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Hepatitis C: a cure firmly on the horizon

Hepatitis C: a cure firmly on the horizon

 - Hepatitis C poses a considerable public health burden but is often under prioritised

 - The availability of new oral treatment combinations will significantly change the way nurses treat and manage patients 

 - The hepatitis C landscape is rapidly changing with the prospect of eradication an exciting and real possibility 
With the arrival of new oral therapies offering clinical cure, what does this mean for nurses on the frontline of hepatitis C care? The Hepatitis C Trust has said that if we act now we can eradicate hepatitis C within a generation.1 With recent advances in hepatitis C treatment, that prediction could become a reality and the long-term outlook for patients is very positive. 
Estimates suggest that around 215,000 individuals are chronically infected with hepatitis C virus (HCV) in the UK today.2 In England, half of those living with the disease are undiagnosed and in most cases, hepatitis C causes no obvious symptoms until the liver has been significantly damaged.3 Despite being a curable infection, only 3% of people receive treatment and almost half of people going to hospital for hepatitis C are from the poorest fifth of society.1 There are many hurdles to overcome in the journey towards eradication and nurses will be at the centre.
Who is at risk?
Hepatitis C is a blood-borne virus that can infect and damage the liver. It is contracted by coming into contact with blood infected with the virus. This can happen in a number of ways including through non-sterile needles (injecting drugs, tattooing, piercing), unprotected sex, blood donations (prior to screening) and sharing of items such as toothbrushes or razors. If left untreated it can lead to potentially fatal cirrhosis or liver cancer.  
Unfortunately hepatitis C continues to be associated with a stigma due to the link with drug use, and like human immunodeficiency virus (HIV), this remains one of the main reasons patients struggle to accept their diagnosis. As nurses we see patients from all walks of life that have been affected by hepatitis C and it is important that we work harder to raise awareness and acceptance of the disease. This is particularly important as the number of people infected with the disease continues to increase.
Hepatitis C and healthcare resources
The advances in hepatitis C treatment are positive, and we are right to be optimistic about the future. However currently the disease poses a considerable burden on healthcare resources, and predictions suggest that HCV infection will increase from 215,000 in 2013 to 370,000 by 2035 if the current situation remains the same.4 
In 2012, healthcare costs associated with the condition were estimated at £82.7m,4 and liver transplants performed due to hepatitis C-related cirrhosis have more than doubled since 1996.5 Each liver transplant can cost the NHS a staggering £70,000.6 It is clear that the health service in England is under a lot of pressure, and often hepatitis C is not considered a priority. 
Lessons can be taken from other countries such as Scotland, where a major emphasis has been placed on increasing the number of people receiving treatment through a £100 million national programme. The multidisciplinary approach is aimed at improving testing, treatment, care and support services for those infected and it is proving to be very effective with the number of patients receiving treatment having tripled since 2007.7
On the front line
As specialist nurses we see first-hand the impact that hepatitis C can have on a person’s life. There are effective treatments (interferon/ribavirin) available that can clear the virus from the blood and prevent damage to the liver, but many patients suffer sustained side effects and are not able to tolerate therapy. Achieving clearance of the virus can be a protracted and complex journey and support and effective management from the specialist nurse is key.  
New interferon-free, oral treatment combinations are becoming available and this is welcome news for patients and nurses alike. One such treatment is daclatasvir which is in a class of medicines that directly prevents the replication of the hepatitis C virus. Daclatasvir is used as part of a combination and has shown high cure rates in patients with genotype one and three which accounts for 90% of the cases in the UK. 
‘Cure’ corresponds to undetectable HCV ribonucleic acid (RNA) at 24 weeks (lower limit of detection <15 IU/ml, SVR24) which has 99% concordance with SVR12 as the definitive cure of HCV infection.8 The hepatitis nurse role is likely to change significantly as these oral therapies become available, moving our focus from managing side effects, towards pill adherence which will need to be closely monitored. 
Aspects of our job will become similar to HIV nurses, and educating patients about the possibility of re-infection will be essential. There are concerns about cost and access to new therapies and that is something that nurses will have to manage carefully with a well-informed patient population. NHS England and Public Health England are currently in consultation with experienced healthcare professionals in identifying patients for the new agents. The role of specialist viral hepatitis nurses will be to educate and inform patients why they have or have not been selected and be aware of current national guidelines. 
Realising eradication of hepatitis C
While there is an extremely positive future on the horizon for hepatitis C, a more aligned and co-ordinated strategy across all aspects of care needs to be implemented in England and this has been identified by Public Health England and NHS England. 
Critical to improving the situation is better education of healthcare professionals both in primary and secondary care. There is a considerable need to educate GPs, practice and community nurses, particularly in rural areas where HCV infection is on the increase. This has been put down to a lack of facilities and community engagement leaving people open to risky behaviours. Specialist nurses, with the help of the pharmaceutical industry, will be instrumental in education efforts, holding meetings and sharing knowledge with primary care colleagues. 
In these very challenging and changing times we as nurses will be at the centre of education. Another element is general awareness and acceptance of hepatitis C. A significant effort is required around public awareness campaigns such as the ones conducted for HIV, which can make a real difference not only to public perceptions and attitudes, but to people recognising risks, identifying symptoms and getting diagnosed. Ultimately more people need to have access to treatment if we have a hope of eradicating this cancer-causing virus for good.  
3. NHS Choices. Hepatitis C – Introduction. Last accessed June 2014

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