8 April 2019
The newly released National Hepatitis B and C Strategies set ambitious targets for 2022, aiming to make significant process toward eliminating viral hepatitis as a public health concern and reducing attributable morbidity and mortality. However data newly released this week demonstrate that while there are regions of Australia that are on track to reach these targets, other areas face significant barriers to access which will make reaching the National Strategy targets much more difficult.
The Viral Hepatitis Mapping Project, which maps the prevalence, diagnosis, monitoring and treatment of hepatitis B and C, is undertaken by the WHO Collaborating Centre for Viral Hepatitis (WHOCCVH) at the Doherty Institute, in partnership with the Australasian Society for HIV, Viral Hepatitis and Sexual Health (ASHM) and funded by the Australian Government Department of Health using data from national communicable disease surveillance, along with records available from Medicare Australia. It identifies priority regions for improving access to treatment and care and highlighting areas where profound progress has been made.
Treatment uptake for chronic hepatitis B (CHB) in 2017 was 8.3% overall in Australia, well short of the target of 20% by 2022. In some Primary Health Networks (PHNs), uptake approached this target, reaching 17% in South Western Sydney PHN and 14% in Western Sydney PHN. However in more than half of PHNs, uptake was less than 5%. All people living with CHB should be engaged in regular monitoring, and the National Strategy target for the proportion of people receiving care is 50%, however in even the highest-achieving PHN, only one-third of people living with CHB were receiving care.
CHB treatment and care access were most limited in rural and remote regions of Australia, highlighting the particular barriers for people located furthest from major cities. In these regions, many primary care practitioners are stepping up to provide hepatitis B treatment, and the PHNs with the highest rates of General Practitioner (GP) monitoring and treatment included the Northern Territory, Northern Queensland, Western NSW, and Country WA.
Even among those people living with CHB who are engaged in care, data suggest that there may be gaps in management for many people. Of those who had a viral load test in the past four years, the majority had had only one, despite clinical guidelines recommending that testing be conducted yearly.
Although small increases were seen between 2016 and 2017 in treatment uptake (from 7.8% to 8.3%) and in care uptake (from 19.6% to 20.2%), by continuing these trends Australia will not reach our national targets in the foreseeable future.
In contrast, treatment for chronic hepatitis C (CHC) has increased dramatically since the new, highly effective direct-acting antivirals were listed on the PBS in March 2016, with more people treated during the first two years than were treated in Australia in the prior two decades. By the end of 2017, it was estimated than one quarter of all Australians living with CHC had received treatment. The National Strategy target is 65% treated by 2022.
However, the pace of uptake is clearly slowing, with the number treated one-third lower in 2017 compared to 2016. This decrease was seen across PHNs, however was generally sharper in those regions with higher initial uptake. Analysis of genotype testing trends demonstrated that areas of high initial uptake were those which had higher numbers of individuals who had completed workup for treatment prior to 1st March 2016.
The PHNs with highest CHC treatment uptake were a combination of metropolitan and regional locations, such as Western Victoria (33.6%), North Coast NSW (32.2%), Adelaide (31.4%), Gippsland VIC (30.9%) and South Eastern Melbourne (30.6%).
Treatment by GPs increased as a proportion of total prescriptions from 10.8% in March 2016 to 37.1% in December 2017. Those PHNs where GP prescribing was highest were generally rural and regional and were mostly in NSW, including Nepean Blue Mountains, North Coast NSW, and Murrumbidgee PHNs, but Western Queensland PHN also had high GP prescribing.
The main goal of identifying priority areas for increasing viral hepatitis care and treatment is to prevent long-term adverse outcomes in those affected, such as liver cancer. Data from the Australian Cancer Atlas demonstrate the significant variation in liver cancer rates according to region, which in some areas reached nearly four times the national average. This variation highlights the association of viral hepatitis with liver cancer at a local level - the five PHNs with the highest liver cancer rates had above-average prevalence of CHB (North Western Melbourne and Western Sydney) or both CHB and CHC (Central and Eastern Sydney, Northern Territory and South Western Sydney).
Professor Benjamin Cowie, Director of the WHO Collaborating Centre for Viral Hepatitis at the Doherty Institute, welcomed the release of the Viral Hepatitis Mapping Project National Report 2017. “For good reason, Australia is viewed globally as a leading example of scaling up treatment access for people living with hepatitis C. This mapping report demonstrates this progress, but also highlights that within these national data lie very substantial differences in uptake of treatment and care, inequities which we must urgently address. Furthermore, our slow progress in providing care for people living with hepatitis B demonstrates that we need to radically transform our current approaches to addressing this condition, which now affects more Australians than HIV and hepatitis C combined.”
According to Professor Cowie, the benefits in treatment scale up for both hepatitis B and C are already being realised. “Liver cancer has been the fastest increasing cause of cancer deaths of Australians for years, but there are indications that the increase in deaths from hepatitis-related liver cancer is already slowing. This is wonderful news, and should lead us to further commit to providing top quality care for all Australians living with viral hepatitis, wherever they live.”