Nationally there has been a push to increase the number of people who are being tested and treated for hepatitis C since 2016, with the introduction of new tablet-based treatments – known as direct acting antivirals (DAAs). Currently it is estimated that there are 130,089 people still living with hepatitis C in Australia, many undiagnosed.¹

Globally, there are millions of people who are undiagnosed with hepatitis C. The World Hepatitis Alliance (WHA) has a global campaign that is raising awareness to ‘find the missing millions’ and eliminate viral hepatitis globally.²

So how do we find the missing millions if they don’t know they are lost?

The most common perception is that hepatitis C is associated with the following risk factors:

• People who inject drugs
• Unsterile tattoo or body piercing
• Needlestick injury
• Blood transfusion (in Australian before 1990)
• Being born in a high prevalence country

If we are to find the missing millions, we need to think much more broadly than this very simple list.

You may have seen the animation that was launched on World Hepatitis Day called ‘Find the Hero Inside You’ which is encouraging all people to have a liver health check and a hepatitis test. We all need to be talking about hepatitis and liver health, and this is the perfect opportunity to start the conversation more broadly with people who are outside of the typically identified priority groups.

For instance, while we need to continue having conversations with people who are currently injecting drugs, we also need to consider those who have a history of injecting, those who may have shared or been injected by another person, those who may have injected just once even many years ago, and people who are accessing drug treatment programs.

We also need to consider people with tattoos, body piercings or body modifications, particularly those performed in a non-sterile environment, not just those who got a prison tattoo (or simply spent time in prison…). These people may have some gorgeous artwork but if it was done on the beach in Bali or someone’s backyard, it may not have been the cleanest or safest.

We should be having discussions with mothers living with hepatitis C, as there is a 5-7% chance that the baby may become positive at birth or during the early years of life. Men who have sex with men (MSM) with, or without a HIV infection also need to be offered testing. Sex workers should be offered testing regularly as a requirement of their profession but also as they may be at an increased risk.

People who are born in countries with a high prevalence of hepatitis C such as Africa, Asia, the Mediterranean and Eastern Europe or refugees and humanitarian entrants to Australia all need to be considered for testing. There are added cultural sensitivities for these priority populations as discussions will involve blood, sex, and hepatitis C. Also, there has been an increase in hepatitis C in people who identify as Aboriginal and/or Torres Strait Islander, and we must continue to have conversations with this group depending on risk factors.

There are also a small population of people who may have contracted hepatitis C from medical procedures or blood transfusions in Australia (before 1990), or while travelling overseas. Additionally, and while only making up a small percentage of the population at risk, people who have sustained a needle stick injury either in the community or in the workplace, should also be tested.

Sadly, some people simply don’t want to know that they have hepatitis C. Many choose not to acknowledge that they could have been living with hepatitis C for many years. The previous treatments were very toxic and saw people taking medications for 6 or 12 months at a time. Many people maybe unaware of the new DAA treatments. This is another factor which may see some people not coming forward for testing because knowing their status may mean they have to endure horrible treatments to achieve a cure.

It is a tricky conversation to start but one that needs to happen more often. By encouraging all people to have a liver health check and a hepatitis test we will begin to normalise the conversation and remove the stigma and discrimination that some people may still be experiencing.

For more information about workforce development contact Lana@hepqld.asn.au or making your practice hep C treatment ready contact Jeanette, nurse@hepqld.asn.au for clinical support.

References:

1. ASHM, Viral Hepatitis Mapping Project: National Report 2018–19. 2020.
2. World Hepatitis Alliance, Finding the Missing Millions, 2018.