26 July 2017

Is new listing key to beating hep C?

Clinical Communicable Disease

GPs will be the key to getting hepatitis C drug prescribing up to the levels needed to reach elimination targets, and an expected PBS listing of the first pan-genotypic drug could help do the trick.

By September last year, one in five people on hepatitis C medication were initiated by their GPs, up from 4% when the drugs were PBS listed in March, a paper on the MJA states.

However, prescribing had dropped off from that high-water mark, when around 100 fewer people were living with hepatitis C each day, Associate Professor Benjamin Cowie, director of the WHO Collaborating Centre for Viral Hepatitis, said.

“Now you’d be estimating it would be in the order of 50 to 60 fewer people living with hepatitis C per day,” he said. “That’s a substantial decline.”

The Medical Republic understands the first pan-genotypic drug for treating hepatitis C will be available on the PBS from next month, and health experts hope this will streamline the management process and boost confidence in prescribing.

The peak body for hepatitis patients, Hepatitis Australia, has called the pan-genotypic drugs the “next major step in treating and eliminating hepatitis C in Australia”.

It means that patients with any hepatitis genotype, from 1 to 6, could be treated with the once-daily pill for 12 weeks.

The velpatasvir and sofosbuvir 400 mg/100 mg (Epclusa, Gilead) combination was TGA approved at the end of last year, and recommended for PBS listing by its advisory committee at the beginning of this year.

The authors of the MJA article suggest the unanticipated early uptake of the first range of hepatitis C drugs may have represented the “low-hanging fruit” of the hepatitis epidemic – those patients already in contact with liver clinics and tertiary care in the era before the direct acting antivirals (DAAs).

“If Australia is to capitalise on the opportunities of universal access to DAA therapies, it will require the converted efforts of general practitioners to improve rates of diagnosis, assessment, treatment and follow-up in the community,” the authors wrote.

Professor Cowie agreed that renewed efforts would be needed within primary care to again reach rates of prescribing that would achieve the goal of eliminating hepatitis C in the country by 2030.

It was also going to be necessary to “turn off the tap” of new infections by prioritising harm-reduction strategies, such as needle-exchange programs and treatment within prisons, to reduce transmission, the infectious diseases physician and epidemiologist said.

Australia was viewed around the world as a model, and the government had to be credited for not only investing such a substantial amount of money, but also for coming up with a favourable deal with drug companies to cap spending after a certain number of patients had been treated, Professor Cowie said.

Nevertheless, he predicted that GPs would be the main prescribers of these new medications as Australia got closer to eliminating the disease, and this would rely on continued investment to provide support for primary care in this new role. While it was important to continue pushing towards aspirational treatment targets, Professor Cowie said the dropping prescribing rates were not all doom and gloom.

At present, less than 190,000 people in Australia are estimated to be living with hepatitis C, down from around 230,000 in March 2016 when the drugs were listed.

“It’s not undermining the fact that there is still 1% of people living with hepatitis C initiating treatment each month,” he said.

“When you put it in a historical perspective, in two months we are still treating the same amount it used to take us a year to treat.”