hepinion: decentralisation and task shifting will accelerate the elimination of viral hepatitis

19 Nov 2019 Lucy Ferrier

Written by Dr Su Wang, WHA President-elect, medical professional, and hepatitis B patient

During The Liver Meeting® 2019 in Boston, the four global hepatology societies, the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), the Latin American Association for the Study of the Liver (ALEH) and the Asian-Pacific Association for the Study of the Liver (APASL), all signed a call-to-action for their members to actively look at ways in which decentralisation and task shifting could help accelerate hepatitis C elimination.

This is a bold and welcome step. From the patient perspective, we have great hopes that it will catalyse the access to hepatitis C diagnosis, care and cure. 290 million people live with viral hepatitis B and C unaware. We know that the most at-risk groups are underserved by health systems. Elimination will not happen if we do not reach those most at-risk and most affected, including people in low-income countries, people who inject drugs (PWID), migrants, men who have sex with men, incarcerated populations and sex workers.

We need to ensure that we are able to test, treat and cure these groups wherever they are, and within services they are already engaged with.

We need to ensure that we are able to test, treat and cure these groups wherever they are, and within services they are already engaged with. Marginalised communities can face difficulties accessing tertiary centres, which traditionally house the more specialised services. Many of those affected by hepatitis have also experienced discrimination and therefore often distrust healthcare systems.

With the increasing availability of testing and simplification of hepatitis C cures (that are pan-genotypic and largely eight week regimens), it is imperative that we develop models of screening and care that can be adopted to front-line settings, especially those which engage with marginalised communities. The call to decentralise and task shift is a call for these life-saving services to be delivered within primary care, needle exchanges, pharmacies and more. We must expand services beyond the traditional settings if we are to achieve elimination.
To achieve decentralisation effectively, we have to put the affected community at the centre of any planning.

Meaningful engagement with people with lived experience should be at the heart of developing and implementing any plans. Only civil society can bring the insights into their unique needs, the barriers they face in the current system, and the most effective strategies to dismantle those barriers. 

Only civil society can bring the insights into their unique needs, the barriers they face in the current system, and the most effective strategies to dismantle those barriers. 

As a physician myself, my mind-set is often admittedly simplistic – that my instructions to a patient will improve their medical condition, and if they just follow through, they will improve their health. But I only see a small slice of their life. I am humbled when I get a glimpse into the challenges some have around medical care – to get an appointment, arrange transportation and time from work or responsibilities, filling their prescriptions and taking the medications daily, navigating the recommended testing and radiology services, and dealing with medical costs. I realise I don’t actually know how their medical condition really impacts their life and what hurdles they’ve jumped to get care and follow through with recommendations. In light of the many barriers, especially in low- and middle-income countries with the largest burdens of hepatitis, we know the reality is that not every hepatitis patient will be able to see a hepatologist or other specialist. If we hold to that expectation and do not decentralise, elimination will certainly be beyond our reach and liver cancer rates will continue to soar.

We are already seeing examples where decentralising and task shifting are happening. At the recent Liver Meeting, Dr. Lynn Taylor described examples where hepatitis C care is delivered alongside medication assisted therapy for opioid addiction, syringe exchange programs or HIV services. Dr Alex Thompson from Australia spoke during the NOhep Medical Visionaries meeting about a nurse-led model of hepatitis C care being undertaken in Australian prisons. Australia has also led the way in training general practitioners to take on the majority of hepatitis C cure care in their country. In the UK, The Hepatitis C Trust is rolling out a “one-stop shop” model where patients can be tested and treated from a mobile clinic that can be placed outside of drug and alcohol centres, homeless shelters and other locations to engage with marginalised communities. We are also seeing more examples of primary care providers being trained to treat and cure hepatitis C as exemplified so well in the ECHO programs which are now happening worldwide. But these practices are still not the norm, so we have much work to do.

The call-to-action is an important first step, but we need to ensure that these new recommendations are put into practice across the world. We must recognise that these changes may not be an easy step for everyone, but it is critical to encourage a more team-based approach, enabling more front line providers to screen and deliver hepatitis C care and making specialists more available to complex patients. Task shifting of screening, care and cure will be vital for expanding beyond our current reach where only 19 per cent of those with hepatitis C have been diagnosed and only seven per cent have accessed treatment, a long way from the 80 per cent treatment target for WHO’s 2030 elimination goal.

We must recognise that these changes may not be an easy step for everyone, but it is critical to encourage a more team-based approach, enabling more front line providers to screen and deliver hepatitis C care and making specialists more available to complex patients.

There also needs to be a similar commitment to decentralising and simplifying access to hepatitis B testing and treatment services. The liver societies have announced they will release a call-to-action on hepatitis B in the future. When they do, it is vital that the affected community is placed at the centre of the planning and implementation process to ensure services meet the needs of the people.

Medical research has brought us this far – with the rapid developments of hepatitis C cures receiving much fanfare and taking centre stage in recent years at liver meetings. What should take centre stage now is implementation science. How do we actually find the missing millions who are unaware they are living with hepatitis C and successfully cure them? The tremendous scientific advances we have made for hepatitis C will be all for naught, if the millions who need it are not identified and cannot access these life-saving treatments.