Hepatitis B and hepatitis C (HBV and HCV) infect the liver and frequently propagate as blood-borne pathogens worldwide. Millions of individuals worldwide have chronic (long-term) HBV and HCV, which can cause the risk of cirrhosis (chronic liver damage), liver cancer, and liver failure. Antiviral medications aim to eradicate HBV and HCV infections. However, the overemphasis on antiviral treatment by manufacturers, patients, and doctors has failed to identify the health needs of people with HBV and HCV. The goal of chronic HBV and HCV infection treatment is to obtain a “functional cure.” However, HBV and HCV treatment must be predominantly defined in the primary health sector, as primary healthcare providers play a pivotal role in delivering care for these patients.
Which Patients Require Intervention for Chronic Hepatitis B and C Infection in Primary Care?
The history of chronic hepatitis B and C comes from studies of patients infected by transfusions and of patients screening for liver disease. These perspectives give different pictures of the natural history of the conditions. Studies of patients close to the time of infection depict a lower level of complications such as cirrhosis, liver cancer, and hepatitis C -related deaths. Further, millions of patients with chronic HCV live full lives with few consequences of the infection. Still, scientists are unable to recognize patients with progressive HCV disease and those who will improve with antiviral therapy.
What Role Do Primary Health Care Providers Have In Managing Chronic Hepatitis B and C Infection?
Chronic HBV and HCV patients need information about the transmission and prevention of the diseases. Primary healthcare providers can explain the illness stage, symptoms, progression prevention, and antiviral treatment options. They can also help patients prevent complications and untoward consequences of the diseases with the following steps.
1. Patients with chronic HBV and HCV must be vaccinated against hepatitis A and B (as these cause acute diseases).
2. Healthcare providers must advise patients to abstain from alcohol. It is because alcohol abuse is a frequent co-occurring condition in HCV. Primary healthcare providers must do alcoholism screening and use interventions to decrease alcohol abuse for HCV patients.
3. Patients injecting illicit drugs are at risk of contracting HIV, HBV, and HCV infections. Further, they can transmit HCV to other drug abusers. Hence, primary healthcare providers must inform them about substance abuse treatment, safer injection practices, and access to sterile syringes.
4. HIV co-infection can accelerate liver disease progression from HCV infection. Hence, patients must be tested for HIV and given care if infected.
5. Drug-induced hepatotoxicity (liver toxicity) is an acute (short-term) or chronic liver injury due to drugs. The principle treatment is the offending drug removal and close patient observation for resolution. Therefore, primary healthcare providers can aid patients in avoiding hepatotoxic drugs.
Primary-care settings are suited to care for chronic HBV and HCV patients because:
- Primary care is more broadly available than specialty care.
- Primary care can build and sustain a continuing relationship between patients and healthcare providers.
- Primary care delivers comprehensive treatment addressing the patient's physical, behavioral, and family needs.
What Are the Novel Treatment Options for Chronic Hepatitis B and C Infection in Primary Care?
In patients with HCV and HBV co-infection, the risk of cirrhosis and liver cancer is higher than in those with a single infection. As a result, these patients require continuous monitoring and aggressive antiviral therapy.
1. Combined Peginterferon (pegIFN) Alfa and Ribavirin:
- Interferons (IFNs) are proteins belonging to the signaling molecules group known as cytokines for immune response upregulation. Peginterferon alfa- 2a is an immunomodulatory, antiviral agent approved by authorities for chronic HBV and HCV infection treatment. Interferon alfa is combined with a polyethylene glycol (PEG, a polyether compound) chain to produce pegIFN alfa- 2a.
- Ribavirin (RBV, an antiviral medication) works by stopping HBV and HCV from spreading inside the body. One must note that Ribavirin does not work against HCV and HBV unless combined with another medication (such as PegIFN alfa- 2a).
- Studies confirm the efficacy of PegIFN plus RBV for the treatment of co-infected patients with active HCV. In addition to HCV infection cure, PegIFN-based therapy can also help in controlling chronic HBV spread in patients with HCV/HBV co-infection. However, promising new antiviral drugs are currently being evaluated. These drugs may provide considerable clinical improvements compared to the recommended Peg IFN alfa and Ribavirin treatment.
2. Direct-Acting Antivirals:
Direct-acting antivirals (DAAs) are novel oral drugs that target virus-specific proteins. DAAs have revolutionized the treatment of chronic HBV and HCV. These drugs have led to high HCV cure rates with decreased treatment duration. Further, patients exhibit excellent tolerance to these drugs compared to PegIFN and RBV-based therapies. DAAs inhibit HCV proteins vital for its replication. Boceprevir, Telaprevir, Simeprevir, Asunaprevir, Ombitasvir, Ledipasvir, Sofosbuvir, and Daclatasvir are some DAAs. Sofosbuvir (SOF) is an effective DAA launched in 2015 and is available at a reasonable price. However, one must note that there is a risk of HBV reactivation after DAA therapy in HBV and HCV-co-infected patients.
What Are the Treatment Considerations for Chronic Hepatitis B and C Infection in Primary Care?
Current treatment regimens against HBV and HCV can achieve a viral load reduction below detectable levels at six months after the end of treatment in about 50 percent of patients. Most patients who achieve viral load reduction are at low risk of HCV infection relapse and can achieve a clinical cure. However, many patients do not receive antiviral medications because:
1. They are unaware of their infection.
2. They have inadequate health insurance, or adequate primary healthcare providers are unavailable.
3. They are considered ineligible for treatment due to continued alcohol use, uncontrolled psychiatric illness, or appointment failure.
4. Although eligible, they do not seek treatment due to concerns about cost, side effects, and desire to wait for improved treatment options.
One must note that antiviral treatment is expensive and challenging for patients and primary healthcare providers. Furthermore, quality of life (QoL) with PegIFN- alfa-2a and Ribavirin treatment deteriorates due to adverse effects such as anemia, depression, and flu-like illness.
Newer antiviral treatments can achieve a functional cure for the disease reducing the risk of co-infection. Such treatments must be given for a limited time and at a reasonable cost. Major advances are made toward understanding the viral life cycle and the mechanisms to evade host immune responses. However, poor awareness, exaggerated fears, contraindications, and insufficient treatment funding contribute to low treatment rates in patients.