A nurse-led,telehealth-driven hepatitis C management initiative in regional Victoria: Cascade of care from referral to cure

Abstract

Introduction

Elimination of hepatitis C virus stands as an unresolved World Health Organization target, and is associated with complications including cirrhosis and hepatocellular carcinoma. Hepatitis C virus management has been revolutionised following the widespread availability of direct-acting antiviral agents in Australia since 2016; however, large proportions of the population remain untreated. Telehealth-based service delivery is an accessible and effective alternative, and we aimed to assess qualitative and clinical outcomes in a clinical nurse consultant-led regional telehealth model.

Methods

A prospective cohort analysis of all patients referred to a Victorian regional hospital’s hepatitis C virus telehealth clinic between 1 April 2017 and 10 June 2020 was conducted. Data were collated from outpatient and electronic medical records.

Results

Fifty-five out of 71 referred patients were booked, with 44 patients (80%) attending at least one appointment. A history of alcohol use disorder and psychiatric comorbidity was seen in 25 (54%) and 24 (52%) patients, respectively. Twenty-one out of 24 (88%) eligible patients had direct-acting antiviral agent treatment and 14 out of 21 (67%) successfully completed the treatment. An average of 46.5 km, 54.6 min and $AUD30.70 was saved per patient for each visit. Observed benefits included: increased medical engagement, adherence to and completion of HCV treatment and cirrhosis monitoring. Telehealth-driven hepatocellular carcinoma surveillance was successful in the cirrhotic subgroup.

Conclusion

Clinical nurse consultant-led hepatitis C virus management via telehealth allows access to marginalised regional populations. Clinical outcomes were comparable to other cohorts with additional cost-benefit, efficiency gains and carbon footprint reduction amongst a previously unreported regional Victorian hepatitis C virus population.

Keywords

Hepatitis C telemedicine telehealth model of care nursing

Introduction

Hepatitis C virus (HCV) has an estimated global prevalence of 71 million cases in 2020, occurring worldwide, with a predominance in continental Asia and Africa.¹ A higher incidence has been observed amongst indigenous and minority communities, the developing world, and amongst the imprisoned and homeless.^2,3 Suboptimal cure rates leading to hepatic complications such as cirrhosis, hepatocellular carcinoma (HCC) and liver failure occurred in the era of ribavirin and interferon therapy due to poor uptake and adherence. HCV therapy has become more acceptable to patients with the introduction of direct-acting antiviral agents (DAAs), making it a World Health Organization (WHO) elimination target. HCV management has been a huge success in urbanised areas, yet it remains a major health issue in marginalised and geographically isolated populations. Reasons for this discrepancy include lack of access to public health care and medical investigation services and poorer health literacy and medical engagement.^4–6 Moreover, in Australia, there stands a stark difference in conductance of viral testing between metropolitan and geographically isolated areas.⁷

The advent of telemedicine in dissolving barriers related to treatment access, reduction in patient travel and costs, and an increase in health service engagement, particularly in the management of infectious diseases, has been well recognised.⁸ Similarly, the impact of DAAs’ availability in achieving comparable sustained virologic response (SVR) rates and eliminating HCV in the primary healthcare setting have been previously reported in Australian and non-Australian studies performed in rural settings.⁹ Of these, multiple studies acknowledge the contributing success of clinical nurse consultant (CNC)-led programmes in achieving HCV treatment, with ongoing barriers largely remaining non-clinical.^10–12

Methods

Inclusion and exclusion criteria

A prospective cohort analysis of all patients referred to the HCV telehealth (TH)-run service at an eastern Victorian regional hospital was conducted between 1 April 2017 and June 10 2020 inclusive. This model began from the triaging system, which determined patient eligibility for the TH service based on predefined criteria (Figure 1). Patients were referred to Healesville and District Hospital via general practitioners (GPs), non-hepatitis medical specialists, or psychiatric clinicians. Patients over the age of 18 years with a diagnosis of confirmed chronic HCV (defined as positive HCV RNA) with a registered address in the Healesville catchment area and who would otherwise be attending the nearest tertiary-based centre for specialist care were deemed eligible for this TH service. Patients with any HCV genotype and detectable qualitative or quantitative RNA were included, as were those with or without prior HCV treatment or deferral history. Patients were excluded from this service if the diagnosis of HCV was not confirmed; they presented with decompensated cirrhosis (Child-Pugh B/C) or had comorbidities making them unsuitable for TH. Excluded patients were redirected to appropriate clinical services within the health network.

Figure 1.

Telehealth clinic model.

Patients then presented for a face-to-face review with the CNC at Healesville Hospital to confirm eligibility and capacity to provide consent. This was obtained via a signed VideoConsult consent form outlining the benefits and risks, privacy and confidentiality rules surrounding TH. This review did not include a specific liver fibrosis or treatment assessment. Patients were booked for their TH appointments with a hepatologist for their subsequent visits, where the patient was located at Healesville Hospital using the Healthdirect video call platform (Healthdirect Australia) and the hepatologist being remotely located at Box Hill Hospital, a supporting metropolitan teaching hospital. A clinical review of their disease status (based on imaging and pathology) and degree of medical engagement (social supports and previous health-seeking behaviours), occurred prior to discussing treatment eligibility. Pathology and liver imaging was ordered where required to determine treatment suitability.

Patients with a prior history of HCV treatment by an external clinician were not included in our treatment-eligible cohort, which only encompassed those who were either treatment naïve, had a history of treatment deferral, or prior treatment failure. DAA prescribed outside of our clinic was usually done at our tertiary hepatology clinic, prior to these patients being identified as suitable for TH follow up for treatment completion, SVR12 confirmation (defined as an undetectable serum HCV RNA at least 12 weeks post treatment completion) and where relevant, cirrhosis surveillance. DAA therapy was offered following counselling on duration, expected adverse effects, and the process of SVR12 confirmation. Patients were followed up until the point of SVR12 confirmation wherever possible. Where appropriate, patients were discharged to their GP once HCV cure was confirmed by our TH service. Ongoing specialist follow-up occurred in cases where cirrhosis or HCC monitoring was required. This study was approved by the Eastern Health Human Research and Ethics Committee (approval QA69-2018).

Data collection: data

Parameters collated included: patient demographic information including age, sex, and Aboriginal and Torres Strait Islander (ATSI) status, HCV diagnosis (risk factors for acquisition, genotype, viral load at diagnosis), treatment details (DAA agent and duration) and clinical outcomes. Also included were relevant co-morbidities, including obesity (defined as calculated body mass index (BMI) >30 kg/m²), a history of mental health disorders (including mood or psychotic disorders) or substance disorder (including alcohol and intravenous drug use). Analysed clinical outcomes included: SVR12 (defined as an undetectable serum HCV RNA at least 12 weeks post-treatment completion) and cirrhosis requiring monitoring for complications including HCC surveillance.

Cost savings calculations

All savings were calculated in comparison with the closest face-to-face specialist providing facility located 36 kilometres (km) away. Travelling savings were calculated based on the average distance in kms between this facility and the geographical centre of the patients’ listed residing suburbs. Similarly, time costs were calculated based on the average time in minutes required to travel between these two location points. Distances and travel time were calculated using Google Maps. A return trip distance using the geographical centre of the individual’s post-code to the Healesville and District Hospital clinic was determined and compared with the cost of a return trip to the specialist centre. The time and distance savings for each individual were determined by taking the difference between these two sets of figures. The dollar saving was determined by using the standardised Australian Tax Office car expense method of 66 cents per kilometre of travel.¹³

Data analysis

Quantitative data are presented using descriptive analyses. Qualitative data involved utilisation of Likert scale surveys, to observe level of patient and clinician satisfaction and overall experience with the TH service.¹⁴ This survey comprised a set of 11 patient-directed and 14 clinician-directed closed-ended questions manually completed post-consult.

Results

A total of 71 patients were referred to the Healesville Hospital HCV TH Clinic during the study period. A total of 16 patients were excluded for not meeting criteria for TH-based HCV treatment (referral indications: n = 5 HCV managed via GP, n = 2 HCV PCR negative/elevated liver biochemistry requiring tertiary-based assessment, n = 2 unsuitable for TH appointments and redirected to face-to-face HCV clinics, n = 1 hepatitis B virus, n = 1 cured HCV, n = 1 biliary cirrhosis, n = 1 established HCV cirrhosis, n = 1 referred for lower gastrointestinal symptoms and n = 2 unknown). The remaining 55 were included in the final study sample, and were booked an appointment. A total of 44 patients (80%), all of whom had a confirmed HCV diagnosis, attended at least once (mean number of appointments 2.88 ± 0.52 95% confidence interval (CI)). The remaining 11 either failed to attend (n = 9) or presented with spontaneously cleared HCV (n = 2), hence were excluded. Of those that did attend (n = 44), 19 patients (43%) had a history of prior HCV treatment deferral, 29 (66%) had had prior HCV treatment and three (7%) had virological relapse. A total of 25 (57%) had a history of alcohol use disorder, 24 (55%) psychiatric comorbidity and five (11%) obesity (Table 1).

Table 1.

Hepatitis C virus telehealth cohort baseline characteristics.

HCV TH cohort descriptive analysis – attendees. Total no. of patients (n = 44)
PWID^a status
Current	n = 2 (5%)
Ex	n = 33 (75%)
Never	n = 5 (11%)
Unknown	n = 4 (9%)
HCV genotype
Genotype 1	n = 17 (39%)
Genotype 2	n = 5 (11%)
Genotype 3	n = 15 (34%)
Genotype 6	n = 1 (2%)
Unknown	n = 6 (14%)
Co-existing co-morbidities
Alcohol use disorder	n = 25 (57%)
Mental health disorder	n = 24 (55%)
Psychiatric medication use	n = 17 (39%)
Obesity (BMI >30 kg/m²)	n = 5 (11%)
DM^b/insulin resistance	n = 3 (7%)
HIV co-infection	n = 0
HBV co-infection	n = 0
Hepatic complications
Liver cirrhosis	n = 8 (18%)
HCC^c	n = 1 (2%)

PWID – person who injects drugs.

DM – diabetes mellitus.

HCC – hepatocellular carcinoma.

A total of patients (44%) were eligible for TH-driven DAA initiation in the presence of active HCV. One individual with decompensated cirrhosis required treatment in a tertiary centre and three elected to be treated by their primary care provider. A total of 16 patients had confirmed SVR12 following community treatment, with 13 requiring ongoing follow up in the setting of cirrhosis. Of the treated patients, the male to female ratio was 1.8:1; two patients identified as ATSI and none were co-infected with hepatitis B or human immunodeficiency virus (HIV) (Table 2). A total of 21 patients (88%) had DAA initiation, with 14 (67%) completing treatment and 13 (93%) achieving sustained virologic response at 12 weeks (SVR12). The remaining patient, awaiting SVR12, remains lost to follow up and remains uncontactable despite multiple attempts to re-engage them with the service. This treatment cascade is represented in Figure 2. Six patients were discharged from clinic following SVR12. There were two deaths in the cohort; one patient refused DAA and developed subsequent HCC, whilst the second developed end-stage liver disease in the setting of ongoing substance abuse. The remaining 20 patients who were not prescribed DAA therapy via our TH clinic were either prescribed treatment externally, and/or were under HCV-related cirrhosis and HCC monitoring, with four (20%) having established cirrhosis (Figure 3).

Figure 2.

Cascade of care describing treatment outcomes amongst the clinical nurse consultant-led hepatitis C virus telehealth cohort.

Figure 3.

Clinic goals for direct-acting antiviral agents treatment ineligible patient sub-cohort.

Table 2.

HCV treatment eligible cohort descriptive analysis.

HCV treatment eligible cohort descriptive analysis
Total no. patients (n = 24)
M:F ratio	1.8 : 1
Average age	54.04 years
^aATSI status
ATSI	n = 2
Non-ATSI	n = 18
Unidentified	n = 4

ATSI = Aboriginal and Torres Strait Islander.

Other evaluated domains included cost effectiveness and overall patient satisfaction. An average of 46.5 km, 54.6 min and $AUD 30.70 were saved per patient for each visit by participating in a TH consult at their local primary healthcare centre instead of a face-to-face metropolitan-based specialist clinic appointment.

Likert scale surveys were used to determine patient satisfaction, with 23 (52%) patient and 33 (75%) clinician survey responses being submitted, respectively. Overall patient feedback was consistently positive, with all patients reporting a clear understanding of the pros and cons, privacy laws surrounding and their choice in engaging with TH. Patients unanimously declared having no visual issues during the consult, feeling comfortable and understanding the role of each professional participant during the appointment. Lastly, the improved convenience and a future willingness to continue TH participation were acknowledged by all respondents. Less positive feedback included occasional audio issues and unwillingness to have TH conferences conducted from the patient's homes. With regard to clinician feedback, equipment set up and connectivity before and during the consultation was deemed satisfactory overall, as was access to patient files remotely, ability to engage audio visually with patients during the consult and willingness to pursue with future TH conferences without negative impact on workflow. Accordingly, observed benefits included increased medical engagement, improved commencement, adherence to and completion of treatment, maintenance of the patient–clinician relationship and predicted improvement in long-term health outcomes at a personal and cohort level.

Discussion

TH-based HCV studies have shown success worldwide, with previous studies using DAAs, pegylated-interferon and ribavirin-based treatments.¹⁵ HCV remains a significant healthcare burden amongst the prison populations and ethnic minorities, with TH initiatives making these groups key international elimination targets.^16–18 In Australia, the HCV burden disproportionately affects ATSI communities and to overcome this, the ‘Close The Gap’ campaign is looking at novel ways to engage this cohort.^19,20 Whilst two Northern American-based cohort analyses have reported similar SVR12 rates amongst their TH and non-TH HCV patient groups (94.7% vs. 94.8%, p=0.99) and (55% vs. 43%, p = 0.36) respectively, the TH cohorts were found to complete treatment (78% vs. 53%, p = 0.03) and attend clinic appointments (0.61 vs. 0.07, p < 0.001) more frequently than non-TH cohorts.^21,22 Similarly, although primarily involving non-DAA therapies, SVR12 rates and TH-based treatment were found to be comparable and non-inferior to face-to-face tertiary-run HCV treatment in a Western Australian study.²³ These results are in keeping with our findings and strongly indicate treatment success that rivals face-to-face specialist centre-run treatment programmes, all of which are integral steps towards achieving the WHO HCV elimination target.^24–26 In the more recent COVID-19 era, economical, logistical and environmental benefits with regards to reduced patient costs, travelling time and distance have been demonstrated, marking it as a viable future pathway to healthcare delivery.^27,28

TH-driven HCV management has reduced disruption to continuity of care in disenfranchised populations amidst the ongoing COVID-19 pandemic. In terms of knowledge gaps, TH is currently limited to rural settings of developed countries, calling for its expansion into the developing world where HCV remains a significant healthcare burden with ongoing treatment access issues.²⁹ Previous studies have adopted similar approaches in difficult to access areas via their Extension for Community Health Outcomes (ECHO) Model, initiatives to continue extrapolating on for future studies.^30–32 Moreover, there remains a paucity of literature reporting the success of TH in monitoring of chronic HCV-related complications including cirrhosis, hepatic failure and HCC amongst the highest risk patients.

The somewhat limited referral numbers received during this study period pinpoints the issue of under-detection and referral to specialist services for HCV management, particularly in non-metropolitan areas. This occurred at our centre despite there being no nearer competing face-to-face or TH-based hepatology service other than the one described. Over the past decade in Australia, we have observed both a spike in HCV testing following the introduction of DAAs, followed by a marked stability in recent years, with non-metropolitan populations being more under-tested in general.³³ Previous reports highlight a gross lack of awareness and education surrounding HCV and its complications including liver cirrhosis and HCC amongst high-risk individuals.^34,35 Moreover, treatment uptake and cure rates significantly improved following the introduction of solid testing, education and treatment programmes for these patients, particularly amongst people who inject drugs (PWIDs) or incarcerated populations. We display interconnecting issues between suboptimal testing, inadequate patient awareness and subsequent poor engagement and treatment uptake amongst the very population we should be protecting the most. The COVID era introduced additional difficulty in prohibiting the initial face-to-face CNC review and markedly limiting recruitment of new patients to this service.

Our study draws on all of these concepts, yet showed considerable success in addressing the local HCV burden in a population with a 0.62% overall population prevalence and only 48.5% treatment uptake within the Yarra Ranges Eastern Melbourne catchment.⁷ Our cohort comprised of the highest risk individuals, including ATSI patients, with our CNC playing a pivotal role in connecting with patients on an individual level. Although not objectively collated, we suspect poor demographical and socio-economic status in our patients, based on clinical interaction during TH assessments. The Healesville catchment sits in the 47th percentile in the index of relative socio-economic disadvantage in Australia. ATSI people comprise 3.7% of the catchment's population, in comparison to a 0.8% overall Victorian prevalence. A significant difference stands between those who reach University or tertiary level education between Healesville and the general Victorian population (7.2% vs. 17.8%). Lastly, 52.2% of the Healesville population is employed full time, compared to 57% of the general Victorian population.³⁶ Many patients presented as PWID with a history of incarceration, which possibly stems from a combination of low education status and employment opportunities given the non-urban area, as well as lack of social supports and overall health literacy. There were high levels of alcohol misuse disorders observed. All of this inevitably contributes to high lifestyle stressors and concurrence of psychiatric comorbidities, which requires separate evaluation. Despite the presence of adequate primary healthcare and accommodation support in this area, patients often struggled to attend and participate in TH appointments. The impact of socio-economic status on medical literacy and engagement continues to hold great interest and would benefit from further study.

As a novel study focussing on a regional rather than rural community, the recruitment process involved a heavy collaborative effort between the CNC and local indigenous healthcare workers in a region with a unique population demographic. TH was delivered in a cost effective and environmentally friendly manner which was comparable to pre-existing rural-based TH studies in the same field, via a CNC-led directive requiring a highly specialised nursing skills set and a close trusting working relationship with the lead hepatologist. Our cascade of care highlights failure to attend clinic as one of the main barriers, suggesting that HCV awareness amongst high-risk individuals remains inadequate. Together with improved testing rates, a strong movement to educate communities on the modes of HCV transmission and potential long-term clinical sequelae of cirrhosis, HCC and death is paramount. Similarly, we demonstrate that patients who do commence DAA treatment most often successfully achieve SVR12 and cure, reiterating that establishing engagement and beginning treatment is the key. A significant proportion of clinic attendees were deemed treatment ineligible via TH due to established cirrhosis; this was both reflective of patients’ age and long duration since HCV infection and indicative of the fact that clinicians should be more proactive in identifying and diagnosing patients as early as possible.

Our study suggests high utility in implementing TH as a portal to engage with patients for long-term management of liver cirrhosis and associated complications in difficult to engage regional cohorts where testing rates, HCV awareness and understanding of chronic complications remain poor. Next steps include focussing on ways to improve both HCV testing rates in regional Victoria and patient understanding of risk factors, acquisition modes, clinical manifestations and long-term complications. A strong focus on the curability of HCV should be emphasised during patient counselling. A possible strategy to improve treatment completion and SVR12 rates could be the introduction of more frequent TH reviews (either CNC- or hepatologist-driven) to assess adherence and address barriers earlier. It is important to recognise the cost effectiveness of this model as a strength, benefitting a cohort that more often than not have financial strains that restrict interest in their medical wellbeing. Our TH model has, to a degree, been usurped by the addition of item numbers allowing widespread uptake of TH consultation in the COVID-19 era. Primary healthcare practitioners and in our particular cohort, indigenous health care workers together with our CNC have played an invaluable role in creating initial rapport with patients ensuring that our model flourished. Future studies are needed to look at the effect of this shift to TH services in COVID era has had on treatment uptake, compliance, SVR12 rates and the role that face-to-face contact has in building a rapport with patients and other shareholders.

Study limitations: This study presents itself with a small sample size. In order to excel in HCV treatment using a TH model, expanded, non-blinded prospective studies analysing both clinician and patient experiences are required. There was no comparable data collected on our TH-ineligible cohort to comment on, making this a highly valid improvement for future studies. Further prospective analyses comparing experiences with TH models adopted during COVID in clinics that do not require physical patient attendance would also be useful. Future studies should more closely focus on the socio-economic status of HCV cohorts and the impact these factors have on medical engagement and cure.

Conclusions

TH-driven HCV management continues to demonstrate excellent HCV treatment, engagement and cure rates amongst high-risk demographical and geographical patient cohorts, comparable to that seen in tertiary-based centres. During the current COVID-19 pandemic, recognising the economical and logistical benefits, and reduced environmental impact, expansion of such services should remain a focus across healthcare organisational levels. Continued studies in developing nations, and with more focus on surveillance for complications of cirrhosis may be the next step in addressing this global, yet treatable, health issue.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Beverly Rodrigues

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