Hepatitis C models of care: approaches to elimination

Abstract

Hepatitis C direct-acting antivirals (DAAs) have an efficacy of 95% or greater, with pangenotypic options. Many regions in Canada have recently abolished the need to demonstrate fibrosis before treatment with DAAs, and several combination therapies are available under public and private insurance coverage. As a result, efforts to increase treatment are largely focused on engaging specific populations and providers. With minimal side effects and decreased need for monitoring, hepatitis C screening, linkage, and treatment can largely be done in a single setting. In this article, we highlight both Canadian and international examples of the specialist's ongoing role and discuss the task shifting of hepatitis C treatment to primary care; specialized community clinics; and mental health, corrections, addictions, and opioid substitution therapy settings. Although specialists continue to support most models of care described in the literature, we highlight the potential for non-specialist care in working toward the elimination of hepatitis C in Canada.

The trouble with normalisation: Transformations to hepatitis C health care and stigma in an era of viral elimination

“…As we noted above, dramatic improvements to treatment and enhancements to treatment uptake-including the dispersal and normalisation of hepatitis C care-have been widely greeted as positive developments enabling improvements to the health and wellbeing of affected communities and progress towards hepatitis C elimination. To achieve elimination, research on hepatitis C models of care increasingly support a reduced emphasis on specialist providers and an increase in on-site services where testing can lead directly to treatment initiation (e.g., Biondi & Feld, 2020). This includes both the normalisation of hepatitis C care in mainstream, primary and preventative health-care settings (Knight & Ti, 2019) and more exceptionalist kinds of approaches-for example, engaging specific community providers and peers (e.g., community health services for people that use drugs) (Biondi & Feld, 2020).…”

“…To achieve elimination, research on hepatitis C models of care increasingly support a reduced emphasis on specialist providers and an increase in on-site services where testing can lead directly to treatment initiation (e.g., Biondi & Feld, 2020). This includes both the normalisation of hepatitis C care in mainstream, primary and preventative health-care settings (Knight & Ti, 2019) and more exceptionalist kinds of approaches-for example, engaging specific community providers and peers (e.g., community health services for people that use drugs) (Biondi & Feld, 2020). Globally, DAA implementation strategies and technologies are geared towards increased efficiencies and enhancements to diagnosis, linkage to care, monitoring and treatment.…”

“…A blood-borne virus commonly transmitted through injection practices, hepatitis C can cause both acute and chronic symptoms ranging in severity from mild fatigue to chronic liver inflammation, cirrhosis and liver disease (World Health Organization, 2021). Previously, hepatitis C was treated with a combination of pegylated interferon and ribavirin; however, these treatments had a low average cure rate of just 40% and often had debilitating side-effects (Biondi & Feld, 2020). The administration of these 'combination-era' treatments required intensive monitoring, highly qualified staff and models of care that were 'necessarily arduous and comprehensive' (Biondi & Feld, 2020, p. 165).…”

Prescribing trends in direct-acting antivirals for the treatment of hepatitis C in Ontario, Canada

“…If Ontario and other jurisdictions are to eliminate HCV, system-level changes are still required. HCV treatment guidelines and elimination strategies call for expanding the range of who delivers testing and for community-based models of care (16). In March 2020, the limited use criteria were further expanded to allow for a broader prescriber base for DAAs that includes nurse practitioners.…”

Nurse practitioners as primary care site champions for the screening and treatment of hepatitis C virus

“…Historically, HCV treatment has been complex, lengthy, with extensive side effects, and with cure rates often of only ;40-50% (Fried et al, 2002;Manns et al, 2001). Initiating patients on therapy was labor intensive and required multidisciplinary teams with specialist oversight (reviewed by (Biondi & Feld, 2019)). Newer all-oral direct-acting antivirals (DAAs) have cure rates of 95-99%, with minimal side effects and are 8-12 weeks in duration (Fierer & Wyles, 2020).…”