National Hepatitis B Strategy 2010–2013

6.4 Clinical management of people with chronic hepatitis B

Page last updated: July 2010

Increasing the number of people accessing clinical management is imperative to reducing the burden of hepatitis B.

Only two per cent of people with chronic hepatitis B, and very few Aboriginal and Torres Strait Islander peoples, receive any clinical management for their infection.18 Factors contributing to low levels of
treatment uptake include:

  • poor understanding of hepatitis B within communities most at risk of chronic infection and by primary care practitioners
  • the asymptomatic nature of chronic hepatitis B infection for most people
  • mandatory liver biopsy to obtain government-funded treatment
  • concerns about antiviral drug resistance
  • the toxicity of interferon-based therapy
  • limited infrastructure for delivery of treatment, particularly in rural and remote areas.
The goal of hepatitis B treatment is to suppress viral replication, reduce the risk of progression to advanced liver disease and reduce the development of complications such as liver failure or liver cancer.

Improving the health of people with chronic hepatitis B includes clinical management through antiviral therapy and regular long-term monitoring, including for the development of hepatocellular carcinoma. This process of monitoring can be challenging, particularly with expectations from patients that clinical service delivery equals the provision of pharmaceutical treatment.

Treatment options for chronic hepatitis B have expanded rapidly. These changes, in addition to the complexity of the virus, complicate the development and implementation of management algorithms,
and increase the difficulty of delivering optimal treatment for general practitioners and specialists who do not have a substantial chronic hepatitis B caseload. General practice as part of a healthcare team is central to the healthcare experience of people living with chronic hepatitis B. A first step to reducing the burden of hepatitis B is to improve the level of awareness among primary care doctors generally.

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People requiring hepatitis B management often experience complex social and psychological challenges. A patient with a good understanding of the impact of chronic infection, the purpose of treatment and the clinical process for treatment is more likely to adhere to treatment and respond effectively to the advice of their treating doctor.

Community-based liver clinics that are physically accessible and respond to the specific needs of the patient group—including by providing trained interpreters, cross cultural training of staff, staff from similar cultural background to patients, and flexibility in delivering care to accommodate patients’ difficulties in attending appointments—are effective.19

The burden of chronic viral hepatitis on specialist liver services is increasing and existing services have lengthy waiting periods for new referrals. This situation necessitates the development of a model of care for delivering hepatitis B care through a range of services (including through the primary care sector) and identifying mechanisms to appropriately resource service delivery.

Liver biopsy is a requirement for access to government-funded hepatitis B treatment. Therefore, people without access to biopsy services cannot access treatment. This has a specific impact on remote Aboriginal and Torres Strait Islander communities. In addition, the cultural beliefs of some CALD communities can conflict with liver biopsy as a procedure.

Priority actions in clinical management

  • Trial innovative models of the monitoring and treatment of hepatitis B which will increase access to clinical services (including increased involvement of general practitioners, nurses and other healthcare professionals in monitoring and follow up) and address the needs of a range of populations, including those living in remote communities and custodial settings.
  • Explore options for primary care practitioners to prescribe hepatitis B treatments, particularly in areas with limited access to specialist care, to free up access to specialist services for more complex management.
  • Review the evidence for removing the requirement for mandatory liver biopsy for treatment, taking into account the impact of this requirement on Aboriginal and Torres Strait Islander communities.
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18 Wallace J. McNally S. & Richmond J 2007, ‘National Hepatitis B Needs Assessment’, La Trobe University, Australian Research Centre in Sex, Health and Society, Monograph no. 64, Melbourne, pp. 6–8.
19 McNally S & Duterte S ‘Improving access to hepatitis C treatment 2008’, The Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Monograph Series no. 66.