Hepatitis C treatment in primary care

Authors

Lukas Hestvik MN-NP(F) BSN (biography, no disclosures), Nance E Cunningham (biography and disclosures), Sofia Bartlett PhD (biography and disclosures) and Julia MacIsaac MD (biography and disclosures)

Nance E Cunningham’s disclosures: I am a volunteer board member of the British Columbia Hepatitis Network. British Columbia Hepatitis Network had no role or influence in the content or approach of this article. I have received grants from the Public Scholars Initiative at UBC. Mitigating potential bias: Recommendations are consistent with published guidelines: Canadian Association of Liver Disease. Recommendations are consistent with current practice patterns. Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.

Sofia Bartlett’s disclosures: Spoken for, consulted for, and participated in medical advisory board programs with Gilead Sciences, AbbVie, and Cepheid (no personal payments accepted). Received investigator-initiated, unrestricted funding from Gilead Sciences, Pfizer, and AbbVie in the form of grants from the Pacific Public Health Foundation held by the Provincial Health Services Authority. Mitigating potential bias: Recommendations are consistent with published guidelines: AASLD-IDSA, BC Guidelines.

Julia MacIsaac disclosures: Speaking honorarium from Gastrointestinal Research Institute (GIRI). GIRI is a non-profit organization with a mission to support clinical research and advance education in gastrointestinal diseases. Mitigating potential bias: Recommendations are consistent with published guidelines: AASLD, IDSA, EASL, CASL. Recommendations are consistent with current practice patterns.

What I did before

In 2016, the World Health Organization set ambitious targets to eliminate the Hepatitis C virus (HCV) as a global public health threat by 2030.¹ Prior to the COVID-19 pandemic, British Columbia (BC) was on track to meet the targets of treating 80% of eligible people, reducing incidence by 90% and reducing mortality by 65%.² Achieving this requires increased efforts to diagnose more British Columbians and link those already diagnosed but untreated to curative care.

Previously, I would complete baseline labs for all my patients who were positive for HCV RNA and refer them to infectious disease or gastroenterology specialists. I referred because a full hepatitis C assessment felt beyond my scope in primary care. The specialist would complete a liver disease assessment, usually including transient elastography such as FibroScan®, and the special authority application. Treatment would not be initiated until a follow-up visit with the specialist. Months could elapse from initial referral until treatment initiation. The extra steps and delays were a barrier, decreasing the likelihood of treatment.

Table 1. Quick facts

What changed my practice

One key strategy to sustain the HCV treatment rate in BC is to provide HCV treatment in primary care settings for adults who have not previously received treatment and don’t have liver disease (i.e., non-cirrhotic) or any other serious complications.

Treating these uncomplicated HCV cases in primary care settings is safe, simple and rewarding, and reduces delays in treatment initiation that are frequently encountered when referring to specialty care.

BC Guidelines for Viral Hepatitis Testing recommend HCV screening at least once for people born between 1945 and 1965. Screening should also be offered to patients with specific HCV risk factors, including previous injection substance use, history of incarceration, and receiving healthcare or living in an HCV-endemic country.³ Meeting Canada’s elimination targets requires a low threshold to screen.^4,5 All primary care professionals, including nurse practitioners like myself, are able to apply for special authority to have HCV pharmacotherapy reimbursed by BC Pharmacare if they have experience with treating hepatitis C infection. Non-invasive tests of liver fibrosis, such as APRI and FIB-4, can be used for fibrosis staging, which are readily calculable in primary care using standard lab variables (AST, ALT, and platelets) with or without demographic factors. In patients who are at low risk of having advanced fibrosis, no specialized tests or equipment are required; all work-up necessary for Special Authority can be completed by any provider who is authorized to order these blood tests, provided they have the necessary training and experience in treating HCV. For patients who have indeterminate values on FIB-4 or APRI, I still refer for a Fibroscan to clarify fibrosis stage, although this is a minority of patients.

To gain experience treating HCV, I completed two free, self-paced online courses: Hepatitis C for Pharmacists and the University of Washington Hepatitis C courses (see resources). This training on streamlined HCV treatment for uncomplicated infections provided a knowledge base. I then shadowed several shifts with a local infectious disease specialist in a clinic which sees a high volume of HCV patients, gaining BC-specific clinical experience with HCV.

What I do now

In my practice, I offer communicable disease screening for all my patients. I follow the process outlined below.

Download the Decision Making in Hepatitis C PDF, or access the PDF at PathwaysBC.

Figure 1. Decision Making in Hepatitis C

When to test

• Whenever testing for any sexually transmitted or blood-borne infection is conducted, I offer comprehensive testing using urine and serology.
• When counselling, I inform patients that:
  • 44% of Canadians who have HCV are unaware of it.⁶
  • People with ongoing potential exposure should be screened annually, or more frequently, according to risk.⁷
  • (For patients with HCV risk factors) Explain their heightened risk for infection and that testing is highly recommended.
  • They have a right to decline, and I am always happy to discuss this further in the future.
• Most patients are comfortable adding on HCV screening to their lab work.

Test/s, results and actions

• Ask patients if they have previously been diagnosed with HCV.
  • If not: I order an antibody test.
  • If they have: About 30% of people in BC will spontaneously clear HCV within six months of initial infection.⁸ If a person has ever had HCV infection, even if they spontaneously cleared or achieved treatment-induced cure, they will always have a positive HCV antibody test. In these cases, I order an HCV RNA test.
• Reflex testing: If a patient tests positive for HCV antibodies and has never previously had an HCV RNA test performed in BC, the BCCDC Public Health Laboratory automatically performs the HCV RNA test, known as ‘reflex testing’.

Pre-treatment assessment

• A positive HCV antibody test triggers the rest of the workup. Now that I have training, I feel comfortable providing simplified HCV care for non-cirrhotic, treatment-naïve people in my practice.
• Perform baseline screening, checking for other causes of liver disease and considering pregnancy:
  1. CBC, liver function tests (LFTs including AST for fibrosis assessment), albumin, total and direct bilirubin, INR, eGFR/creatinine, electrolytes, HIV serology, syphilis serology, hepatitis A immunity, HBsAg, HBsAb, HbcAb.
  2. Urine pregnancy test if appropriate.
• Vaccinate for hepatitis B if HBsAb concentration is < 10 mIU/ml.
• Assess liver fibrosis:
  • Assessing platelets, INR and albumin are valuable for liver-function assessment. I then use APRI and FIB-4 calculators to assess for cirrhosis. An APRI score above 2 is highly suggestive of cirrhosis, and less than 0.5 means cirrhosis is unlikely. A FIB-4 of 1.45 or less has a negative predictive value of 90% for advanced fibrosis, and >3.25 has a 97% specificity and 65% positive predictive value for advanced fibrosis. I order an abdominal ultrasound at this time, but do not let this delay treatment in non-cirrhotic patients.

Treatment

• Apply for special authority:
  • If a patient does not appear to have signs of cirrhosis, is not co-infected with HIV or hepatitis B virus (HBV), or renal failure and the current HCV infection has not been treated previously, then I apply for special authority and independently initiate treatment.
  • I perform comprehensive assessments of patients to evaluate ongoing risk factors, emerging signs and symptoms of cirrhosis, past medical history, medications, allergies and physical exam findings to assess for stigmata of liver disease.
  • I recommend sexually active people with childbearing potential use reliable contraception, as treatment is contraindicated during pregnancy.
  • Eform special authority requests are typically responded to significantly quicker.
• Refer to a specialist:
  • I refer patients to a specialist if they have HCV treatment failure, are pregnant, have HIV or HBV co-infection, indeterminate fibrosis staging or signs of cirrhosis.
• Treatment options:
  • In BC, most non-cirrhotic, treatment-naïve patients who are treated in primary care are treated with one of two medication options: glecaprevir-pibrentasvir (G/P) for 8 weeks or sofosbuvir-velpatasvir (SOF/VEL) for 12 weeks. These direct-acting antiviral combination regimens are highly effective, highly tolerable, and can be prescribed for all HCV genotypes, with cure rates higher than 95%.⁹
  • I check for drug interactions using the Liverpool drug interaction checker. Given that some folks may have competing priorities, making adherence to daily medication a challenge, I prescribe the 8-week course if there are no contraindications. Many potential drug interactions are easily managed and not a contraindication to therapy. In these situations, I consult with a pharmacist.

Monitoring and follow up

• Follow up:
  • I follow up with patients 1-2 weeks after initiating treatment to assess tolerance and adherence.
  • I also counsel them that follow-up blood tests will be needed after completing treatment to confirm a cure, referred to as sustained virological response (SVR). One of the fantastic things about HCV is that we can actually say “You are cured!”. This is one of my most rewarding moments in clinical medicine. I try to do an early HCV RNA at 4-weeks post-treatment as SVR4 has over 99% concordance with the traditional SVR12, which is considered a cure.¹⁰
• Post-treatment counselling:
  • I educate patients that they are never immune to HCV—they can acquire it again.
  • I use the opportunity to discuss harm reduction strategies and safety, and ensure they have access to new substance-use kits.
  • I usually will do LFTs with each SVR check. If LFTs are not improving, I want to assess for other causes.

Special populations

• Ensure all your patients have equitable, respectful health services to draw on. Some pharmacies will not dispense DAAs, but the medication can be filled at a larger pharmacy that dispenses DAAs and sent by mail to the patient’s regular pharmacy. Discuss the importance of staying with the same pharmacy during treatment, as changing pharmacies can result in delayed or interrupted treatment if the prescription is not transferred.
• People with a history of substance use or substance use disorders are at elevated risk of HCV due to both the risk of shared equipment with traces of blood and due to behaviours related to substance use, e.g., reduced inhibitions resulting in other risks. DAA treatment is highly effective for people with active substance use, and as they are at high risk of onward transmission, they are a priority treatment population. If your patient is on OAT or other regularly dispensed prescriptions, consider dispensing DAAs with them.
• Unstable housing may put people at risk for HCV indirectly due to associated exposures related to a lack of resources. Stable housing is not a condition for DAA treatment, but discuss your patient’s living arrangements and the best prescription model if there is a possibility of loss of their possessions.
• Discuss any special considerations for Indigenous patients, e.g., Do they have far to travel to pick up a prescription? Are they comfortable with the dispensing pharmacy?

Summary

In summary, treatment of hepatitis C in my primary care practice has decreased several barriers to treatment for many of my patients and substantially improved their health. I find treating HCV rewarding and, after training, it has been much easier than I had anticipated. Broad-scale treatment in primary care settings will go a long way to bolster the effort to eliminate Hepatitis C as a major public health threat in BC.

Additional resources

Resources for patients

• CATIE: Hepatitis C basics
• British Columbia Centre for Excellence: HCV fact sheet

Resources for healthcare providers

Courses for healthcare professionals:

• International Network on Health and Hepatitis in Substance Users (INHSU): Hepatitis C courses for providers in Canada (available in English and French)
• University of Washington: Hepatitis C online courses

Online resources for healthcare professionals:

• BC Guidelines: Viral hepatitis testing guideline
• University of Washington: Fibrosis-4 (FIB-4) calculator
• University of Washington: AST to Platelet Ratio Index (APRI) calculator
• BC Guidelines: Hepatitis B and Hepatitis C endemic countries (PDF)
• BCCDC Public Health Laboratory eLab Handbook (In the “Search for test” field, enter ‘Hepatitis C serology’. Select ‘Hepatitis C Serology’ in the records returned)
• BCCDC Communicable Disease Control Manual Hepatitis C Guideline
• BCCDC: STBBI and TB report dashboard
• HCV Guidelines (especially helpful for more complex cases)
• NS5A resistance testing form
• University of Liverpool: Drug interaction checker

References

1. Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030: A pan-Canadian framework for action. Ministry of Health. Public Health Agency of Canada. Updated July 9, 2018. Accessed August 19, 2020. (View on canada.ca)
2. Feld JJ. HCV elimination: It will take a village and then some. J Hepatol. 2020;72(4):601-603. doi:10.1016/j.jhep.2020.01.002 (View or view on UBC)
3. Blueprint to inform hepatitis C elimination efforts in Canada. Canadian Network on Hepatitis C Blueprint Writing Committee and Working Groups. 2019. Accessed April 22, 2020. (View PDF)
4. Shah H, Bilodeau M, Burak KW, et al. The management of chronic hepatitis C: 2018 guideline update from the Canadian Association for the Study of the Liver. CMAJ. 2018;190(22):E677-E687. doi:10.1503/cmaj.170453 (View)
5. Wong WW, Haines A, Farhang Zangneh H, Shah H. Can we afford not to screen and treat hepatitis C virus infection in Canada?. Can Liver J. 2018;1(2):51-65. Published 2018 Jul 17. doi:10.3138/canlivj.1.2.005 (View)
6. Rotermann M, Langlois K, Andonov A, Trubnikov M. Seroprevalence of hepatitis B and C virus infections: Results from the 2007 to 2009 and 2009 to 2011 Canadian Health Measures Survey. Health Rep. 2013;24(11):3-13. (View PDF)
7. Primary care guidelines for the management of adults living with HIV/AIDS in British Columbia. British Columbia Centre for Excellence in HIV/AIDS. Accessed March 13, 2025. (View PDF)
8. Bartlett SR, Yu A, Chapinal N, et al. The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: Impact of direct acting antivirals. Liver Int. 2019;39(12):2261-2272. doi:10.1111/liv.14227 (View or view on UBC)
9. Di Marco L, Cannova S, Ferrigno E, et al. A comprehensive review of antiviral therapy for hepatitis c: The long journey from interferon to pan-genotypic direct-acting antivirals (DAAs). Viruses. 2025;17(2):163. Published 2025 Jan 24. doi:10.3390/v17020163 (View)
10. Gane E, de Ledinghen V, Dylla DE, et al. Positive predictive value of sustained virologic response 4 weeks posttreatment for achieving sustained virologic response 12 weeks posttreatment in patients receiving glecaprevir/pibrentasvir in Phase 2 and 3 clinical trials. J Viral Hepat. 2021;28(11):1635-1642. doi:10.1111/jvh.13600 (View)

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