Thinking Forward in HCV: What Next?

A report back om Dr Nicola Allard's session: Preventing HCC in primary care settings

This session delved into the factors affecting liver cancer prevention in primary care. Some major differences include the diversity of settings within primary care, diverse people and structures, and a low frequency of cancer diagnosis. There are other challenges too such as time limitations, with the average length of a GP consult being 14 minutes and the median at 12 minutes (which is surprisingly more than the 6 minute medicine we were led to believe!) But more people are seeing the GP compared to 10 years ago, with 85% of Australians seeing a GP at least once in the previous year, which represents an important opportunity for engagement in preventive health activities.

On a primary prevention level, we can vaccinate for HBV, discuss harm reduction and lifestyle modification. On a secondary prevention level, we can provide timely diagnoses and cure hepatitis C, monitor hepatitis B and treat if eligible, address other comorbidities to reduce harm such as alcohol, smoking and obesity. On a tertiary prevention level, we have a role in HCC surveillance and providing early diagnosis and treatment of HCC.

The majority of viral hepatitis diagnoses are made in primary care but unlike tackling HIV where high case-load clinics exist, viral hepatitis is not concentrated in a few clinics (prisons are the exception). Hence we need to cast a wider net through opportunistic assessment. Nicole Allard has made an important observation, that there is little mention of HCV screening activities in the RACGP Red Book and has suggested that this could reasonably be done in the setting of other preventive health activities. There is a service gap in terms of coverage of the response to HCV in primary care, currently 1% of GPs are prescribers and 10% of antiviral scripts were by GPs. Not only do we need to continue to ramp up testing for HCV but we also need to look at streamlining treatment and monitoring.

Other strategies such as incorporating lab reflex HCV RNA testing has been topically discussed during AVHEC19, as was the incredible effort by New Zealand in building widespread awareness through mass media campaigns to make patients into the best advocates. This session also sparked active discussion from the audience around the follow up of notifications to improve the cascade for people already diagnosed and how this data could be better shared among healthcare collaborators to improve HCC surveillance. 

So it appears that having widely available and effective DAA’s is just the tip of the iceberg. There are still exciting times ahead and time to get more primary care providers involved across all levels of HCV preventive health activities.

Author bio: Caran is a General Practitioner working in an inner city general practice and also with marginalised populations in Sydney where she has been involved in managing viral hepatitis, HIV and OAT prescribing.