Can primary care treat hepatitis C?

Primary Care Can Effectively Treat Hepatitis C with Direct-Acting Antivirals

Primary care physicians can effectively treat hepatitis C using direct-acting antivirals (DAAs), achieving cure rates comparable to specialty care while increasing treatment access and uptake. 1

Evidence Supporting Primary Care HCV Treatment

• With the advent of safe, effective, and well-tolerated DAA regimens that achieve >95% cure rates, hepatitis C treatment has been simplified enough to be successfully managed in primary care settings. 1

• The American Association for the Study of Liver Diseases-Infectious Diseases Society of America (AASLD-IDSA) guidelines support expanding the number of healthcare providers administering antiviral therapy beyond specialists to include primary care physicians. 1

• A randomized controlled trial demonstrated that providing HCV treatment in primary care significantly increased treatment uptake (75% vs 34%) and cure rates (49% vs 30%) compared to hospital-based specialty care. 2

• A systematic review and meta-analysis found that community and primary care-based HCV treatment services using DAAs are feasible and can achieve similar sustained virologic response (SVR) rates to secondary care. 3

Treatment Algorithm for Primary Care Management

1. Screening and Diagnosis: 4

   • Perform anti-HCV antibody testing for at-risk individuals
   • Confirm active infection with HCV RNA testing
   • Additional testing includes viral genotype determination and liver damage assessment

2. Pre-Treatment Assessment: 5

   • Evaluate liver fibrosis stage using non-invasive methods (transient elastography or serum biomarkers)
   • Screen for potential drug-drug interactions with concurrent medications
   • Assess for comorbidities that may affect treatment

3. Treatment Selection: 1, 4

   • Use pangenotypic DAA regimens for 8-12 weeks
   • Select appropriate regimen based on patient characteristics, comorbidities, and potential drug interactions
   • Consider simplified treatment algorithms for treatment-naïve adults without cirrhosis or with compensated cirrhosis

4. Monitoring: 5, 4

   • Minimal monitoring required during treatment due to excellent safety profile of DAAs
   • Assess for SVR at 12 weeks post-treatment to confirm cure

Benefits of Primary Care HCV Treatment

• Increased treatment uptake and improved access to care, addressing significant gaps in the HCV care cascade. 1, 2

• Comparable SVR rates to specialist care, with studies showing >90% cure rates in primary care settings. 6

• Integration of HCV care into venues where patients already access services, particularly important for people who inject drugs (PWID). 1

• Reduced barriers to care by eliminating the need for specialist referrals, which often result in loss to follow-up. 1

Potential Challenges and Solutions

• Knowledge gaps: Many primary care physicians may be unfamiliar with current HCV treatments, with surveys showing that some PCPs are unaware that HCV can be cured or that oral therapies are available. 1

  • Solution: Implement training programs and telemedicine support from specialists

• Complex patients: Some patients may require specialist referral. 1

  • Solution: Establish clear referral criteria for patients with decompensated cirrhosis, complex drug interactions, or treatment failure

• Monitoring requirements: Primary care practices need systems to ensure appropriate follow-up. 5

  • Solution: Implement reminder systems and patient navigation programs

• Reimbursement issues: Insurance restrictions may limit who can prescribe DAAs. 1

  • Solution: Advocate for policy changes to expand prescribing authority

Models of Care for Primary Care HCV Treatment

• Primary care with specialist support: PCPs manage treatment with consultation from specialists as needed, often through telemedicine. 1

• Integrated care: HCV treatment integrated into existing primary care services, particularly effective in settings serving high-risk populations. 1

• Task-shifting: Expanding HCV care to include nurse practitioners, clinical pharmacy specialists, and physician assistants working in primary care settings. 1, 7

By implementing these approaches, primary care can play a crucial role in achieving the goal of hepatitis C elimination through increased diagnosis, linkage to care, and treatment of infected individuals.