HEPATITIS C ON

PRIMARY CARE SETTING

 Why Primary Care Setting ?

▷ Hepatitis C virus (HCV) infection is a significant

health problem worldwide
▷ Dramatic improvement on HCV treatment
▷ Medication : efficacy is more than 90%, high
barrier to resistance, few side effects
▷ A new era where primary care physicians, family
doctors, and general internists to be on the
forefront

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Natural History HCV Infection

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Acute Hepatitis C

▷ Up to 4 million people are newly infected with HCV annually

▷ Acute illness is clinically mild and is typically unrecognised
and undiagnosed
▷ Between 20-35% of infected individuals spontaneously clear
HCV
▷ Acute resolution of HCV is not associated with any longterm
sequelae. For that, Treatment is indicated only in patients
who are likely will develop chronic hepatitis

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Chronic Hepatitis C

▷ The leading cause of end-stage liver disease, HCC and liver

related deaths
▷ Fibrosis progression rates are extremely variable and are
influenced by host, viral and environmental factors
▷ Achievement of a sustained virologic response (SVR) is
associated with a reduction in portal hypertension, hepatic
decompensation, HCC and mortality

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 “
Even though HCV infection is a slow growing
disease, All this expensive effort will give a
benefit - Not a direct result but long term
result

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Which part does primary
care hold ?

▷ Find new case

▷ Manage new case
▷ Manage post treatment case

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Finding new case

▷ Difficult to find acute case as Only 20 % has

symtom : flulike syndrom, jaundice, fatigue,
nausea, dark colour urine
▷ Routine Anti HCV examination is rare

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▷ Survei from 1200 Family Physician selected
randomly from American Family Physician
▷ Result : 48% care for at least 6 Hepatitis C
patients in their practice and 21% care for at
least 11 Hepatitis C patients

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10
EASL GUIDELINE

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High Risk Population
• Keluarga dari penderita hepatitis (serumah / pasangan)
• Orang dengan pola hubungan sexual tidak sehat : berganti-ganti
pasangan, homosexual
• Orang yang menjalani pengobatan berkaitan dengan darah : pasien
hemodialisa, pasien transfusi berulang
• Orang yang melakukan tatto, tindik bukan di fasilitas yang steril,
pengguna jarum suntik bergantian
• Bayi yang lahir dari ibu hepatitis C
• Petugas kesehatan
• Orang yang pernah dipenjara

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Testing Algoritm on HCV

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Testing Algoritm for HCV exposure

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Sources of acute hepatitis C infection by
geographic region

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 To Find New Case

“
▷ Do anti HCV examination on high risk
population and person who has abnormal
AST/ALT
▷ But Actively asking the risk factors ?
▷ If anti HCV positive - proceed to HCV RNA

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 Manage new case

▷ Define acute or chronic

▷ Screen for Cirrhosis and HCC
▷ Find comorbid disease

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Define Acute or Chronic

Acute :
▷ Known exposure

▷ Suspected : high ALT, symptom, no

other liver disease
Chronic :
▷ 6 months HCV RNA can still detected

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Screening for Cirrhosis and HCC

▷ Liver biopsy already rare

▷ Noninvasive test ( transient elastography )
▷ Noninvasive blood marker panels [aspartate
aminotransferase - platelet ratio index (APRI),
fibrosis - 4 (FIB-4), FibroTest, Hepascore,
FibroMeter, and FibroFast]
▷ Ultrasound to detect nodul

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APRI SCORE and Interpretation

https://www.hepatitisc.uw.edu/go/evaluation-staging-
monitoring/evaluation-staging/calculating-apri

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 HCV INFECTION TREATMENT

▷ Who has an authority to treat the patients

▷ Acute infection - when to treat ?
▷ Chronic hepatitis C - should we do genotype
test ?

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 ACUTE HCV INFECTION TREATMENT

▷ Spontaneous sesolution 20 – 40 %, median time to

clearance was 16.5 weeks, 30 % clearance at 3
mounth, the rest at 6 and 12 mounth
▷ 2 metaanalysis show that treatment of patient with
acute HCV infection is beneficial and cost effective
▷ Eventough immediate treatment is not
recommended → only to those who likely will
develop chronic infection

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Can Clearance of Infection Be Predicted ?

▷ Sympomatic
▷ Female
▷ Less than 40 years old
▷ Childeren
▷ No HIV concomitant

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 TREATMENT REGIMEN
▷ No consensus on a standardized treatment regimen
▷ No trials comparing the efficacy of PEG-IFN a-2b
with PEG-IFN a-2a.
▷ only limited data on the additional benefit provided
by combining ribavirin
▷ The clearance rate difference between the 12- and
24-week treatment groups was not significant

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 Acute HCV Treatment

“
▷ For acute HCV infection, wait for 12 weeks ,
before start the treatment
▷ Hold treatment to those who likely will reach
spontaneous clearance
▷ Treatment of choice Peg-Interferon 12 weeks
--> might be not for primary care setting

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CHRONIC HCV INFECTION TREATMENT

▷ Safer
▷ Shorter
▷ High efficacy

Interferon Direct acting antivirus

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 Direct Acting Anti Viral
▷ Inhibit specific HCV non-structural proteins (NS) that are
vital for its replication

▷ The three nonstructural proteins (NS3/4A, NS5A, and

NS5B) are important for HCV replication,

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Direct Acting Anti Viral

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Direct Acting Anti Viral

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▷

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Pangenotype DAA

▷ Sofosbuvir
▷ Sofosbuvir + Daclatatsvir
▷ Sofosbuvir + Dclatatsvir + Ribavirin
▷ Sofosbuvir + Velpatasvir

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Treatment chronic hepatitis C

“
▷ DAA era give wider oppurtunity for non
hepatologist to treat HCV infection
▷ Pangenotype DAA - can be used without
genotype examination
▷ But is that really that easy ? --> need training

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Manage Post Treatment
• Those who already in cirrhosis state still have
risk of HCC
• Those who keep on a risk of HCV infection
(hemodialysis, repeated transfusion, drugs
abuser) need evaluation
• Those already finished the treatment need to
be educated continuously to avoid a high risk
activity

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 Conclusion :

“
▷ HCV infection treatment change dramatically
▷ DAA give better efficacy and less side effect
▷ The existence of pangenotype drug like sofosbuvir ,
reducing laboratory cost and make treatment more
reachable for primary care setting

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