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Hepatitis C treatment outcomes for Australian First Nations Peoples: equivalent SVR rate but higher rates of loss to follow-up | BMC Gastroenterology


In this study, antiviral treatment was just as effective for First Nations Peoples with HCV as for non-Indigenous Australians with these real-world Australian data consistent with clinical trials and other treatment settings [14,15,16]. In 2017, HCV notification rate in the First Nations Peoples in 5 Australian jurisdictions was 4.4 times higher than that of non-Indigenous Australians (168.1 per 100 000 vs. 38.4 per 100,000, respectively), and they had lower lifetime (37% vs. 47%) uptake of treatment [17]. In our study, once commenced DAA treatment adherence was high. Many patients with HCV have complex health needs and challenging social situations, however relative to non-Indigenous Australians with HCV, First Nations Peoples experienced higher rates of social disadvantage, more co-morbidity including psychiatric illness [18]. These competing social and medical needs constitute barriers to HCV cure for this population [4, 19].

In a recent Australian HCV study (REACH-C) [16], younger age was independently associated with LTFU in a cohort of Australians treated with DAA (adj-OR = 0.97, 95% CI 0.97–0.98, p < 0.01). Other predictors of LTFU were IDU and initiation of treatment after 2016, while HIV coinfection and previous interferon-based HCV treatment were associated with decrease in LTFU. Unlike our study, REACH-C had lower rates of liver disease, and in MVA no difference was seen in LTFU based on Indigenous identification. In our study all patients initiated HCV treatment through hospital services, while in the REACH-C study 53% of patients initiated HCV treatment through specialist liver clinics and 47% through other services (e.g. general practice, community health clinics, sexual health and drug and alcohol services, and prison). Hospital-based care is more difficult for First Nations Peoples to attend regularly, and there are opportunities to address barriers already cited such as racism in health care [20], structural barriers to access care (e.g. access to a suitable transport service) [21, 22], and communication between First Nations Peoples and health professionals [20, 23]. In our study, LTFU was 2.5-fold higher among First Nations Peoples than non-Indigenous Australians, and in MVA restricted to First Nations Peoples, younger age, treatment initiation in 2018–2019 versus 2016, and those with less liver fibrosis were predictors of LTFU. It is likely that the characteristics of the HCV population initiating treatment has changed over time, maybe including more vulnerable groups and patients with recent HCV infection. Some apathy toward SVR testing may have developed over time following observation of consistently high cure rate coupled with the change in the guidelines now suggesting that SVR testing is optional. Understanding the sociodemographic and clinical characteristics of First Nations Peoples with HCV offers insights to optimise engagement [18].

In this study, First Nations Peoples seeking treatment were likely to be younger and have less liver fibrosis and cirrhosis. Despite being younger, First Nations Peoples with HCV more frequently consulted health carer providers 12-month prior to and during DAA therapy (GP visits and specialists) and had more comorbidities. The group of medications for mental health conditions were the most commonly used group of medicines dispensed to First Nations Peoples with HCV, and dispensed more commonly than to non-Indigenous Australians. For First Nations Peoples, determinants of mental health illness are multi-factorial including life circumstances related to culture and spirituality, family and community kinships, historical, social and economic factors, fear of mental health services, loss of cultural identity, and connection to traditional lands and communities [24, 25]. Nasir et al. reported that the rates of anxiety, substance abuse and alcohol misuse among First Nations Peoples was nearly seven times higher than the general Australian population [24], with half the mental illness among First Nations Peoples living on traditional lands [24]. Opportunities for contributing to Australia’s HCV elimination targets among First Nations Peoples lay within Indigenous primary care services where community led responses are best at juggling competing health and social priorities. However barriers that prevent clients and primary care providers delivering optimal HCV treatment and cure need to be addressed. Facilitators of HCV treatment previously cited include incentives for providing HCV treatment, good systems including patient provider rapport and targeted case finding should be implemented to assist the elimination targets for First Nations Peoples [26].

Rates of alcohol abstinence were higher among First Nations Peoples included in the study compared to non-Indigenous patients. According to the Australian Institute of Health and Welfare, in 2016 a higher proportion of First Nations Peoples abstained from drinking alcohol compared to non-Indigenous Australians [27]. Despite higher abstinence rates, community efforts to reduce of harmful alcohol consumption among Indigenous Australian communities is ongoing, and rates of harmful drinking and harms caused by alcohol such as cirrhosis and mental health problems, remain health priority for First Nations Peoples [27]. We also showed that, similar to non-Indigenous Australians, the most common mode of HCV acquisition for First Nations Peoples was IDU. Methamphetamine, heroin and methadone IDU pose an emerging threat for regional and urban Indigenous communities alike [28]. Compared to non-Indigenous Australians, proportionally more First Nations Peoples were prescribed opioid substitution, reflecting positive impacts on the dynamic epidemiology of substance dependence. Social disruption and intergenerational trauma are recognised contributors to alcohol and substance abuse and mental illness among First Nations Peoples [29, 30]. Incidence of HCV and substance dependence and IDU are interwoven. Reducing the HCV burden for First Nations Peoples by increasing HCV treatments, will be undermined by failure to co-manage the addictions driving transmission. Contextualising these impacts is critical to understand the barriers First Nations Peoples must negotiate to access HCV treatment.

Despite the overrepresentation of First Nations Peoples among patients with HCV and higher morbidity and mortality [4, 19], services specifically targeting care among this patient group are few. The Deadly Liver Mob Program [5], for example, is a peer-driven HCV health promotion program operated in co-located needle and syringe programs and sexual health clinics in New South Wales that shown to improve clinic attendance. Nesting HCV treatment within Indigenous primary health services offers a mechanism to increase diagnosis and treatment while concurrently attending to diverse competing needs such as mental health, income and housing insecurity [18]. While increased GP visits in First Nations Peoples may reflect the higher rates of comorbidity, they also identify critical opportunities to improve HCV screening, treatment uptake, and cure at the GP level. The SCALE-C study, currently being tested in selected Aboriginal Community Controlled Health Services (ACCHS) [31], will evaluate a test-and-treat model and long-term impacts on HCV prevalence and transmission.

This study reflects HCV treatment delivered through mainstream services as patients were treated in hospitals by liver specialists in regional and metropolitan settings. Moreover, it does not include HCV treatment delivered through ACCHS and Aboriginal Medical Services which have been identified as critical in this priority population [32]. Other than liver-related comorbidities and diabetes, the use of medications as a surrogate to identify people with comorbidities may underestimate comorbidity. The use of non-pharmacological approaches are used for some conditions. Despite these limitations, the RxRisk-V has been validated and used in Australian and international cohorts [12, 13]. While the OPERA-C study included a large number of patients recruited across Australia, the relatively small number of First Nations Peoples reflects under-treatment. This is a limitation of treatment programs and may limit generalizability to all First Nations Peoples with HCV. Some patients who were LTFU may have accessed HCV care elsewhere, but this data could not be captured in the study, and linkage data does not provide sufficient clinical granularity to assess. Lastly, unmeasured confounders and omitted variable bias (when a relevant independent variable is not included in the model) can lead to biased associations between exposure and outcome in observational studies, and therefore must be considered when interpreting our findings.



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