September 2022

Australia: Hep C-Free by 2030?

By Katie Horneshaw

With highly effective new treatments available since 2016, Australia has committed to eliminate hepatitis C by 2030. Katie Horneshaw explains that outreach to vulnerable populations will need to be ramped up if we are to hit that target.

In 2016 Australia celebrated a huge health victory with the arrival of direct-acting antiviral drugs (DAAs) for the treatment of hepatitis C. Unlike previous therapies, which were less reliable and produced a number of distressing side effects, DAAs are well tolerated and provide a cure in 95 per cent of recipients.

The Australian Government was quick to commit to the ambitious target of complete elimination of hepatitis C by 2030, but the achievement of that goal will require a health sector-wide approach to extend diagnosis and treatment services to high-risk communities, such as Aboriginal and Torres Strait Islanders, people in prison, and people with insecure housing.

Aside from the logistical challenges of reaching people in vulnerable communities, the stigma associated with the diagnosis can render at-risk people reluctant to engage with treatment.

“It’s always at the back of your mind,” admits Sarah, 34, from Melbourne, who has lived experience of injecting drug use, “but when you think about facing judgemental healthcare workers, having to hide it from employers, or your family thinking less of you… sometimes it’s just easier not to know.”

Hepatitis C is primarily spread through the sharing of injecting equipment, tattoo needles, and razors. In Australia approximately 232,000 people are still living with the illness, many of whom inject drugs. Professor Jason Grebely, who leads the research team for the national hepatitis C point-of-care testing program at the Kirby Institute in New South Wales, believes Australia is capable of bringing this number to zero by 2030.

“Among people who inject drugs, treatment uptake is currently at around 70 per cent, and rates of infection have dropped to around 16 per cent.” In 2016 alone, 30,000 people were treated with DAAs.

Jason believes a potential solution to the issue of reaching high-risk people lies in the new point-of-care testing program, which is designed to allow for one-stop treatment and testing, significantly reducing the travel and time burden involved in getting diagnosed and initiated into treatment.

“I couldn’t believe how easy it was” says Marc (not his real name), 50, who was shocked to discover he had hepatitis C after his GP encouraged him to take a test last year. Although Marc had injected drugs for many years, he hadn’t noticed any symptoms and had assumed he was in the clear.

I’m actually glad I didn’t find out till recently because it meant I was instantly treated with the new medication. I went from freaking out that I had what I thought was a life-threatening illness to finding out I was about to be cured of it, all in the same GP visit!

But there are still major obstacles that must be negotiated if Australia is to meet its target. The rate of treatment uptake has been steadily dropping, with only 6,500 people inducted onto the antiviral medications in 2021.

Jason explains: “The decline is happening because the populations that remain to be treated are those with multiple categories of vulnerability, and they are harder to reach.”

This is reflected in data from the Annual Needle and Syringe Program National Report, which shows the proportion of people of Aboriginal and Torres Strait Islander descent who have hepatitis C has increased from 18 per cent of total Australian cases in 2017 to 25 per cent in 2021; over the same period the percentage reporting incarceration in the 12 months prior to the survey increased from 11 per cent of all respondents to 13 per cent.

Peta Gava, Peer Health Clinic & Outreach Worker at Peer Based Harm Reduction WA, stresses the importance of adapting to the needs of vulnerable communities: “In WA geographic distances and travel times to centralised services are a significant barrier. At PBHRWA we employ peer case management workers and peer educators to engage effectively with the most vulnerable populations.” (A peer is a person with lived experience.)

“Our fixed-site clinics are co-located with our needle and syringe exchanges and can provide testing and treatment in house, without the need to refer people to other agencies. To reach the people who are not currently accessing testing and treatment, we need to go where they are, not expect them to make an appointment and come to us.”

Point-of-care testing “is a really exciting development,” says Jason, “because it provides an opportunity for people to receive on-the-spot diagnosis and treatment when they attend needle and syringe access points, opioid substitution therapy (such as methadone treatment), or at their alcohol and drug counselling service.” This means patients can be offered both test and treatment when they make contact with their usual services.

Margaret Randle of Hepatitis South Australia seconds the need to increase diagnostic and treatment uptake in vulnerable communities, which include people experiencing homelessness and people who continue to inject drugs. “But it’s not as simple as increasing access points,” she cautions.

We won’t see the rates of treatment we’re hoping for until we address the issue of stigma. Many people in vulnerable populations avoid health services altogether because they don’t want to be pigeon-holed as an injecting drug user. Once that is on your file you will be asked about it every time you go to the doctor.

Margaret Randle

Penni Moore, NSP Peer Educator at Hepatitis SA, confirms the problem is widespread: “A lot of people from these types of backgrounds have zero trust in the health sector — they’ve had negative experiences in the past where they’ve felt judged or have been denied health care based on their drug use status — and when you combine that with the lack of urgency because most people with hep C don’t feel sick and are busy just trying to get by, the chances of them turning up for diagnosis are very low.”

Peta of PBHRWA has been on the receiving end of stigmatising attitudes from healthcare professionals. She underscores the value of people with experience of stigma being able to access diagnostic and treatment services through peer networks: “We can invest trust in the healthcare experience when it comes from someone with parallel life experience to us, who has lived with hep C and experienced treatment for themselves.”

PBHRWA has responded to this need through a hep C peer education project. “The people who’ve accessed care through this initiative have consistently told us that they would not have spoken to a GP about hep C because of concerns about stigma and discrimination and that talking to a peer educator is the only way they would have heard the information.”

Dr Kate Seear

We need to have testing available that doesn't require people to attend a medical service and that can be done anonymously.

Professor Kate Seear of La Trobe University in Victoria echoes Peta’s views on the provision of peer-based care: “We need to have testing available that doesn’t require people to attend a medical service and that can be done anonymously,” she advises. “One option would be to train peer workers (people with lived experience of injecting drug use and/or hep C) to provide the treatment at needle and syringe access points.”

Kate believes a national strategy is needed “to commit to addressing stigma more explicitly, through the implementation of initiatives to reduce discrimination in health care settings and increase patient comfort levels with treatment access points.”

A final hurdle to achieving the 2030 goal is the presence of continued transmission. “In communities where transmission is particularly high,” explains Jason, “we are seeing people cured and reinfected two or three times.”

Sarah  asserts that it’s not always easy to avoid transmission risks: “We’re lucky to have access to needles in Australia, but it can be harder than you’d think to get your hands on them. If I score at midnight, there’s nowhere within hours of me to get clean fits. If it’s during the day, I can go to the local pharmacy, but they charge $6 for 4 needles, which is a lot of money when you’re only just getting by. And I have to deal with the salespeople giving me the stink eye.

In smaller communities, everyone knows everyone. I wouldn’t want to risk going into the local community hub and asking for needles to inject drugs with.

All told, Jason believes that we’re on the right track. “Australia has a very progressive approach, and the funding is there to get this thing done. Unlike many other countries, we have GPs and nurse practitioners prescribing the DAA medicines, and there is a spirit of cooperation in the sector that’s great to see.”

Despite this, Jason agrees that it will be impossible to reach vulnerable communities without new initiatives to address stigma and distrust in the health sector, as well as increase access to injecting equipment. He joins the many voices calling for comprehensive anti-stigma training in healthcare, anonymous point-of-care testing and treatment, and most importantly, the adoption of treatment methods that can be provided through peer networks, bypassing the need for clinic visits.

“I know plenty of people who want to be tested and treated, but they’ve got higher priorities,” explains Sarah. “If you want to stop transmission and get everyone onto these hep C drugs, you’ve got to make it convenient enough that it’s not going to get in the way of their lives.”