi, for sharing her knowledge and time this evening.  We hope to see you all for the last webinar of this ASHM series, Introduction to sexual and reproductive health, on Thursday, 29 July 2021.  Okay.
Thank you and have a good night.
All the very best.  Thank you so much.
And keep safe in Sydney.

Other RACGP online events

Originally recorded:

14 July 2021

The Australian Government has endorsed the World Health Organisation targets of 90% of people living with chronic HCV infection to be diagnosed, with 80% treatment coverage by 2030. Since the introduction of interferon-free direct acting antiviral (DAA) therapy on the Pharmaceutical Benefits Scheme in March 2016, an estimated 70, 260 people have been treated in Australia.

Australia is a world leader in progressing the elimination of HCV as a public health threat by 2030. A key feature of the Australian HCV treatment landscape since the DAA program commenced has been the involvement of non-specialists in prescribing.

Join Dr Jodi Stevenson for this free interactive webinar which provides general practitioners in primary and related care settings with an overview of the hepatitis C management in primary care settings in Qld including case finding, testing, patient assessment and treatment.

Learning outcomes

  1. Identify priority populations for HCV screening
  2. Order and interpret tests appropriately to diagnose chronic HCV infection
  3. Describe the recommended pre-treatment assessment
  4. Demonstrate understanding of antiviral therapy for treatment of HCV
  5. Communicate confidently with patients about HCV
This event attracts 3 CPD points

This event attracts 3 CPD points

This event is part of ASHM Series. Events in this series are:


Dr Michael Burke

Michael Burke works in Western Sydney GP. He is committed to improving health equity, treatment and care for people with blood borne viruses including HIV. He works in whole person medicine framework, and enjoys getting to know his patients, reading, writing, and birdwatching.


Dr Jodi Stevenson
General Practitioner, Inala Health Service

Dr Jodi Stevenson is a GP who has worked in Indigenous Health for the last 20 years. She has been working at Inala Indigenous Health in Brisbane since 2014. As liver disease and Hepatitis C is over represented in this community, she has pursued a specialist interest in prescribing in this area.



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