Heterogeneity in hepatitis C treatment prescribing and uptake in Australia: a geospatial analysis of a year of unrestricted treatment access

Abstract

Background and aim: Direct-acting antiviral (DAA) treatments became available for all people living with hepatitis C virus (HCV) in Australia in March 2016. We assess variations in treatment rates and prescribing patterns across Australia's 338 Statistical Area 3 (SA3) geographical units.

Methods: Geocoded DAA treatment initiation data were analysed for the period 1 March 2016 to 30 June 2017. Regression models tested associations between the population demographics and healthcare service coverage of geographical areas and (a) their treatment rates; and (b) the proportion of prescriptions written by specialists compared to non-specialists.

Results: Across the 320 areas (95%) recording treatments, a median 76 (interquartile range [IQR] 35-207, range 4-3834) per 100,000 were initiated, corresponding to an estimated median 7.9% (IQR 2.9-23.6%, range 0-100%) treatment uptake. Major cities, areas of socioeconomic advantage and areas with lower proportions of the population born overseas had the highest per capita treatment rates. Non-specialists prescribed 46% (20,323/44,382) of treatment initiations. Prescriptions were written by non-specialists only in 163 areas (51%), while in other areas a median 40.0% (IQR 21.8-62.5%) of prescriptions were written by non-specialists. Non-specialist prescribing was higher in regional areas, as well as areas that had greater proportions of Indigenous Australians.

Conclusions: High national-level treatment uptake of 20% in Australia masks underlying health system limitations; more than half of geographical areas may have treated less than 8% of people living with HCV. Areas of socioeconomic disadvantage and areas with a higher proportion of the population born overseas may need targeting with interventions to improve treatment uptake.

Keywords: direct-acting antivirals; elimination; geospatial analysis; hepatitis C virus.

Figure 1.

DAA treatments per capita from March 2016 to June 2017 in each of Australia's Statistical Area 3 geographical regions. Due to the extreme heterogeneity in treatment rates (ranging from 0 to 3834 per 100,000), SA3s were colour-coded by decile to aid visualisation

Figure 2.

Heterogeneity of treatments measures across Australia's Statistical Area 3 geographical regions. The estimated percentage of people living with HCV who were treated (blue, left); percentage of treatments prescribed by specialists (blue, centre); and treatments per 100,000 population (red, right). Boxplot whiskers represent observations greater than the 90^th percentile or less than the 10^th percentile. The right-hand y-axis scale excludes a single outlier, Adelaide City, which had 3834 treatments per 100,000 (897 treatments). The median of zero on the central bar indicates that greater than 50% of geographical areas had no specialist prescriptions

Figure 3.

Percentage of people living with HCV who commenced DAA treatment from each of Australia's Statistical Area 3 geographical regions. Denominator numbers of people living with HCV in each region estimated using the statistical regression model from Hainsworth et al.

Figure 4.

Proportion of DAAs prescribed by specialists in each of Australia's Statistical Area 3 geographical regions