'Sussing that doctor out.' Experiences and perspectives of people affected by hepatitis C regarding engagement with private general practitioners in South Australia: a qualitative study

The cascade of care for hepatitis C in Victoria, Australia: a data linkage cohort study

BACKGROUND

Highly effective hepatitis C therapies are available in Australia. However, people living with hepatitis C face various barriers to accessing care and treatment.

AIMS

To identify gaps in the cascade of care for hepatitis C and generate estimates of the number living with untreated infection according to population group, using a representative longitudinal study population.

METHODS

We linked hepatitis C notification data from Victoria to national pathology, prescribing and death registry data. We assessed receipt of key clinical services in a large cohort who tested positive for hepatitis C from 1 January 2000 to 31 December 2016, with follow-up to 30 June 2018. We estimated the number still living with hepatitis C, adjusting for spontaneous clearance and mortality.

RESULTS

The cohort comprised 45 391 people positive for hepatitis C. Of these, 13 346 (29%) received treatment and an estimated 28% (95% confidence interval (CI): 26-30%) were still living with chronic infection at 30 June 2018, with the remainder still living following spontaneous clearance (30%, 95% CI: 29-32%) or having died (12%, 95% CI: 12-12%). Half (50%) of those still living with hepatitis C were born from 1965 to 1980, and 74% first tested positive before 2011.

CONCLUSIONS

Despite an enabling policy environment and subsidised therapy, many people in this cohort were not treated. Increased measures may be needed to engage people in care, including those who acquired hepatitis C more than 10 years ago.

General practitioners' perceptions of the provision of direct-acting antivirals for hepatitis C within Australian private general practice: an exploratory qualitative study

BACKGROUND

There is a need to increase the involvement of Australian general practitioners (GPs) working in private practice to realise the potential of direct-acting antiviral (DAA) treatments for people with the hepatitis C virus.

METHODS

Semi-structured interviews were conducted in 2018 with seven GPs and two practice nurses working in private general practice to elicit the experiences and perceptions of their involvement in providing care for patients with hepatitis C virus in this setting. The interviews were recorded, transcribed and thematically analysed to inform interventions to maximise the provision of DAA in private general practice.

RESULTS

Participants described individual GPs purposely limiting their scope of clinical practice (SOCP) and expressed an expectation that DAA provision would not be included in all GP's SOCP. When GPs delineate their SOCP, their confidence to competently provide quality health care to their patients and GPs' professional special interests are important considerations.

CONCLUSION

Providing DAA training, skill development, support and resources to GPs is necessary, but may not ensure that individual private GPs will provide this care. Where GPs do not include DAA in their SOCP, care pathways need to be developed for patients who will benefit from DAA, including GP-to-GP referral. These findings may be applicable to other areas of unmet need that rely on GPs including provision of care in their SOCP.

Perceptions of hepatitis C treatment and reinfection risk among HIV-positive men who have sex with men and engage in high risk behaviours for hepatitis C transmission: The CEASE qualitative study

BACKGROUND

Globally, treatment uptake for hepatitis C virus (HCV) infection among HIV-HCV coinfected men who have sex with men (MSM) has substantially increased since the advent of interferon-free direct-acting antivirals (DAA). However, HIV-positive MSM who engage in high risk behaviours are at an increased risk of HCV reinfection post-treatment. The aim of this study was to investigate perceptions of HCV diagnosis, treatment and reinfection risk among HCV-HIV coinfected MSM who engage in drug use and/or high risk sexual behavior in Sydney, Australia.

METHODS

Participants were recruited from the Control and Elimination within AuStralia of HEpatitis C from people living with HIV (CEASE) cohort (n=402) who reported engaging in drug use and/or high risk sexual behavior for transmission of HCV infection. Participants were interviewed about their perceptions of HCV diagnosis, treatment, and reinfection risk. Interview data were transcribed, coded, and analyzed thematically.

RESULTS

Of 33 participants interviewed (mean age 49 years), many participants were 'shocked' by their HCV diagnosis. Participants who believed they acquired HCV infection through sexual exposure felt it was important that their healthcare practitioner agreed with their perspective to mitigate stigmatizing experiences. Overall, participants expressed high satisfaction with their treatment experience due to long-standing therapeutic relationships with their HIV physician. Many participants expressed knowledge of how to prevent HCV reinfection from injection drug use, yet other than condom usage, most were unsure how to reduce high risk sexual activity with such discussions occurring less frequently with healthcare practitioners.

CONCLUSION

Findings indicate that MSM who engage in drug use and high risk sexual activity would benefit from additional education on reducing reinfection risk through sexual activity and services to reduce substance use, if requested.

Qualitative analysis of the barriers and facilitators influencing uptake of direct-acting antiviral therapy for hepatitis C in a primary healthcare environment

Historical interferon and ribavirin therapies for hepatitis C virus have been replaced by modern treatments with improved efficacy and tolerability. Despite the availability of direct-acting antiviral therapy, evidence demonstrates poor uptake in Australia. Presently, the barriers and facilitators influencing uptake of direct-acting antiviral therapy are not fully understood, especially in a primary healthcare environment. Our study aimed to discover methods of improving uptake of treatment in the community. We conducted 15 semi-structured, face-to-face interviews in a metropolitan, primary healthcare clinic in Australia. Interviews were recorded, transcribed and subsequently analysed using thematic content analysis. We identified patient-related and healthcare system-related barriers and facilitators to commencing treatment. This included established themes from current literature, and novel themes unique to direct-acting antiviral therapy and primary care. Overall, our study reinforces the importance of public health campaigns to promote community awareness and emphasises the concomitant role of mental health in fostering treatment uptake. Informed by our findings, we suggest further research on an integrated model of care, focused on the domains of disease awareness, patient engagement and treatment adherence. Hence, a community-oriented approach, driven by primary healthcare, ultimately underpins a successful public strategy to improve outcomes for patients affected by hepatitis C.

Personal, provider and system level barriers and enablers for hepatitis C treatment in the era of direct-acting antivirals: Experiences of patients who inject drugs accessing treatment in general practice settings in Australia

Direct acting antiviral (DAA) treatment has made the elimination of hepatitis C virus (HCV) a realisable global public health goal and people who inject drugs are a key target population. This study investigates barriers and enablers to DAA treatment of HCV in general practice settings in Australia, from the patient perspective. Semi-structured interviews were conducted with 28 patients; of these patients, seventeen participants were currently on opioid agonist therapy, and four were currently injecting drugs. Thematic data analysis was undertaken and a personal, provider and systems framework was used to describe the barriers and enablers to DAA treatment. Results suggest a range of initiatives are required to support the uptake of DAA in general practice settings. These include the provision of formalised peer information and support, and increasing the accessibility of blood tests and liver assessment on-site. Further, there remains a need to address stigma and discrimination affecting people who inject drugs in community healthcare settings.

Enablers and barriers for the provision of community-based HCV treatment: A case study of a real-world practice

BACKGROUND

Although the availability of fully funded direct-acting antivirals (DAAs) and the eligibility of primary care providers (PCPs) to provide hepatitis C virus (HCV) have removed barriers related to access to hospital-based HCV treatment in Australia, there are still many barriers to the provision of HCV treatment in community settings. There is a lack of knowledge regarding the barriers to, and enablers of HCV treatment in community settings in Australia. This study aimed to identify barriers and enablers for the provision of community-based HCV treatment.

METHODS

This study was a part of a mixed-method case study of the Cure-It programme. The programme was studied to better understand barriers and enablers experienced by stakeholders of such programmes. The programme is delivered through the Prince Charles Hospital in Brisbane, Australia, and aimed to improve access to HCV treatment in community settings. Data were collected using semi-structured interviews with 12 healthcare providers and nine patients between July and December 2018. Purposive sampling was used to ensure diverse views were captured. The interview transcripts were analysed using inductive thematic analysis.

RESULTS

Ease of access to specialist support, easy and high value treatment, co-location with or providing other services and motivated patients enabled PCPs to be engaged with the Cure-It programme. Several interconnected factors related to patients' characteristics and health system acted synergistically to enable patients to initiate and complete treatment. These included a desire to remove HCV as a source of shame, having children, awareness of HCV consequences, access to DAAs for free, ease of access to general practices and drug and alcohol services, and access to a safe and enabling environment. The identified barriers were interconnected at the levels of patients, PCPs and primary care systems and acted synergistically to prevent patients and PCPs from becoming engaged with HCV treatment. PCPs' related barriers included a lack of knowledge, their perception of HCV as a specialist area and of patients with HCV as 'hard to manage' patients along with the practice preferences and priorities. Patients' related barriers included their socioeconomic characteristics, internalized stigma, perception of not being sick and lack of knowledge. Additionally, the unavailability of support for patients and existence of stigma in primary health care, along with poor communication between the hospital and primary care system, and the unavailability of FibroScan^® in primary care discouraged PCPs and patients engagement specifically with the provision of community-based HCV treatment.

CONCLUSION

Various strategies are needed to improve PCPs and patients' knowledge and awareness of HCV treatment. Training and support for PCPs need to be easy to access and should cover both clinical and social aspect of HCV. Connecting PCPs to other related services may improve PCPs' and patients' engagement with HCV treatment.

Framework for community-based models for treating hepatitis C virus

Objective Although community-based models for treating hepatitis C virus (HCV) are widely recognised for reaching more people who require treatment, little is known about their organisational and operational elements. This study aimed to address this gap and develop a framework for designing, implementing and evaluating community-based models for treating HCV. Methods This study was a systematic review in which 17 databases were searched for published and unpublished studies. The final search of databases was performed in September 2017. A qualitative inductive thematic approach was used to extract and categorise organisational and operational elements of community-based models for treating HCV. Results Data analysis yielded 13 organisational and operational elements that were categorised into three domains: support for patients, support for healthcare providers and service delivery facilitation. In the support for patients domain, support was categorised into four elements: peer support, psychological assessment and support, social assessment and support and adherence support. In the support for healthcare providers domain, the elements included the provision of educational opportunities for HCV care providers, specialist mentoring, decision making support and rewarding and recognition for HCV care providers. Finally, the service delivery facilitation domain included seven elements that target service-level enablers for community-based HCV treatment, including essential infrastructure, policy implementation and collocation and collaboration with other related services. Conclusion This framework for understanding the components of models of community-based HCV treatment may be used as a guide for designing, implementing and evaluating models of care in support of HCV elimination. HCV care providers and patients need to be supported to improve their engagement with the provision of community-based treatment. In addition, evidence-based strategies to facilitate service delivery need to be included. What is known about the topic? Community-based models for treating HCV are widely recognised as having the advantage of reaching more people who require treatment. These types of models aim to remove barriers related to accessibility and acceptability associated with tertiary centre-based HCV treatment. What does this paper add? Community-based models for treating HCV use various organisational and operational elements to improve the accessibility, effectiveness and acceptability of these services. The elements we identified target three main domains: support for patients with HCV, support for HCV care providers and service delivery facilitation. The importance of these organisational and operational elements designed to improve health and health services outcomes of community-based models for treating HCV is strongly influenced by context, and dependent on both the setting and target population. What are the implications for practitioners? Health policy makers and practitioners need to consider a patient’s psychosocial and economic status and provide support when needed. To successfully deliver HCV treatment in community settings, HCV care providers need to be trained and supported, and need to establish linkages, collaborations or colocations with other related services.

The distribution and socioeconomic burden of Hepatitis C virus in South Australia: a cross-sectional study 2010-2016

BACKGROUND

Hepatitis C virus infection (HCV) is a communicable disease of increasing global importance with 1.75 million new infections and 400,000 related deaths annually. Until recently, treatment options have had low uptake and most infected people remain untreated. New Direct Acting Antiviral medications can clear the virus in around 95% of cases, with few side-effects. These medications are restricted in most countries but freely accessible in Australia, yet most people still remain untreated. This study applies a cross-sectional research design to investigate the socio-spatial distribution of HCV in South Australia, to identify vulnerable populations, and examine epidemiological factors to potentially inform future targeted strategies for improved treatment uptake.

METHOD

HCV surveillance data were sourced from South Australia's Communicable Diseases Control Branch and socio-economic population data from the Australian Bureau of Statistics from January 2010 to December 2016 inclusive. HCV cases were spatially mapped at postcode level. Multivariate logistic regression identified independent predictors of demographic risks for HCV notification and notification source.

RESULTS

HCV notifications (n = 3356) were seven times more likely to be from people residing in the poorest areas with high rates of non-employment (75%; n = 1876) and injecting drug use (74%; n = 1862) reported. Notifications among Aboriginal and Torres Strait Islander people were around six times that of non-Indigenous people. HCV notifications negatively correlated (Spearman's rho - 0.426; p < 0.001) with socio-economic status (residential postcode socio-economic resources Index). History of imprisonment independently predicted HCV diagnoses in lesser economically-resourced areas (RR1.5; p < 0.001). Independent predictors of diagnosis elsewhere than in general practices were non-employment (RR 4.6; p = 0.028), being male (RR 2.5; p < 0.001), and younger than mean age at diagnosis (RR 2.1; p = 0.006).

CONCLUSIONS

Most people diagnosed with HCV were from marginalised sub-populations. Given general practitioners are pivotal to providing effective HCV treatment for many people in Australia a most concerning finding was that non-employed people were statistically less likely to be diagnosed by general practitioners. These findings highlight a need for further action aimed at improving healthcare access and treatment uptake to help reduce the burden of HCV for marginalised people, and progress the vision of eliminating HCV as a major public health threat.

Elements of community-based models for treating hepatitis C virus in supporting HCV elimination in Australia: A Delphi study

BACKGROUND

A key to achieving the goal of hepatitis C virus (HCV) elimination is the provision of its treatment in community settings. This study aimed to identify the important organisational and operational elements of community-based models for treating HCV and their feasibility in the Australian context.

METHODS

A Delphi study was conducted with 33 experts from Australia. The questionnaire included 13 elements drawn from the literature. Participants rated each element on a five-point Likert scale for importance and feasibility and suggested additional elements. Consensus was identified when the sum of categories 1 and 2 or 4 and 5 of the five-point Likert scale reached greater than or equal to 70%.

RESULTS

Eight elements reached consensus in regard to importance including "Safe and enabling environment," "Training and support for healthcare providers," "Open referral policy," "Linkage with or providing outreach services," "Person-centred approach," "On-site screening and assessment," "Linkage or co-location with harm reduction services," and "Linkage or co-location with drug and alcohol services." At least 65% of participants agreed implementing elements of open referral policy, Training and support for healthcare providers, and Person-centred approach are usually or always/very feasible. For the other five elements, this was agreed to by a range of 15.2%-57.6% of participants.

CONCLUSION

Successful community-based models for treating HCV in Australia are dependent on the integration and coordination of care and the support provided for both patients and healthcare providers. Substantial work is required across policy and health service planning to integrate these highly rated elements into Australian primary health care.