For intravenous drug users, hepatitis C has long been an occupational hazard and almost a fait accompli.
In 2019, about 45 per cent of intravenous users carried antibodies indicating exposure to the potentially lethal virus. They faced the risk of cirrhosis, liver failure and liver cancer. According to the Australian Government’s Fifth National Hepatitis C Strategy, there were an estimated 621 hep C-related deaths in 2016
But a medical magic bullet has virtually upended all that in just five years, changing lives and saving lives.
The direct-acting antiviral agents have reduced the treatment time for hepatitis C by over half. They are almost 100 per cent effective, and there are little to no side-effects.
A modern miracle
Since 2016 almost half of all Australians living with chronic hep C have been cured of the disease, according to physician and Kirby Institute researcher Professor Greg Dore.
This is mostly thanks to a new direct-acting antiviral agent treatment (DAA). When Greg calls DAA treatment “one of the medical world’s modern miracles” he is not exaggerating.
“The DAAs have reduced the treatment time for hepatitis C by over half. They are almost 100 per cent effective, and there are little to no side-effects,” he says.
The per-prescription cost to the client of DAA treatment for hep C ranges from $7 for those with a Medicare number to about $40 for those without one.
After six years of trialling, several DAA treatments were added to the Pharmaceutical Benefits Scheme and made publicly available in 2016 to everyone with hep C.
There was a large uptake of DAA treatment when it was first introduced, and in 2016 and 2017 one-third of Australians living with chronic hep C were cured of the disease, according to a Kirby Institute report.
March 1 marked the fifth anniversary of the introduction of DAA treatment for hep C. More than 90,000 people living with hep C have been treated in this time.
Before DAAs, the treatment was an Interferon-based therapy which tried to control the virus by boosting the immune system. This was not entirely effective and had lengthy treatment times and side-effects comparable to chemotherapy, says Greg.
“There could be some nasty side-effects: general fatigue, psychological side-effects like changes in mood and depression, insomnia, hair loss, skin reactions – a whole range of stuff,” he said.
“Treatment times were around 6–12 months. That’s a prolonged period of time to be exposed to that kind of toxicity.”
Before I got treated I felt tainted. I was always thinking, ‘What’s the point in getting clean? I got hep C. That’s gonna stay with me forever.’ Since I got treated in jail I feel like a new man.
In 2016 “James” (not his real name) had been living with hep C for six years. He didn’t want interferon-based therapy because of the side-effects and a misconception he had about drug-abstinence requirements, which Greg says was common.
“We actually treated heaps of people who were still injecting,” he says.
“The abstinence requirement was dropped in the early 2000s. There was evidence that treating people with Interferon who were still injecting drugs had reasonably good outcomes.”
James declined the Interferon-based treatment, as did many of his peers, and was in a Perth prison when the new DAA treatment became available. Although he was a sceptic, he says once he saw how effective it was, getting treatment was a no-brainer.
“It sounded too good to be true. I didn’t believe it. Then I saw other mates getting cured and how it changed them,” he says.
James says it went beyond treating the virus and helped him to address some of the underlying factors and feelings contributing to his drug use.
“Before I got treated I felt tainted. I was always thinking, ‘What’s the point in getting clean? I got hep C. That’s gonna stay with me forever’’ he says.
“Since I got treated in jail I feel like a new man. It’s definitely made me think more seriously about getting clean and feeling like I can make a clean break.”
One of the keys to Australia’s success to date has been the cooperation of state and territory governments and peak health service organisations, says Australian Injecting and Illicit Drug Users League (AIVL) CEO, Melanie Walker.
This cooperation is facilitated by the Commonwealth’s National Hepatitis Strategy, which outlines a clear plan and goals for eliminating hep C, Melanie says.
Many of the treatment targets set in the 2014–17 strategy were met and even exceeded, with an estimated 43,360 people initiating treatment and 69 per cent of people living with chronic hep C being treated.
Since that early success, however, the rate of testing and treatment has slowed. The biggest issue continues to be engaging with and accessing people who inject drugs, which the 2018–22 strategy outlines as a key focus.
“If we’re going to eliminate hep C in Australia we need to look at the priority populations who aren’t accessing mainstream health services,” Melanie says.
“It’s about coming up with innovative models of care that reach those populations that haven’t engaged with treatment so far.
“It’s one thing for someone with good access to health services to be able to access that treatment. It’s another thing for someone who is experiencing homelessness or has complex needs to access treatment.
“If you don’t have a roof over your head, you just don’t have the brain space to think about chronic conditions that will hurt you over time.
“That’s the new frontier in eliminating hep C in Australia. How do you access those people, and what sort of support do they need?”
All around the country, NSPs and health care services are finding ways to vary their models of care to better treat marginalised populations and, ultimately, eliminate hep C.
A key priority for Melanie has been preventative work like implementing NSPs in ACT prisons. (Although it has not yet established these, the ACT is the only state or territory so far which has committed to doing this.)
“There are prisons all around the country offering hep C treatments but without NSPs in prisons it’s ineffective,” she said.
“Let’s be real here: people are still using drugs in jail, and if they don’t have access to clean injecting equipment you can be sure they’ll catch it back pretty quickly.
“It’s about making the investment worthwhile by ensuring people have access to prevention – in prison and in the community.”
In Queensland, the Queensland Injectors Health Network (QuIHN) has focused on peer-based methods, outreach and various kinds of targeted marketing to access people marginalised from mainstream health, says project officer Amanda Kvassay.
“In Brisbane our main office is in Bowen Hills and we offer four or five outreach clinics to outer Brisbane so we can get closer to where people live rather than expect people to come to us,” she says.
“That is one thing that is really valuable in trying to reach more people. We try to do that across all our centres.”
QuIHN has also promotes hep C testing and treatment through messaging on syringe packets distributed from secure dispensing units (vending machines).
“We do a bit of targeted marketing through our network of syringe vending machines across the state,” says Amanda.
“Because we’re an NGO we’re able to do hep C treatment outreach at some Queensland health sites and we try to promote those sites through the vending machines to let people know that we’re around and that hep C treatment is readily available. And testing – there’s a big push for testing, too.”
For us, a big concern has been that people who use drugs don’t necessarily access GPs or aren’t open with them.
Offering support and resources to GPs has been a critical part of this, Judith says, and is a key part of finding and treating hep C in such a large and isolated state.
“Getting GPs up to speed with prescribing has been a big component of workforce development,” she says.
“It’s about educating consumers but also about educating the health workforce in particular: letting GPs know that they can prescribe these treatments and there’s support for them to prescribe these things.”
However, Judith also says that – just like in other states – the key to access lies in bringing services to people.
“For us a big concern has been that people who use drugs don’t necessarily access GPs or aren’t open with them,” she says.
“Trying to take services to where people are and to access them through other health services they may be already accessing – like a needle exchange or opioid substitution therapy providers – is key.”
When it comes to eliminating hep C, Australia is one of the most successful countries in the world.
Greg says while it’s not possible to completely eliminate the virus, Australia is on track to control it locally by 2026 – and our experience may offer a successful model for other countries to adopt.
“You can’t get everyone on the treatment. You need a vaccine to be able to eradicate the disease, but we can control the epidemic – bring it under control in the way that we have HIV,” he says.
“We’ve now treated around half of the people living with chronic hep C. Yes, there’s still a long way to go, but Australia has led the world in terms of access to the treatment. Thanks to the collaborative efforts of all involved we’re on track to a future without hep C.”
– Tom de Souza
What are DAAs?
Direct-acting antivirals (DAAs for short) are a safe and highly effective form of treatment for hepatitis C.
Unlike the previous Interferon-based therapy which used the body’s immune system to kill the virus – and often produced serious side-effects – DAAs stop the hep C replicating inside the liver.
The treatment period for the DAAs is very short (usually 8–12 weeks) compared to the old treatment, which took nine months or more.
Unlike the earlier Interferon-based treatment, DAAs don’t involve injections – they’re taken as tablets. Patients on DAA treatment report minimal side-effects compared to the older therapy.
A liver biopsy is no longer necessary to assess the liver prior to treatment and has been replaced by a fibroscan, which is a non-invasive and simple procedure.
Virtually everyone with hep C can receive DAA treatment, including people who were ineligible for Interferon-based therapy.