GPs ‘underutilised’ for hepatitis B care

For the more than 200,000 Australians living with chronic hepatitis B, only small numbers of those are accessing treatment.
 
And to help increase these numbers, experts say more care can be moved into the primary care setting, including expanding prescribing specific medications for hepatitis.
 
However, there are restrictions around prescribing medications for hepatitis B and C treatment due to their classification as S100 ‘highly specialised drugs’, and GPs currently need to undergo additional training to become accredited S100 prescribers to provide quality care within primary care settings.
 
Under its endorsement and recommendations on the Federal Government’s draft Hepatitis B strategy 2023–30, the RACGP is calling for the removal of these additional training requirements for GPs, provided they continue to access clinical guidelines and HealthPathways.
 
The College is proposing to change the Authority to a ‘Streamlined Authority’ to remove time constraints on prescribing without removing the criteria required to prescribe, and that non-GP prescribers of antivirals should be required to communicate the treatment plan to the patient’s regular GP, to ensure holistic care ‘before, during and after antiviral treatment’.
 
Dr Jill Benson is one of those GPs who has undergone training and is an accredited hepatitis B S100 community prescribing doctor, working in remote communities across Western and South Australia.
 
She believes more GPs should be able to undergo the training to be able to prescribe the medications.
 
‘What we know is that a lot of people with hepatitis B have not been correctly diagnosed,’ Dr Benson told newsGP.
 
‘We need more GPs to be trained, because then we can diagnose the people who have hepatitis B, and those GPs will then know who to treat and who not to treat, what’s the best treatment and when to refer, because they definitely do not all need referral to another specialist.
 
‘The majority of people can be treated in general practice, but I feel quite strongly that you need to do the action training before you do that, because it’s complex.
 
‘We need more GPs to be aware that hepatitis B can cause people to die, we need more people to be aware that they can prevent that.’
 
Dr Benson said it is because hepatitis B is a ‘very complex illness’ which requires proper diagnosis and timely treatment, prescribing the specialise medicine requires additional training.
 
‘Working out when to treat is not intuitive, because the interpretation of the results is quite complicated and the treatment isn’t for everybody … there are different criteria used to both start and stop the treatment. And different criteria you would use as a GP to trigger a referral to a specialist,’ she explained.
 
‘These are people who unless we treat them at the appropriate time, have an increased risk of getting end-stage cirrhosis or hepatocellular cancer – and these are preventable cancers.
 
‘And unless we diagnose them correctly, we can’t give them the appropriate treatment at the time that they need it and prevent them dying.’
 
Dr Benson also points out that because people more likely to have hepatitis B are vulnerable groups in the community, such as people who inject drugs, refugee people, and Aboriginal and Torres Strait Islander people, and these are ‘not often’ the people who spend a lot of time coming to see their GP, it is important for GPs to be more aware.
 
According to the latest data from the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine’s (ASHM) Viral Hepatitis Mapping Project: Hepatitis B which tracked geographic diversity in chronic hepatitis B prevalence, management and treatment in 2021, uptake of hepatitis B antiviral medicines was just 12.7% – well below the target of 20% set for the following year.
 
The number of people engaged in care, via either treatment or monitoring, also fell short of the 50% target by 2022 at 26%.
 
ASHM’s Mapping Project’s data, used to inform part of the draft Hepatitis B strategy 2023–30, provides updated assessments of which Primary Health Networks are on track to meet strategic treatment targets.
 
According to ASHM CEO Alexis Apostolellis, the report demonstrates the importance of expanding the range of treatment pathways available to people living with hepatitis B, including more management within the primary care setting and referrals to appropriate prescribers for medicines to help boost treatment uptake.
 
While hepatitis B diagnoses can be managed by accredited S100 community prescribers in primary care in many cases, he said GPs are being ‘underutilised’ in this space.
 
‘Despite the fact that a lot of people being treated for hepatitis B can be managed exclusively in primary care, only about 10% are,’ Mr Apostolellis said.
 
‘Not only are community S100 prescribers an underutilised resource for hepatitis B care, we also know patients in primary care typically receive faster treatment, are less prone to disconnect from health services and are more likely to adhere to treatment regimes.’
 
In its recommendations to the draft strategy, the RACGP outlined equitable access to safe and affordable testing, management and treatment of hepatitis B for all communities as priority actions, and is calling for a GP-led shared care model to support treatment pathways for people with hepatitis.
 
‘Testing, monitoring, management and treatment for hepatitis B and C is part of core work for GPs,’ RACGP President Dr Nicole Higgins wrote in the College’s submission.
 
‘GPs often initiate testing, play a key role in raising awareness of infection and reinfection, and in implementing primary and secondary prevention measures. The holistic, patient-centred, and relationship-based approach of general practice can ensure the effective delivery of preventive care and treatment.’
 
Dr Benson agrees that while hepatitis B is a complex disease, with the right kind of training – which she encourages – more of its care can be managed in general practice.

‘This is a general practice thing. But there’s so many people who go to hospitals and [other] specialists, and they don’t need to,’ she said.
 
‘GPs should be trained – they don’t have to be trained, but I think they should be trained because it’s so complex.
 
‘But once you get the hang of it, understanding hepatitis B is not that complex. Getting your head around all the diagnostic criteria and when is the appropriate time to treat, that takes quite a bit of learning, but once you’ve got it, it’s smooth sailing from there.’

To coincide with the latest release of the Mapping Project’s data, ASHM has also released a suite of resources to support clinicians at the time of diagnosis to refer patients on to community S100 prescribers, including a map to find local primary care S100 prescribers, and clinical tools to support referral and prescribing pathways.
 
GPs can also undertake appropriate training with ASHM.
 
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elimination strategy hepatitis B S100 medications treatment access