By Gideon Warhaft
New direct-acting antiviral treatments for hepatitis C are a game-changer. What part can NSPs play in the roll-out? And is complacency now likely to become a big issue?
It was no surprise only a few thousand people a year used to sign up for the tough regime of treating hepatitis C. Notorious for harrowing side-effects including depression, weight- and hair-loss, and occasional psychosis, the treatments combining interferon and ribavirin took up to 12 gruelling months to complete.
For the approximately 240,000 Australians living with the virus, the therapy also involved frequent trips to hospitals and specialist clinics – and there was a good chance of the treatment failing, anyway.
The outlook has changed dramatically. Since March 2016 new direct-acting antiviral (DAA) hepatitis C treatments have been listed on the Pharmaceutical Benefits Scheme (PBS), making these previously prohibitively expensive treatments available to everybody.
Professor Alex Thompson, director of gastroenterology at St Vincent’s Hospital in Melbourne, says the new DAA drugs are a revolution in hepatitis C treatment. “It’s fair to say that this is one of the most dramatic new medical interventions of the last decade or two. Previously we were treating a very small fraction of the hepatitis C population, where we were chasing our tail and could never use a treatment as prevention strategy,” Professor Thompson says.
“Now we are going to be very aggressive, treat everybody, use treatment as prevention to decrease prevalence, and really focus on the elimination of hepatitis C transmission in Australia over the next decade.”
So how do the new drugs compare with the old combination treatments? “For a start, they are interferon-free, so there are no injections, only between one and two tablets a day,” Professor Thompson says.
“There’s no restriction [to qualify for treatment] – that you’ve got to have bad liver disease or some complication of hepatitis C. They’re available for everybody.”
With a success rate of between 90-95 per cent (averaged out over the different genotypes of the virus) and a treatment period of only eight to 12 weeks for most people (24 weeks for a minority of people with cirrhosis), treatment is now an attractive and viable option for almost everybody living with the disease.
Perhaps the biggest benefits of the new treatments are the near-absent side-effects. Ms Niki Parry, who runs the Pharmacotherapy Support Program at QuIHN, a non-government drug and alcohol organisation in Queensland, says: “Pretty much all of the people who have done the treatment that I’ve spoken with have experienced almost zero side-effects. The most I hear about is the
occasional headache or dizziness. But absolutely minimal.”
Ms Parry says there are few reasons to avoid treatment. “Even people who are using [illicit drugs] quite a lot – we’ve supported a lot of homeless people through it, a lot of people with quite complex mental-health issues. So it’s opened the door for people who may not have been suitable or eligible for the old treatment.”
The Federal Government has negotiated a deal with the drugs’ manufacturers allowing almost unlimited patient access to the treatments. “In every other jurisdiction in the world there are effective restrictions on the number of people who can be treated,” Professor Thompson says. “The Australian Government has negotiated a cap whereby it guarantees that X amount of money will be spent per year on hepatitis C treatment, regardless of how many people we treat. So we have a real incentive to treat as many people as we can. The more we treat, effectively the cheaper it gets. And we’re not going to run out of treatment. This is an important message: people shouldn’t think that treatment’s going to be whisked away in the future.”
As well as being a game-changer for individuals living with hepatitis C, the new treatments allow for strategies to reduce the pool of the virus among people who inject drugs, perhaps effectively eliminating its presence altogether. To achieve this, there is a vital role for NSPs to both promote and facilitate the treatment to their clients.
This includes bringing treatment services into NSP settings, something that wasn’t possible with the older, more clinically intensive treatments.
Professor Carla Treloar, director of the Centre for Social Research in Health at the University of New South Wales, says NSPs have a key role in helping to make treatment equally available to all people.
But she says fear and mistrust of services remain. “That’s not going to go away just because the drugs are really good and everybody can theoretically get them.”
QuHIN is among a handful of organisations offering hepatitis C treatment through their NSP. Their Treatment In an Injecting Drug Environment (TIDE) program operates in Brisbane, the Gold Coast and Sunshine Coast, and Townsville area.
“Basically we use the NSP as a way to engage people around their hepatitis C: a bit of peer support, a bit of awareness and education about hepatitis C,” Ms Parry says. “That wrap-around support, not having to go anywhere else, being able to get all their hep C needs met under the one roof and it not being a huge hassle like it can be at the public clinic. People can come in, catch up with the harm-reduction worker or the hep C treatment worker, anytime they’re in. So it’s not ‘we’ll see you in three months’; it’s ‘come in any time’.”
Professor Thompson also says NSPs are vital for the wider hepatitis C reduction strategy. “We know that if we can treat people who are injecting and are at high risk of transmission then at a public-health level we’re making a much bigger impact on the prevalence of hep C in the country. It’s a big opportunity to work with NSPs over the next five to 10 years to really make big inroads into hepatitis C in Australia.”
The first steps towards treatment typically involve testing for hepatitis C and ascertaining liver damage using a FibroScan or abdominal ultrasound. “A client would see one of the harm-reduction workers to do an initial screening: around their drug use, around their health, around their social supports,” Ms Parry says. “From there we give them some information, we explain the project, and then the next step is to link them in with our medical team to get testing.”
Of course, treating people who currently inject drugs doesn’t prevent them from being re-infected once treatment has been completed. “There’s a risk of that,” Professor Thompson says.
“We’ve certainly seen this in other diseases. But the PBS doesn’t prevent us from re-treating. The basic strategy is that as the pool of treated people gets larger, the risk of reinfection is reduced.
“We want to be targeting high-risk people to interrupt transmission, so we expect to see some re-infections – the cost of re-infection is not an issue because we can just re-treat them. So if we’re not seeing re-infections, we’re not treating the right populations in terms of decreasing that pool, decreasing transmission.”
There is also the threat that such successful treatments might cause complacency within NSPs or among policy-makers who support them.
“It is a danger because people love this idea of the silver bullet, the magic cure-all,” Professor Treloar says. “So much money will have been spent on these new medicines, I think that we need to inoculate ourselves against the idea that NSPs become far less important. Because NSPs do so many things – blood-borne viruses is obviously a key thing but there are many others essential for the health of people who may be very marginalised and disadvantaged in our community.
“The theme in HIV is that you can never assume the job is done. The fact that HIV is low now and has been for a while, that’s because NSPs have been working so well. If you de-invest from that, what might happen? The same remains for hepatitis C.”
Hepatitis C treatments: what NSPs can do
NSP workers can have a huge impact on hepatitis C rates among people who inject drugs.
According to the Kirby Institute’s Annual Surveillance Report on HIV, viral hepatitis and sexually transmissible infections in Australia (2012), hepatitis C prevalence among people attending needle and syringe programs was at high levels in 2002–2011. It found hepatitis C prevalence in 2011 was 52 per cent among men and 54 per cent among women.
• Prevention: NSPs are the principal hepatitis C prevention tool in Australia, according to the Fourth National Hepatitis C Strategy 2014-2017. NSP workers provide sterile injecting equipment and information about harm minimisation.
• Referral: They can offer pathways to medical care, counselling and other services.
• Education: NSP workers can let clients know about the new hepatitis C treatments. They can discuss high rates of success at clearing the virus, the relatively short treatment periods and the low incidence of side-effects.
• Reducing stigma: Talking with clients in a non-judgmental way, NSP workers can help reduce feelings of shame around hepatitis C infection.
• Peer support: Peers are credible, trusted sources of information. They can connect with hard-to-reach groups to share prevention messages and education.