Monday, August 26, 2019

Who should treat hepatitis C?

- Jennifer Middleton, MD, MPH

A compelling Close-Ups in the August 15 issue of AFP shares the story of "DN," a patient recently released from prison with hepatitis C. DN reports excellent treatment outcomes after his family doctor treated his hepatitis C. He was able to avoid "going to see an expensive subspecialist I didn't know," and the persistence of his family physician and her office team helped DN overcome his struggles with keeping appointments and adhering to his medication regimen. Recent studies suggest that this family physician is in the minority as a treatment provider for hepatitis C, but DN's story supports the premise that, once armed with knowledge and resources, family physicians can be at least as effective at treating this disease as our subspecialist colleagues.

Despite the hesitation of some family physicians to provide this treatment, a 2018 AFP editorial asserts that "Family Physicians Can Manage Hepatitis C." The family physician author reviews screening recommendations for hepatitis C, defines sustained viral response (SVR), discusses viral genotyping, and describes the current medication options available. The editorialist advises obtaining additional online training (there are several free options) and cites the Centers for Disease Control and Prevention's (CDC) recommendation that primary care physicians provide this treatment.

A 2017 survey of primary care physicians and nurse practitioners identified that few were currently providing hepatitis C treatment, though 84% were interested in obtaining more training to do so:
Willingness to provide treatment was strongly linked to having a high proportion of HCV-infected patients (>20% versus <20%; OR 3.9; 95% confidence interval [CI] 1.5–10) and availability of other services at the primary care site including HIV treatment (OR 6.5; 95% CI 2.5–16.5), substance abuse treatment (OR 3.3; 95% CI 1.3–8.4) and mental health services (OR 4.9; 95% CI 2.0–12.1).
Connecting to local resources in the form of substance abuse treatment (since most hepatitis C infection in the United States is due to injection drug use), mental health services, and integrated clinical pharmacists (as DN's family doctor did) are critical to empowering more family physicians to prescribe hepatitis C treatment. Willingness to care for formerly incarcerated persons may also play a role; this 2018 post from Dr. Lin reminds us of the health risks these patients face when they re-enter society, which are at least partially attributable to the challenges they face accessing primary care.

Resources to learn more include this 2015 AFP feature article on "Diagnosis and Management of Hepatitis C" along with the AFP By Topics on Hepatitis (and Other Liver Diseases) and Substance Abuse. The CDC also has a sizable "Hepatitis C" resource page with multiple resources for physicians and patients. 

If you are treating hepatitis C, what barriers and/or successes have you experienced? If not, what might encourage you to do so?