Hepatitis C elimination: amplifying the role of primary care nurses in Australia

Introduction

Globally, there are an estimated 57 million people living with the hepatitis C virus (The Polaris Observatory HCV Collaborators 2022). With the advent of curative treatment, the World Health Organization (WHO) set a global goal to eliminate hepatitis C by 2030, defining elimination as a 90% reduction in incidence and 65% reduction in mortality for hepatitis B and hepatitis C (WHO 2022). The declaration of a global elimination target raised the priority attached to viral hepatitis, making it a critical focus for public health efforts worldwide. To achieve elimination, the WHO (2018) promotes the delivery of hepatitis C care through simplified, decentralised service models, integrated with local services with reach into the communities where people with/at risk of hepatitis C live their lives. Task-shifting and task-sharing approaches, and enabling nurses to work to their full scope of practice will contribute to primary care services working at their most efficient, and help to propel hepatitis C elimination efforts. In Australia, a nurse’s scope of practice depends on their level of education, competence to practice and regulations set forth by the law (Nursing and Midwifery Board of Australia (NMBA) 2016).

Nurse-led hepatitis C care has traditionally been provided using a hub and spoke model, where specialist hepatitis C nurses, employed by tertiary hospitals, provide outreach services in community health and primary care settings, including general practice, pharmacies and custodial settings (Papaluca et al. 2019; Byrne et al. 2022; Harney et al. 2022). These models build the hepatitis C capacity of the primary care workforce with supported, case-based mentoring, thereby ensuring access to hepatitis C care outside the tertiary hospital system. Hepatitis C treatment availability in primary care settings has demonstrated high uptake and high cure rates among vulnerable people who often struggle to access care (Radley et al. 2020; Wade et al. 2020). Indeed, delivery of hepatitis C testing and treatment through primary care settings is identified as the most economical and efficient mechanism to achieve hepatitis C elimination (Biondi and Feld 2020). Australia committed to the WHO’s global elimination goal by scaling up access to publicly funded, curative direct acting antiviral (DAA) medications, building the capacity of the health and community workforce caring for priority populations, and transitioning hepatitis C testing and treatment to primary care services (Australian Government Department of Health 2018; Hepatitis C Virus Infection Consensus Statement Working Group 2022). It is estimated that over 95,000 people (51%) were treated between 2016 and 2021, leaving an estimated 117,800 people yet to be treated (Burnet Institute and Kirby Institute 2022). Yet, Australia is at risk of not achieving our hepatitis C elimination goal (Kwon et al. 2021).

The safety and simplicity of DAAs has enabled general practitioners (GP) and nurse practitioners (NPs) in Australia to prescribe treatment without additional training. This, alongside DAA dispensing through community pharmacies and point of care testing in settings regularly attended by people with/at risk of hepatitis C creates opportunities to actively involve primary care nurses in hepatitis C care. Similarly in Canada, while acknowledging differences in health structures and service access and delivery, primary care has also been identified as an opportunity to engage individuals across the hepatitis C care cascade (Biondi and Feld 2020). However, following an initial spike in treatment in 2016 upon release of DAAs, treatment rates have been steadily declining. There is a need to increase testing to diagnose and link people to treatment (Scott et al. 2020). Primary care nurses are a potential workforce to drive this testing scale up.

NP-led models of care are increasingly being recognised as improving access to testing and treatment in geographically isolated regions, and in locations accessed by people with/at risk of hepatitis C (Biondi and Feld 2020). In Australia, NPs have been eligible to prescribe medicines since the inception of the role in 2000 (Australia and New Zealand Council of Chief Nursing and Midwifery Officers and NMBA 2017). In 2017, NPs experienced in treating hepatitis C became eligible to prescribe DAAs (Hepatitis C Virus Infection Consensus Statement Working Group 2022). NPs are currently the only group of nursing professionals eligible to prescribe medicines in Australia (Australia and New Zealand Council of Chief Nursing and Midwifery Officers and NMBA 2017).

Disease-specific, community-based, nurse-led clinics also have a positive impact on patient satisfaction (Randall et al. 2017). Primary care nurses play an increasingly important role in supporting hepatitis C treatment access through engaging people at risk in hepatitis C screening, diagnosis, linkage to care and providing care coordination, patient education and follow up (Rashidi et al. 2020). Primary care nurses work within general practice, but also in midwifery, pharmacy, dentistry, Aboriginal health services and allied health settings (Australian Institute of Health and Welfare 2023). These settings are often the first point of contact for people with previous and ongoing risk factors with the health system (Biondi and Feld 2020).

This study aimed to identify the specific activities and roles primary care nurses play in the Australian hepatitis C elimination response. We used a socio-ecological model to explore how primary care nurses have responded to hepatitis C by identifying the characteristics, systems and supports that enable integration of hepatitis C care into the scope of these nurses in Australia.

Methods

Primary care nurses actively involved in the delivery of hepatitis C care, including screening and diagnosis, involvement in treatment delivery and/or provision of hepatitis C education or counselling, were recruited through ASHM Health, the Australian Primary Health Care Nurses Association, and through the researchers’ professional networks. Participants were eligible for recruitment in the study if they had attended a hepatitis C training program with ASHM Health or identified an interest in hepatitis C through previous contact with a member of the research team. Information describing the study along with an invitation to participate were distributed through ASHM Health and the Australian Primary Health Care Nurses Association membership lists. Nurses were invited to contact the principal investigator (author JR) to enrol in the study. The principal investigator determined participants’ suitability by assessing their area of work to ensure distribution of participants across the various primary care settings, involvement in delivering care to patients with hepatitis C and geographic diversity. Participants provided verbal consent, after being given information detailing the aims and purpose of the research. Participation involved an electronically recorded, semi-structured interview, conducted over the telephone between October and December 2020. Participants were offered reimbursement for their time. Interviews were conducted by one of two researchers (JR or JW) and lasted between 20 and 50 min.

The interviews explored participants’:

The interview data were transcribed verbatim, coded and entered into NVivo 12 (QSR International, Vic, Australia) and analysed using the stages outlined by Braun and Clarke (2006), with coding and analysis conducted using thematic analysis. Working independently, authors JW and JR familiarised themselves with the data by reading and re-reading the transcripts, and systematically identified codes and grouped the coded data into themes. The coding framework was independently constructed by author JW. Codes were compared, with consensus reached between JW and JR on the identification of themes. Author MH independently reviewed the transcripts and cross-checked the coding framework. De-identified quotes from participants are used to illustrate perspectives.

Our research team consists of three professionals with extensive viral hepatitis and/or nursing expertise: JR is a viral hepatitis nursing expert and thought leader; MH is a nurse with extensive experience in blood-borne virus and sexually transmissible infections education, and policy development, and JW is an internationally recognised viral hepatitis social researcher and advocate. Given our experience, the research team reduced potential bias by reflecting on its potential impact and allocating interviews to researchers without a previous relationship with the participant.

The interview findings are framed using a socio-ecological framework (McLaren and Hawe 2005) to explore the role of primary care nurses in the hepatitis C elimination response, and identify the critical elements that support the delivery of hepatitis C care in primary care settings. This framework provides a holistic approach to understanding and analysing the interconnected interactions between different levels of the health system, and encompasses enablers at individual, interpersonal, primary care, and community and structural, and public policy spheres.

The study was approved by the Alfred Health Ethics Committee (Number 485/20).

Results

Thirty primary care nurses expressed interest in being involved in the study. Sixteen participants consented to be interviewed between September and December 2020. Eight participants were excluded, because they did not respond to follow-up emails. Six participants were excluded after being assessed against the inclusion criteria. The primary care settings where participants worked included general practice, community health, alcohol and other drug services, and custodial settings; to assist interpretation of the findings, participant code, qualification and primary care setting are identified in Table 1. Participant characteristics are presented in Table 2.

Discussion

The current study reinforces the distinctive role primary care nurses have in supporting national hepatitis C elimination goals. We identified five overarching themes addressing individual, interpersonal and primary care enablers, the social and community contexts in which these occur, and structural and public policy suggestions. These themes highlight the commitment of primary care nurses to caring for marginalised populations, which is a product of their professional role and context, and their personal values. To achieve hepatitis C elimination, flexible and holistic care must be delivered in accessible settings (Australian Government Department of Health 2018). Participants in the current study demonstrated an ability and desire to be actively involved in delivering decentralised care.

The curable nature of hepatitis C provides a positive and motivating work area for primary care nurses, particularly given their unique access to people with/at risk of hepatitis C. Participants in this study discussed how hepatitis C cure was viewed as a ‘positive news story’, and as an important entry point to engage clients in care for other health issues (Biondi and Feld 2020). Leveraging the positive outcomes of hepatitis C cure helped to normalise hepatitis C, which is an important strategy to relieve the stigma experienced by many people when they encounter the health system (Treloar et al. 2016).

Participants in the current study demonstrated attributes, such as empathy and compassion, and a willingness to advocate for clients deemed ‘too hard for everyone else’. Belief in their role as a client advocate was common. Enhancing the role of nurses in hepatitis C care fundamentally recognises their comprehensive skill set of carer, communicator and advocate, and their unique ability to engage people who are marginalised due to the flexible, person-centred approach embodied by the nursing model of care (Australian College of Nursing 2019), with primary care nurses in the unique position of delivering care across an individual’s lifespan. McCormack and McCance (2017) highlight that a person-centred approach leads to improvement in the quality of care delivered through fostering healthy and respectful relationships between healthcare workers and patients and their significant others. In particular, the current study highlighted the ability of primary care nurses to build rapport and trust with people who have experienced stigma in the healthcare system, through a flexible and adaptable approach. Actively collaborating with other health and community workers, to meet people ‘where they are’ rather than expecting them to ‘find us’ enables a person-centred approach to hepatitis C care delivery and is an important enabler for successful models of care (Richmond et al. 2020).

Of interest, the infrastructure that exists within the primary care system, such as electronic patient management systems, was not identified as enablers by participants in this study. This may be a result of the broad nature of the primary care system in Australia, and the lack of shared systems between primary care services. Like Wallace et al. (2020), who identified that GPs were more likely to manage hepatitis B if their practice had a supportive culture, including nurses being empowered to care for clients with hepatitis B, the current study identified that a supportive workplace culture enabled primary care nurses to incorporate hepatitis C into their scope of practice. Participants described the role of equality and mutual respect between nurses and their medical colleagues in creating a positive and constructive workplace for nurses to meet the needs of their clients, and practice to their full scope of practice.

The role of primary care nurses to respond to the needs of people with hepatitis C is affected by funding models. The flexibility for some nurses to deliver care without the restrictions applied by a fee for service funding model meant they were empowered to deliver holistic care for clients with additional and complex needs. However, participants working in general practice described the negative impact of restrictive internal workflow systems created by inadequate or non-existent funding on their ability to work to their full scope. Creating billing and reimbursement strategies for nurse-led activities is one strategy that could allow primary care nurses to offer unique, person-centred models that take advantage of the positive policy environment created by the Australian Government in pursuit of hepatitis C elimination.

Australia is recognised as a global leader in hepatitis C public policy, which has supported the implementation of innovative prevention, testing and treatment strategies (Burnet Institute and Kirby Institute 2022). The Fifth National Hepatitis C Strategy (Australian Government Department of Health 2018) maps the hepatitis C care cascade, and clearly articulates the need for training and collaboration within the multidisciplinary team, including nurses, peers, community workers and specialist liver services, in the provision of care and all levels of the health system. Future national policies and jurisdictional strategies need to better recognise how primary care nurses undertake their work across different settings, and the contribution they can make to engaging and caring for marginalised individuals.

More can be done to create an enabling environment for hepatitis C elimination in Australia. Several innovative models are being implemented internationally in response to the desire to achieve hepatitis C elimination. In Aotearoa New Zealand, nurses with appropriate knowledge and experience to treat people with hepatitis C (including those working in primary care, but not qualified NPs) have been authorised to prescribe DAAs, increasing accessibility and uptake (Medsafe – New Zealand Medicines and Medical Devices Safety Authority 2022). This follows the endorsement of nurses and pharmacists to prescribe DAAs in Scotland (Radley et al. 2020). Expanding prescribing rights to non-medical health professionals, including specialist nurses not registered as a NP, could streamline service delivery and improve access for marginalised populations, including in rural and remote regions. Although a model of designated registered nurse prescribing is being proposed by the NMBA (2023), it is uncertain how and when nurse prescribing of DAAs would be considered within a new framework. Any opportunity to simplify care pathways and offer hepatitis C testing and treatment in primary care settings, where people feel comfortable, needs to be considered as we head towards the final phase of elimination.

In many countries, including the US and Australia, the roles and responsibilities of primary care nurses have evolved (Bodenheimer and Bauer 2016), with specialised NP roles and nurse-led clinics considered standard care for many chronic health conditions. Nurses have a professional responsibility to engage in therapeutic and professional relationships, including knowledge sharing, coordination and consultation to enable person-centred care and positive health outcomes (NMBA 2016). Primary care nurse-led models are acknowledged as a critical way of expanding access to hepatitis C care, while also building trust with people who are marginalised due to drug use, homelessness and mental illness, and have experienced stigma and discrimination in the healthcare setting (Gilliver et al. 2022; Selfridge et al. 2022). People who have experiences of past or current injecting drug use and/or incarceration benefit from the stability and consistency of a primary care relationship (Biondi and Feld 2020).

This study demonstrates there are primary care nurses who prioritise the delivery of hepatitis C care because they are motivated by social justice principles. However, the role of education and specialist (nurse) mentorship has an important role in identifying and creating new champions. The role of specialist hepatitis C nurses in mentoring primary care nurses through shared care models, case conferencing and providing education and support is critical to build nursing capacity (Richmond et al. 2014).

The findings of this study reveal opportunities for further research specifically measuring the impact of primary care nursing on patient engagement across the hepatitis C care cascade. The role of a collaborative care arrangement between primary care and tertiary-based nurses, using a case management approach to link marginalised clients with hepatitis C to testing and treatment services is worthy of further investigation. In addition, codesigning the scope of practice of primary care nurses across settings serving marginalised communities would enable clear definition of roles and responsibilities, and create an enabling environment to support greater involvement of primary care nurses in Australian’s elimination response.

Limitations

There are several limitations that should be acknowledged when interpreting these data. Recruiting participants through the ASHM Health nursing membership potentially biased the results, because these nurses have attended blood-borne virus training and could be more likely to have an existing interest in hepatitis C. Second, the primary healthcare sector includes a diverse range of settings, and the nursing role differs between settings in terms of autonomy and scope of practice. Therefore, compiling the experiences and beliefs of participants, and presenting a consensus opinion or experience according to primary care setting is challenging. Third, half the participants resided in the Australian jurisdiction of Victoria (n = 8). Considering the diversity between nursing roles in primary care settings, it is possible that the diversity in experience and exposure to people with/at risk of hepatitis C is also influenced by geography. Fourth, the experience and public profile of the research team may have influenced participants’ choice to be involved in this study, hence steps were taken to reduce the potential of bias.

Conclusion

The primary care sector needs to be strengthened to better address society’s health challenges, with hepatitis C being a contemporary health issue requiring a whole of health system response. Given that GPs are over-burdened and under-funded, mobilising primary care nurses to integrate hepatitis C into their scope of practice supports an enabling health system to increase hepatitis C testing and treatment, and achieve hepatitis C elimination. Leveraging the trust developed with marginalised clients over time creates an opportunity for a substantive role for primary care nurses in delivering hepatitis C care in collaboration with prescribing NPs and GPs, hospital-based nurses and medical specialists, and alcohol and other drug and mental health case workers. If Australia is committed to achieving its elimination target, there needs to be health system changes, including access to primary care nurse-led funding and task shifting mechanisms, that allow nurses to work to their full scope of practice to create multiple touchpoints for people with/at risk of hepatitis C in the health system and beyond.