Stigma limiting hepatitis C treatment

Despite some of the highest hepatitis C diagnosis numbers in the world, rates in Australia have fallen since 2000.
 
This is related to a reduction in the prevalence of injecting-drug use and improved harm-reduction measures, such as needle and syringe programs and opioid-substitution treatment.
 
When direct-acting antivirals (DAAs) were introduced to the Pharmaceutical Benefits Scheme (PBS) in 2016, hepatitis C treatment became affordable and accessible, and uptake was high.
 
Prior to the PBS addition, annual treatment of people with hepatitis C was just 1–2%.
 
Further treatment was added in 2018, and there are now three pan-genotypic DAA treatment options listed on the PBS. These come under the Department of Health’s National Hepatitis C Strategy, which aims to treat as many patients as possible and work towards eliminating hepatitis C by 2021, in alignment with global targets set by the World Health Organization.
 
An estimated 70,260 people were treated with DAA therapy through the PBS in 2016–18, plus more than 4000 treated pre-PBS, equalling 33% of the estimated population with hepatitis C.
 
Since initial introduction of DAAs on the PBS in 2016, however, treatment uptake has slowed.
 
The 2020 report from the Kirby and Burnet institutes found stigma and discrimination associated with people who inject drugs and people living with hepatitis C remains prevalent, and has a direct impact on access to healthcare.
 
But understanding stigma experiences can provide context for other indicators such as the lack of progress in testing and treatment uptake.
 
The report tracks Australia’s progress in eliminating hepatitis C using data from primary healthcare clinics whose main patient populations are those who inject drugs, and gay and bisexual men.
 
The report also includes data on people in prison, revealing an estimated 29% of people treated for hepatitis C in 2019 were treated within the correctional system.
 
Overall, the report confirms that fewer Australians are seeking testing and treatment for the disease, particularly testing for hepatitis C ribonucleic acid (RNA) to detect new infections, and fewer people are progressing to need liver transplants because of the disease.
 
Reports of stigma or discrimination by the general public towards people because of their hepatitis C status has declined over the three-year period since 2017, but a notable proportion of stigma or discrimination still exists, particularly towards people who inject drugs.
 
‘Monitoring of perceived stigma is important for understanding barriers individuals face in accessing testing, diagnosis and treatment for hepatitis C, and for understanding and responding to the needs of affected communities,’ the authors wrote.
 
Dr David Baker is a GP and clinical adviser with the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). He is not surprised by the findings that stigma leads to people avoiding testing and treatment for hepatitis C.
 
‘Someone who injects drugs might not want to get tested, for example, because they’re afraid of being judged not only for their hepatitis C status, but for their drug use,’ he told newsGP.
 
‘Stigmatising practices within clinics might also be barriers to accessing care, from the ways patients are treated by reception staff to insufficient private registration processes.
 
‘In some cases, it doesn’t matter whether these practices actually go on in a clinic: if a patient has had these experiences in the past or has heard about them from other patients, the effect of stigma is the same.’
 
Dr Baker believes GPs can help reduce these barriers by making their clinics more accessible.
 
‘One simple, useful approach is to provide brochures about hepatitis C in the waiting room to let patients know testing and treatment is available,’ he said.
 
‘It can also be useful to have practice meetings to develop a hepatitis C plan – along with other blood borne viruses – that updates all practice staff regarding the best way to introduce testing and treatment into your practice.’
 
Burnet Institute Deputy Director and co-author of the report Professor Margaret Hellard agrees that collaboration between healthcare professionals and communities is needed.
 
‘Now is a pivotal time in the effort to eliminate hepatitis C in Australia,’ she said.
 
‘After great success in the first few years that DAAs were available … we need to review, renew and refocus our efforts, engaging with key affected populations to ensure hepatitis C testing and treatment is easily accessible to the people who need it, when they need it, where they need it.’
 
A focus on primary prevention is key, the report states, with efforts needed to include improved access to sterile needles and syringes to reduce sharing among people who inject drugs, and expanding health promotion activities.
 
Improved access to treatment in rural and remote areas also needs to be addressed, with the report findings showing opportunity inequities in these areas.
 
The report’s take-home message is that increasing testing, diagnosis and linkage to care, as well as reducing associated stigma, is essential for Australia to achieve elimination of hepatitis C.
 
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blood-borne viruses: DAAs PBS healthcare hepatitis C stigma