AUSTRALIA is currently enjoying international acclaim for its revolutionary response to hepatitis C. And rightly so. We are the only country in the world to offer universal access to new, highly effective cures, and our willingness to embrace the latest research and build evidence-based responses founded on multisector collaboration are the envy of the world. A relatively small number of clinicians is providing the bulk of curative treatment and care to people with hepatitis C.
Yet despite these successes, stigma and discrimination by the health workforce threaten to prevent us from optimising these achievements.
Stigma and discrimination in health can take many forms, including denial of care, inferior care, unjust barriers to service provision and lack of respect. The impact is considerable, not just for the individual involved, but to the efforts to reduce the disease prevalence.
Unless stigma towards hepatitis C is understood and addressed, we will not maintain the current rates of treatment uptake, and our much lauded progress towards disease elimination will stall.
New national reports (here and here), released at the 10th Australasian Viral Hepatitis Conference, made clear how Australians who acquired hepatitis C through the use of non-sterile injecting equipment found that experiencing discrimination from health workers lessened their likelihood of engaging in future treatment.
General practitioners have a vital role to play here, starting by remembering that all the evidence makes it clear that how a person contracted hepatitis C is irrelevant to their treatment outcome.
Understanding transmission routes and associated behaviour is also important.
Hepatitis C is highly stigmatised because of the association with injection drug use, and patients may fear previous or current injection drug use being disclosed or assumed. Hepatitis C can also be transmitted through tattooing and other skin penetration.
While highly associated with injection drug use in Australia, hepatitis C is also common in a number of culturally and linguistically diverse groups where transmission has been iatrogenic. Hepatitis C is also sexually transmissible, particularly among men who have sex with men and HIV positive men, but remains very rarely sexually transmitted heterosexually.
GPs will also be central to efforts to test and bring in to care the estimated 41 000 Australians still undiagnosed with the disease (page 19).
Simple audit software can identify patients who have had a positive hepatitis C virus (HCV) polymerase chain reaction (PCR) test. It can also enable clinicians to identify patients with positive HCV antibody tests but no PCR test. At the conference, we heard how almost 20% of patients being assessed for treatment in one service had not had a previous PCR test. Many of these patients had cleared the virus.
Such a patient review would allow people who have been partially diagnosed to get a true understanding of whether their hepatitis C status is cleared or chronic, and for those with confirmed chronic infection to commence treatment. A number of clinicians have called for reminders to accompany hepatitis C antibody positive pathology results. This is something which we, at the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) will pursue with laboratories.
These efforts to test and treat must be accompanied by enhanced harm reduction strategies, such as needle and syringe programs and access to opioid substitution therapy (OST), while barriers to accessing clean injecting equipment must be removed. While the cost of OST is covered, there are different dispensing arrangements in place which can make maintenance therapy costly – as much as $7 or more per day. Some people may be unable to cover the cost of dispensing on a given day, and importantly, it makes it cheaper and easier to secure prescription opioids than OST.
These barriers to care, stemming from stigma and discrimination must end.
The ASHM has initiated a project – supported by a number of colleges, professional societies and health service associations – to identify, document and address destructive and alienating policies and attitudes. But it will require collaboration – including support from primary care – if these are to be lasting and for Australia to reach the ultimate goal: the disease elimination by 2026. For more information about the ASHM project email SandDproject@ashm.org.au.
Levinia Crooks is Chief Executive Officer of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. She is Adjunct Associate Professor of Public Health and Human Biosciences at La Trobe University, and at the University of NSW’s Centre for Social Research in Health.
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