Role of primary care providers in hepatitis C prevention and care

Hepatitis C virus (HCV), a blood-borne virus that infects the liver, is a serious global health threat. Worldwide, an estimated 150 million people are infected with HCV, and 3 to 4 million new infections are documented every year.¹ Chronic hepatitis C, a condition that develops in most of those who acquire HCV, can progress into life-threatening illnesses such as liver cirrhosis and liver cancer.² Currently, HCV-infected individuals constitute most of the liver transplant candidates in both Canada³ and the United States.⁴

Injection drug use is the main driving force behind the substantial spread of hepatitis C, particularly in developed countries.⁵ High-risk injection behaviour (ie, sharing of syringes, needles, and other injection equipment) is responsible for 55% to 90% of recently documented hepatitis C cases in Canada, the United States, and Australia.⁵ Nationally, only 1 in 3 persons who injects drugs (PWIDs) is estimated to be HCV-free.⁶ Moreover, with an estimated incidence rate of 26 cases per 100 person-years in urban settings like the greater Montreal area, 1 in 4 HCV-negative PWIDs is at risk of becoming infected with HCV this coming year.⁶

Decreases in HCV incidence and prevalence, and in the corresponding disease burden, can only be accomplished by reducing transmission rates among high-risk persons, and enhancing treatment access for those at the greatest risk of disease progression. To achieve this goal, prevention, early screening, and treatment initiation for HCV infection among PWIDs are key. All these strategies could, and should, be effectively delivered in primary health care settings. Indeed, primary health care physicians are ideally positioned to offer comprehensive and long-term care, and build a supportive relationship with patients. Through interdisciplinary work and approaches focused on the specific needs of patients, they can play an essential role in containing the HCV epidemic.

What primary care physicians can do

In the context of primary health care settings, PWIDs could have access to information on risks of HCV transmission and could benefit from HCV screening. While most PWIDs are well aware of the risks associated with syringe sharing, only a few are familiar with the risks of sharing paraphernalia (eg, cotton, cookers, rinse water).^7,8 Not surprisingly, in the province of Quebec, almost 25% of PWIDs who are found to be seropositive for HCV are not even aware of being infected,⁶ and this proportion is greater than rates reported elsewhere.⁹ The key role of primary care physicians in HCV screening is underscored by the fact that patients without a regular source of care are 19 times more likely to be unaware of their HCV infection.⁹ This is alarming, as infection with HCV is often silent until the very late stage of the disease, when severe liver damage has already occurred. Hence, in order to improve the health outcomes of HCV-infected individuals, early detection is essential.

With current therapy regimens including interferon, HCV treatment is mainly offered in specialized settings. Nevertheless, primary care physicians can play a considerable role in HCV care by fostering engagement in continuity of care. They can perform appropriate investigations and help the HCV-infected person make an informed decision about when and how to get treatment and establish contact with appropriate resources. Indeed, PWIDs who see their primary care providers are 4 times more likely to receive referrals to a liver clinic.¹⁰ Currently, HCV-infected individuals who decide to undertake treatment are confronted with a challenging therapy regimen. Yet, primary care providers can help improve adherence to HCV therapy by offering timely support to patients in treatment and managing medication side effects. Furthermore, within only a few years, well tolerated oral HCV therapies with greater than 90% cure rates are expected to reach the market.¹¹ These new regimens represent a new era for HCV treatment, with the potential to substantially increase its availability in primary care settings.

More broadly, access to a primary care physician provides an opportunity for PWIDs to set goals for improving their overall health and well-being by addressing drug-related problems. Similar to asthma and type 2 diabetes, substance misuse is now recognized as a chronic condition with alternating relapse and remission periods, requiring a continuum of care.¹² Primary care physicians are in an ideal position to offer screening for and diagnosis of substance use disorders, provide access to drug addiction therapy, and encourage positive behavioural change. Multiple sources of evidence have illustrated that receipt of primary health care has a positive effect on addiction severity and relapse prevention, thus emphasizing the value of contact with primary care providers.^13,14

In addition to HCV-related diseases and substance abuse, PWIDs are confronted with a plethora of medical and social ills. As part of integrated health care settings, primary care physicians are in a key position to provide comprehensive care to these individuals. This can be achieved by offering diagnosis and treatment interventions themselves, and by coordinating care with a range of professional groups. For instance, compared with the general population, PWIDs are at greater risk of acquiring hepatitis A and B.¹⁵ Not only do these infections pose a health problem in and of themselves, but also, they directly affect liver function, thus accelerating the development of chronic hepatitis and ensuing illnesses among HCV-infected individuals. As patient advocates, primary care physicians can help prevent these infections by linking PWIDs to appropriate community-based out-reach services, which are well equipped to offer immunizations. In addition to health-related problems, PWIDs are commonly faced with housing and family issues, and lack stable employment positions, all of which can impinge on their ability to adopt and maintain a healthy lifestyle. Yet again, primary care physicians can play an important role in improving the well-being of these individuals by linking them with adequate social support services.

Despite the numerous benefits associated with seeing primary care providers, PWIDs have generally poor access to primary health care services.¹⁶ Consequently, they rely on emergency departments as their main source of care. Moreover, owing to delays in seeking care, they require hospital admissions for conditions that could have been prevented, treated, or well managed in primary care settings.¹⁶

Conclusion

There is an indisputable need for a shift toward preventive, continuous, and comprehensive care for PWIDs in order to improve their overall health status and to diminish the health burden posed by HCV. Increasing efforts should be directed toward linking PWIDs to primary care physicians. A considerable body of indirect evidence points to the potential effect of primary care physicians on reducing the transmission of HCV. However, in light of the current era of evidence-based medicine and practice, clinical evidence providing explicit data supporting this hypothesis is urgently needed. Future research should, therefore, concentrate on exploring this matter.