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Decentralisation of hepatitis C virus care into community settings: A key approach on the path to elimination

As we rapidly approach the final years in attempting to meet the World Health Organization (WHO) viral hepatitis elimination goals, only 11 highincome countries are on track to eliminate hepatitis c virus (HCV) as a public health threat by 2030.1,2 Most countries are almost 20 years from achieving this milestone based on current estimates. Approximately only 21% of those estimated to be infected with HCV globally have been diagnosed and, of those, only 62% have been treated with highly effective directacting antivirals (DAA).3 Complementary strategies, such as microelimination, have been proposed to improve the implementation of elimination initiatives, and novel models of care (MoC) are important tools to achieve this; however, several heavily burdened countries have not yet published an elimination strategy aligned to the WHO targets. 4,5 Further, even in multiple European countries, where elimination progress is on track, implementation of WHOaligned elimination strategies is suboptimal.6 Consequently, it is imperative to trial and share effective MoC which optimise patient outcomes in key populations, while minimising attrition through the clinical pathway for HCV. To this end, we read with interest the paper presented by Harney et al,7 who present the findings of a communityembedded nurseled model of HCV care (MoC) for those attending alcohol and other drug (AOD) services in Melbourne, Australia. The study pathway embedded routine nurse visits to AOD services in greater metropolitan Melbourne to provide testing and conduct pretreatment assessments for HCV RNApositive individuals. In noncomplicated cases of infection— that is noncirrhotic— onsite general practitioners (GPs) or nurse practitioners prescribed DAA treatment in line with national guidelines. Those prescribed treatment were followed up by nurses to support adherence and test for sustained virologic response at 12 weeks posttreatment (SVR12). The study team engaged 640 people in care and tested 518 (81%) of those for HCV RNA. Among those tested, the incidence of infectivity was high with 381 (74%) RNA positive. Treatment uptake was similarly high (n = 281; 74%); however, there was a critical point of attrition with only 57.3% (n = 161) returning for SVR12 testing. Among those tested for SVR12, most achieved a cure (n = 157, 97.5%). Critically, most participants were treatment naïve (n = 318; 83.5%) and reported recent injection drug use (IDU) (68.5%), suggesting the MoC reached a new and highrisk population. Statistical analysis suggested that receipt of opioid agonist therapy (OAT) was associated with increased odds of treatment initiation, while unstable housing was associated with decreased likelihood of engagement. Meanwhile, receiving treatment from a specialist, and recent IDU, was associated with increased odds of SVR12 testing. The results presented are comparable with other nurseled programmes and again suggest that HCV testing and treatment uptake in decentralised AOD settings can be high. Increased patient– provider contact can facilitate treatment initiation, while further tailored interventions are required to improve service traction with unstably housed persons and SVR12 testing uptake. Clearly, this timely study— underpinned by the safety and efficacy profile of DAAs— encourages reflection on the design of care pathways for HCV and suggests that decentralisation should be a core tenet of service design to accomplish relative elimination targets. Again, this work fundamentally highlights the critical need in ensuring appropriate care for the right individual in the right place, as we continue to plan and refine our public health responses to HCV globally. It is well recognised that DAAs are highly effective across populations, and there are multiple clinically validated diagnostic tools available for use in devolved environments. It is now necessary to shift the focus from what tools to use, to how to use them best for patient benefit, that is patientcentred care.8 This study provided interesting insights into the various professionals involved in the care network within Australia, and so the generalisability of the MoC for those looking to replicate this communitybased approach. While hospital specialists can provide a key role in delivering integrated HCV care, hospital referrals should be reserved for complex cases with considerable challenges and, therefore, a more nuanced role for secondary care ought to be encouraged. Where decentralisation of tasks conventionally performed by a clinician cannot be achieved, telehealth can play a critical role in diminishing the requirement for hospital visits for vulnerable patient groups. For example, Jiménez Galán et al. successfully implemented a telehealth approach to eliminate HCV in a Spanish prison, achieving cure rates of 97%, despite a high HIV coinfection burden (43%).9 Satisfaction with the MoC was high at 67% among inmates and clinical staff. Telemedicine in the prison context has been reported as costsaving10 and ensures equity of access to specialist care for prisoners if required. Where decentralisation of tasks such as diagnosis and DAA prescription can be undertaken, support from a multidisciplinary team (MDT) for complex cases could be considered. This can be facilitated