The successful HCV cures achieved in more than 600 prison inmates with a nurse-led model of care point the way to eradicating the infection in hard-to-reach populations, NSW researchers say.
With prescribing of direct acting antivirals (DAAs) now in sharp decline following initial high rates of treatment of easy-to-access patients, a shift is needed from predominately tertiary specialist treatment to community-based treatment, according to study investigators from the Prince of Wales Hospital, Sydney and the University of NSW.
In the largest evaluation of a treatment program for chronic HCV in prison environment since the wide spread availability of DAAs, they report how a nurse-led program in NSW achieved 90% cure rates in 698 prison inmates treated in 2016-2017.
In the program run by Justice Health NSW, population health nurses conducted initial clinical assessments and confirmatory testing for HCV in prison inmates. Patients were referred to a Hepatitis Clinical Nurse Consultant for protocol-driven assessment, including transient elastography to assess hepatic fibrosis. The nurse then discussed the case with an infectious diseases physician via telemedicine link and DAA therapies were prescribed. More than 30% of those treated were Indigenous Australians.
Of those who completed treatment and had the sustained virological response assessed at 12 weeks (SVR12) whilst in prison, the cure rate was 92%.
Of the 34 non-responders five had decompensated cirrhosis, 16 reported ongoing injecting drug use, including seven who had documented reinfection with a different genotype.
Overall 16% of patients were cirrhotic, and the most common genotypes were 1 (53.4%) and 3 (41.5%).
The researchers said the success of the program provided a template for nurse-led HCV care pathways for marginalised patient populations such as prison inmates, injecting drug users and the homeless, who do not access specialist physician or GP services.
“The successful outcomes argue for infrastructure investment in such programs to improve the previously low treatment rates,” they wrote in the International Journal of Drug Policy.
“Elimination of HCV as public health threat by 2030 will not be possible without a major focus on DAA access and optimised outcomes within the marginalised prison population,” they concluded.
Their conclusion was backed by Victorian gastroenterologists, who wrote in the Medical Journal of Australia that scale up of nurse-led treatment program in settings such as prisons is key to national elimination of HCV.
“The decline [in prescribing of DAAs by specialist physicians] highlights the need for development and implementation of comprehensive models of care in settings outside tertiary hospitals, to ensure HCV testing and DAA treatment uptake are sustained at higher levels so that elimination targets are met,’ said Dr Tim Papaluca, hepatology fellow at St Vincent’s Hospital in Melbourne.