2018 Australasian Viral Hepatitis Conference: Nurse-led Models-of-care Report by Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM)

KEY MESSAGES FROM NURSE-LED MODELS OF CARE FORUM AND SELECTED PRESENTATIONS

Also available 2018 Australasian Viral Hepatitis Conference Key Findings Report http://bit.ly/VH18_KeyFindingsReport

11TH AUSTRALASIAN VIRAL HEPATITIS CONFERENCE 2018 â&#x20AC;&#x153;We have the knowledge and insight to simplify hepatitis C treatment to improve the uptake and outcomes in various population groups. This, combined with holistic care models and peer support as well as a continuing focus on prevention over cure is vital moving forward.â&#x20AC;? ISABELLE PURCELL Hepatitis Victoria

We are in an exciting time. We have the opportunity to impact viral hepatitis in a way never before possible. However, as with every great endeavour, there is the risk that some people will miss the opportunities afforded by recent advances in therapeutics, implementation and policy. Worse, those who miss out may be the people who could benefit most. Our conference was inspired by the 2030 Agenda for Sustainable Development and its focus on inclusion and health for all. The program showcased and critically examined ways to effectively reach everyone living with viral hepatitis, while being inclusive of their experiences and concerns. This report provides a snapshot of highlights, with links to speaker presentations, abstracts, audio recordings and video.

Contents Key messages from Nurse-led Models-of-care Forum

3–6

Engaging hard to reach hepatitis C populations: A New Zealand regional experience Delivering Innovative Nurse led models of care for Viral Hepatitis from the Arafura to the Hunter – an ongoing collaboration Nurse Practitioner and peer-based model of care to meet the needs of injecting drug users DeLIVERing Integrated care Pathways to treatment for a difficult-to-treat population

Key messages from Australasian Viral Hepatitis Conference presentations

6 – 14

Collaborative partnerships are needed to eliminate hepatitis C in marginalised populations Peer Support Service for CALD people living with Hepatitis B-The Efforts, The Risks and The Benefits “I love not being infectious": Perceptions of hepatitis C cure post DAA treatment Effectiveness and acceptance of an intensive screening and case finding intervention in a public OST clinic When Hep C care and treatment meets NSP…It's positively hep [TITLE MISSING] Partnering Hepatology Nurses and Peer Workers to increase treatment among marginalised people Recall can increase treatment uptake: An audit of positive hepatitis C PCR tests at Kirketon Road Centre Quiet achievers: A multidisciplinary approach to HEPATITIS C treatment and management in marginalised populations - The QuIHN outreach model Implementation of a hospital led, community-based Hepatology Nurse Practitioner model of care in an inner-city Sydney setting

Testimonials from Nurse-led Models-of-care Forum

15 – 22

Don't miss out on the 2019 Australasian Viral Hepatitis Elimination Conference. Find out more at www.avhec2019.com.au or follow @ASHMmedia on twitter.

Key Messages from Nurse-led Models-of-care Forum ENGAGING HARD TO REACH HEPATITIS C POPULATIONS: A NEW ZEALAND REGIONAL EXPERIENCE Presentation by Lynnaire Mathews “Keep marching forward to a future of hepatitis C elimination”

Commentary by Wendy Sue Forder – Registered Nurse Harm Minimisation Program Redfern Sydney Local Health District Drug Health Services, New South Wales

Lynnaire – mother and grandmother, spoke about her 42 years of varied nursing experience and of the close-knit community in New Zealand. She knew of nurses who have known their clients since babies. New Zealand is still awaiting a pan-genotypic treatment for hepatitis C. Her view was that GPs had low level of knowledge about hepatitis C treatment. Her suggestions of ways to access the hard-to-reach hepatitis C clients included: • Identify the barriers and consider various communication options • Contact details need to be checked • Collaborate with other health providers such as GP and social workers • Gain the clients trust • Use a Maori health worker • Gain access to hospital database to find clients with hepatitis C • Send reminder text messages • Send information on what the testing involves, and send this by post Some further advice: • Alcohol-dependent clients in the morning may not feel well and not consider treatment • Social workers could refer homeless people to a nurse • Clients fear bad results if testing was to occur • Clients frequently changing their address • Clinic locations are at times problematic • Clients believe they need a liver biopsy and this puts them off • Running a clinic in a physiotherapist’s room was a great suggestion for clients who wanted more privacy and that these rooms are plentiful so therefore increase options Listen to Lynnaire Matthews, #HepC Community Nurse @HepFoundationNZ, who shared innovative strategies to engage hard-to-reach ppl thru nurse-led models of care in community settings at @ASHMMedia Viral Hep Nursing Forum, a satellite #VH18 event. @APNAnurses @aus_hep @acnp_national @DANAnews1

https://twitter.com/ASHMMedia/status/1028553104227151872

DELIVERING INNOVATIVE NURSE-LED MODELS-OF-CARE FOR VIRAL HEPATITIS FROM THE ARAFURA TO THE HUNTER – AN ONGOING COLLABORATION Presentation by Jaclyn Tate Baker, Matthew Madison, Suresh Sharma Outreach clinics and telehealth continue to be the mainstay for addressing access to health care in these vast geographical locations with priority populations Commentary by Katherine McQuillan – Nurse Specialist Bathurst Liver Clinic, Victoria

Peppered by a case study, this presentation showed how two services from Darwin to John Hunter provide innovative care to patients with viral hepatitis within geographically isolated communities. Data from the ASHM Mapping project – https://www.ashm.org.au/HBV/hepatitis-b-mappingreports – shows that the Northern Territory regions have the highest national average of hepatitis B cases and double the national average for hepatitis C. This can be partly attributed to a very culturally diverse region with a youthful transient population. Due to the tyranny of distance with this geographical area, more proactive screening and engagement of viral hepatitis care was sought. Innovative outreach clinics – comprising of a doctor, nurse and sonographer fly in to the remote communities to provide a “one stop shop” including assessment, treatment and reviews, health education, vaccination and hepatocellular carcinoma (HCC) screening, thus reducing the need for clients to travel long distances to specialist care. The cost of transport, patient confusion and anxiety about diagnosis, were identified as barriers that needed to be addressed to improve client outcomes. Varying attendance rates showed competing priorities for clients, especially with cultural responsibilities and family business. Telehealth was another successful way to engage clients in care – via smart phone or home PC in their own environment, reducing the need for travel. People accessed care via the nurse-led model clinic and shared care approach with a specialist. The scope of the nursing role included, but is not limited to: • Telephone support • Coordination of scripts • Community engagement • Involvement in multidisciplinary team meetings • Maintaining databases Patients are managed in the ‘stable group’ (screening and surveillance) or ‘active group’ proactively case managed, highlighting that navigation of care in these client groups is vital, to improve client outcomes.

A RESPONSIVE MODEL-OF-CARE UTILISING A COLLABORATIVE NURSE PRACTITIONER AND PEER-BASED MODEL OF CARE TO MEET THE NEEDS OF INJECTING DRUG USERS Presentation by Leanne Myers Commentary by Sam Blake – Registered Nurse, Nurse Practitioner Candidate Swan Hill District Health, Victoria

‘One-Stop Shop’ – this was a phrase repeated many times throughout the conference and rang true in the service delivery model that Leanne and her team provide. Many barriers face the injecting drug users – especially those who are homeless or live in isolated areas. Barriers such as poor venous access, transient lifestyles, no mobile phone contact, and scarce resources can be minimised by providing a ‘one-stop shop’ approach. A service delivery model that is flexible – this is proving to be effective in engaging the hard to reach clients as it is taking the service to the people and provides a broad range of services including sexual health, blood borne virus (BBV), NSP and education. The other important aspects of this are:

• The inclusion of peer workers as key in the delivery of service and • Ensuring the needs of the consumer are the priority. A collaborative arrangement/approach is made with the clients, peer workers, health professionals and the various health services to ensure access is easy, and needs can be met a seamless way. As a result, Leanne reports she and her team have experienced great health and wellbeing outcomes and hope to be able to continue and expand their service delivery.

A RESPONSIVE MODEL-OF-CARE UTILISING A COLLABORATIVE NURSE PRACTITIONER AND PEER-BASED MODEL OF CARE TO MEET THE NEEDS OF INJECTING DRUG USERS Presentation by Jana Van der Jagt; Alexandra Wade The idea of a “no wrong door” policy was discussed and seemed a great initiative to increase access to care. Commentary by Matthew Maddison – Hepatitis C Clinical Nurse Consultant Department of Health, Northern Territory

Jana and Alex are a Nurse Practitioner (NP) and Clinical Nurse Consultant (CNC) working in Port Macquarie, NSW. They shared with us how they set up a model-ofcare to look after people with viral hepatitis and chronic liver disease. This model-of-care integrates nursing staff – from across the health service to work together to improve outcomes. The viral hepatitis unit was expanded upon in this project and a NP and a CNC position was established that was funded by the existing service and the drug and alcohol department. This was a great example of how different units can work together to improve outcomes for those with viral hepatitis and chronic liver disease.

PATHWAYS TO TREATMENT FOR A DIFFICULT-TO-TREAT POPULATION Presentation by Ken Murray “Making the once impossible to possible - The challenges of treating and managing viral hepatitis in people with chronic mental conditions”. Commentary by Suresh Sharma – Nurse Practitioner John Hunter Hospital, New South Wales

The nursing forum organising committee saved one of the best talks of the day for the closing session, Ken provided a fresh insight of the challenges of people living with severe chronic mental health conditions receiving management for their chronic conditions including viral hepatitis. Ken is the CNC for the chronic conditions for the Mental Health Service in the South Eastern Sydney Local Health District. He discussed how for most, mortality for people with chronic mental health conditions isn’t from their mental health condition but rather from cancer, cardiovascular, respiratory and other chronic conditions and which is responsible for >90% of all deaths within this group. In addition to expressively pointing out that there is at least a ten year “mortality-gap” in life expectancy for people with chronic mental health conditions. Nurse and other health care providers can play a key role – in facilitating individuals modifying risk factors which may improve the premature death rate, including: • Smoking of cigarettes • Reducing alcohol intake • Treating and/or managing chronic infections and conditions   Ken provided his first-hand experience and guidance on how providing care in a non-judgemental, personally acceptable and dynamic way, is essential to enabling these individuals to reach their full health potential.  However, workforce challenges remain for those working within this area as management of chronic conditions outside of mental health conditions is seen as “out-of-scope” or “outside of their current skill set” which present a major challenge. Ken provided a quite detailed and animated description of how to engage some prescribers to initiate hepatitis C treatment for this population. Individuals are keen, willing and wanting to engage in treatments which can improve their well-being and long-term health.  Challenges remain for people accessing treatment for viral hepatitis to people with chronic mental illness, however advocacy by individuals like Ken provides promise that more holistic approaches to managing chronic conditions is possible. Listen to Ken Murray, CNC @SEastSydHealth today shared pathways to viral hepatitis treatment for a difficult-to-treat population at the 1-day @ASHMMedia Viral Hep Nursing Forum, a satellite #VH18 event in #Adelaide

https://twitter.com/ASHMMedia/status/1028532748598689792

Key Messages from 2018 Australasian Viral Hepatitis Conference presentations COLLABORATIVE PARTNERSHIPS ARE NEEDED TO ELIMINATE HEPATITIS C IN MARGINALISED POPULATIONS Presentation by Janice Pritchard-Jones Commentary by Jacki Seaward – Community Hepatitis Nurse The Hepatitis Foundation of New Zealand

Marginalisation is defined as the reduced opportunities individual experiences compared to others, due to their inadequate access to the resources within their communities. Risk factors for marginalisation include such things as financial hardship, social isolation, stigmatisation and early life disadvantage. Janice Pritchard-Jones, Hepatitis Co-ordinator from the Sydney Local Health District stressed the critical part collaboration of partnerships played in addressing the negative impact marginalisation had on the individual and their communities. At the forefront of these collaborations were nurses, who appeared to be in pivotal positions to bring together health providers and all stakeholders by encouraging and supporting innovative strategies to enhance uptake.  It is with the strong collaborations between nurses and other community initiatives, along with resource sharing and selling buy in for all, that the benefits of strong health outcomes would follow ensuring that 'No one is left behind'. However, despite steady progress towards hepatitis C elimination, further development of strategies to address barriers is needed if we are to catch the next wave of people. Finally, when asked, Janice Pritchard-Jones stated that the biggest factor besides collaboration, resource sharing and further investigation of the barriers, is heart. We can't continue to focus on the hepatitis, we need to focus on the person as-a-whole, through eyes of empathy and compassion where the ultimately partnership takes place.

PEER SUPPORT SERVICE FOR CALD PEOPLE LIVING WITH HEPATITIS B-THE EFFORTS, THE RISKS AND THE BENEFITS Presentation by Enaam Oudih View Presentation notes

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Commentary by Jaclyn Tate-Baker – Registered Nurse Department of Health, Northern Territory

PEACE multicultural service has been developing a peer support program as a sustainable hepatitis B model of care. The framework for their model includes: lived experiences, service providers, and literature review.

PEACE is funded by South Australia Health and is the only multicultural BBV and STI service. Community consultation and education, improving resources, counselling and case management are some of the services provided by PEACE. Lived experience of disease and treatment is a powerful tool in advocating for change and understanding service delivery. PEACE identifies that it is arrogant for service providers to think that they understand all CALD lived experience. There is not much literature regarding hepatitis B peer support programs. However, literature review identifies many widely accepted peer support programs for other chronic diseases which aim to assist patients with: • Disease self-management • Self-efficiency • Treatment adherence Consequently, PEACE has identified possible leaders for their program. Solomon Woreta has been working with PEACE for 3 years and shared his lived experience with attendees of the Viral Hepatitis Conference. PEACE mentor and assist with education opportunities for their peer leaders. However, had to be mindful that asking the CALD peer support person to speak publicly of their lived experience and share their ‘shame’ with an audience potentially leaves them vulnerable and test their acceptance of their disease. CALD people with Hepatitis B are confronted with many challenges: • Language • Poor understanding of healthcare system/Low health literacy • Financial stress • Trauma • Stigma, Discrimination and Isolation Service providers need to have ongoing consultation with CALD people to assist with staff understanding of CALD experiences and deliver culturally appropriate consultation. Making their lived experience the centre of care to assist with understanding CALD experiences such as: • Authority and Power come with age • Disease is considered disability • Bringing shame to your family because of disease • Acculturation distress

NURSE-LED MODEL OF HEPATITIS C CARE AND TREATMENT IN VICTORIA PRISONS Presentation by Anne Craigie View Presentation notes

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Commentary by Jillian White – Fibroscan and Hepatitis Nurse The Hepatitis Foundation of New Zealand

Anne is a ‘Champion of Hepatitis’ and works with-in the state-wide hepatitis program in Victorian Prisons, a nurse-led model of care which has been in place since October 2015.

The program encompasses seventeen prison sites through-out the state of Victoria and delivers a nursing led model of care for hepatitis assessment for predominantly hepatitis B and C (and sometimes includes hepatitis D and HIV co-infected patients). This was a presentation regarding the nursing model of care for hepatitis assessment and possible treatment within those prisons. The model of care uses a protocol driven nursing assessment and sometimes includes a thorough drug and alcohol assessment where appropriate. Although a nursing model of care, nurses also include an individualised approach with regards to the patient, considering the prison setting. This is also determined with regards to prison sites, for example some are maximum security and are very different to freedom of movement sites. Prison health care regarding hepatitis assessment and treatment are nursing led models of care. This is important as a thorough nursing assessment is carried out in order to formulate a therapeutic approach to patient care from a nursing perspective before referring patients for treatment, which is prescribed by the hepatitis specialist. If the patient is PCR positive and has completed a full nursing assessment, the patient is then referred for hepatitis C treatment to the hepatitis specialist. Genotyping in the prison system helps the ‘Medical Team’ assess treatment failure, hepatitis C infection re-lapses or a possible reinfection. This information is needed as it may affect the next line of treatment within the prison setting, if required. Discharge planning from a nursing perspective is just as important as the initial patient assessment in preparation for referral and treatment.

“I LOVE NOT BEING INFECTIOUS": PERCEPTIONS OF HEPATITIS C CURE POST DAA TREATMENT Presentation by Jacqui Richmond View Abstract Commentary by Jana Van der Jagt – Nurse Practitioner Hepatology Mid North Coast Local Health District, New South Wales

In her engaging, compassionate and articulate style, Jacqui provided the results of a qualitative study of 20 people which explored what it felt like for them to be cured of their hepatitis C infection. Peoples responses were grouped into five main themes: 1. Psychological impacts (reduced stress) 2. Reduced uncertainty and fear ("if I get sick ... I've just got the flu ... it's not that my liver's packing up on me") 3. 'Feeling normal' 4. Breaking a connection to the past ("...it's like the last mark is now gone") and 5. Physical impact The key message that I took away was that cure had a profound impact on people’s sense of wellbeing, in particular the emotional aspect. People expressed relief at no longer being infectious and feeling that they had to change their behaviour for fear of transmitting the virus as well as excitement about being able to plan for their future. Understanding and sharing these experiences may be a useful tool to reach people who are not engaged in care and link them to treatment.

EFFECTIVENESS AND ACCEPTANCE OF AN INTENSIVE SCREENING AND CASE FINDING INTERVENTION IN A PUBLIC OST CLINIC Presentation by Janice Pritchard-Jones View Abstract Commentary by Lisa Clements – Clinical Practice Nurse Companion House Medical Centre, Canberra

This session discussed an intensive screening hepatitis C case finding intervention in a public opioid substitution therapy (OST) clinic. The partnership was between a liver clinic, health promotion team and drug health service. The intervention was over 4 days and included additional eight staff and two peer educators attending the morning session of an inner West Sydney OST clinic in March 2018. Their Intervention involved blood taking, a fibroscan and clinical assessment. Forty nine percent of total daily dosing clients engaged with the intervention. Of those who engaged, 11 had completed or were currently taking hepatitis C treatment, 7 had untreated hepatitis C, as well as also identifying a hepatitis C/hepatitis B coinfection. Also, 2 cases of chronic hepatitis B were identified. Case management plans were developed for those who needed treatment. However just over 50% of clients still need to be engaged and the next intervention aims to identify strategies as to why the other half of the clients did not engage. This strategy highlights the value of meeting clients where that are at, and not expecting them to come to your liver clinic at the hospital… and tell the clients they will feel better when their hepatitis is treated.

WHEN HEP C CARE AND TREATMENT MEETS NSP… IT'S POSITIVELY HEP Presentation by Julie-Anne Downie View Abstract Commentary by Alexandra Wade – Clinical Nurse Consultant Hastings Macleay Liver Clinic, Mid North Coast Local Health District, New South Wales

This model was in line with the Deadly Liver Mob and used incentivised peer driven intervention to engage, educate, screen and treat clients of the Needle Syringe Program (NSP) for their hepatitis C. They highlighted the importance of the link between existing services for people who inject drugs (PWID) for access to hepatitis C treatment. This has been mentioned over the entire conference and they were able to provide a really positive example of this concept in action. Results of the program are ‘positively hep’ in that they have educated 326 clients with 25 commencing treatment via the clinic. This is an example of providing care to PWID in the places they are already accessing that are free of stigma and discrimination – leading to better outcomes for both the client, service and community.

TOO SOON FOR BACK-SLAPPING AND COUNTING CHICKENS: ENGAGEMENTWITH SUB-POPULATIONS OF PEOPLE WHO USE DRUGS Presentation by Melanie Walker View Presentation notes

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Commentary by Joanne Teague – Clinical Nurse Northern Drug and Alcohol Services South Australia

Melanie Walker, CEO at the Australian Injecting & Illicit Drug Users league (AIVL) pointed out, just like her peer presenters, the gaps in enabling ‘everyone' who has hepatitis C, to obtain equity treatment in this country, more so for PWID. A fundamental and key aspect on reducing the incidence in this group is ‘harm minimisation', which in turn, is more cost effective than the actual treatment. Melanie addressed groups of people that are being under represented, one being PWID, people who are incarcerated and needing follow up in the community as well as our aged population in nursing homes, specifically. Are these people being checked, diagnosed, managed, treated or supported, along with their families? Another fundamental aspect of PWID, is looking at the age group of about 12-25, using amphetamines (not necessarily injecting) and having unprotected sex, particularly in rural areas. This then looks at the increase in sexually transmissible infections (STIs) amongst this group and are these people able to access affordable, equitable, non-judgemental treatment and appropriate follow up care? Some STIs are notifiable diseases, so how is this managed in a rural setting I ask?

PARTNERING HEPATOLOGY NURSES AND PEER WORKERS TO INCREASE TREATMENT AMONG MARGINALISED PEOPLE Presentation by Kyle Leadbeatter View Presentation notes

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Commentary by Nicole Daley – Remote Area Nurse Department of Health, Northern Territory

To meet the unique barriers that such marginalised people face, a novel approach is essential. Peerbased treatment access programs, peers working in partnership with hepatology nurses, mobile testing and meeting patients at an individual level of health needs form this innovative approach. Kyle details the traditional model of care for hepatitis C, a somewhat convoluted process unlikely to suit many people living with hepatitis C and the known social difficulties that come with this disease. A simple, streamlined model with far less engagement of service would appear pertinent to success of accessing care with flexible models targeting OST, homelessness, residential rehabilitation services, community and youth centres and supervised injecting centres.

Underpinning these models are two key stakeholders – hepatology nurses and peer workers. Hepatology nurses bring their niche expertise to their patients through clinical outreach beyond the city, building strong and respectful rapport and focusing on clinical evaluation. Dedicated and passionate paid peer workers offer their diverse experience of living with hepatitis c and support the nurses by focusing on engagement through appointment reminders, spreading the word about cure and debunking myths and fears. Through the strong partnership of nurses and peer workers focusing on a person-centred approach, flexible models of care combined with assisting greater social needs is paramount to the achievable success in living hepatitis C free.

RECALL CAN INCREASE TREATMENT UPTAKE: AN AUDIT OF POSITIVE HEPATITIS C PCR TESTS AT KIRKETON ROAD CENTRE Presentation by Rebecca Lothian View Presentation notes

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Commentary by Ken Murray – GP Liaison Nurse Consultant South Eastern Sydney Local Health District

This presentation illustrates the usefulness of a research approach to demonstrate practice. The client group includes people experiencing homelessness, as well as injecting drug use.  Contact details of a marginalised and transient population often change. Therefore, many clients were unable to be followed up. However, of the clients who were able to be followed up, active recall boosted significantly the number of clients successfully engaged in care (an increase of 17% engaged in care).

QUIET ACHIEVERS: A MULTIDISCIPLINARY APPROACH TO HEPATITIS C TREATMENT AND MANAGEMENT IN MARGINALISED POPULATIONS – THE QUIHN OUTREACH MODEL Presentation by Mary Fenech View Presentation notes

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Commentary by Lynnaire Matthews - Hepatitis Community Nurse The Hepatitis Foundation of New Zealand

A multi-disciplinary approach to hepatitis C assessment, fibroscan and treatment in this marginalised population through a Nurse Practitioner (NP); nurse led Queensland Injectors Health Network (QuIHN) outreach model of care, taking the service to the people and working in their primary care setting. Also, not pressuring the General Practitioners (GP) who don’t feel equipped to assess and treat the patients but providing support to those who do.

Mary commented that in the cascade of care that we mustn’t forget the patient as an individual, that it’s not always about the numbers but about the people, not positioning them on a conveyer belt of care. Mary believes in a holistic approach in her engagement of care, using brief intervention as a valuable tool to help facilitate positive health outcomes. Gaining trust to enable a willingness to re-engage if re-infected especially post release from prison. Mary is working with release prisoners on parole as these people so often become lost to follow up and are not often engaged with health services after release. As a NP she can prescribe direct acting antivirals (DAAs) providing the ease of access to getting treated, I hope to see this happen in New Zealand soon. By providing a ‘one stop shop’ with an acceptable, accessible and effective model of care through collaboration. If we are going to reach and provide care and treatment for our high-risk hepatitis C population it needs to be through a collaborative approach. The NP model can be used in a variety of settings for those who are not choosing to use mainstream treatment services.

IMPLEMENTATION OF A HOSPITAL LED, COMMUNITY BASED HEPATOLOGY NURSE PRACTITIONER MODEL OF CARE IN AN INNER-CITY SYDNEY SETTING Presentation by Sinead Shiels View Presentation notes

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Commentary by Pieter Herbold – Registered Nurse, Mental Health Clinical Care Coordinator Nunkuwarrin Yunti Community Health Centre, South Australia

This model of care was developed to support primary care services in the delivery of care in managing consumers with hepatitis. This was an example of a model of care specifically directed at a certain population. The population targeted was a marginalised, vulnerable cohort with little engagement in health provision. The people targeted were on OST but did not engage with a GP. Their OST prescriptions were provided by people other than GPs, Psychiatrists and other non-GP providers. Of this group, blood samples were obtained from 60%. Less than 1% were diagnosed with hepatitis B, 13% had cirrhosis and 50% had a positive hepatitis C RNA. This model of care took into account the individuals needs for specific engagement strategies that although labour intensive, could and would not have occurred without a dedicated person targeting this specific group of people and their ways of engaging. It was described by the presenter as case by case micro elimination. This model of care highlighted the need to provide hepatitis treatment on an individual level. To place the individual at the center of care to assure treatment.

Testimonials from Nurse-led Models-of-care Forum Jacki Seaward - Community Hepatitis Nurse The Hepatitis Foundation of New Zealand The 11th Australasian Viral Hepatitis Conference is a biennial event that brings together clinicians, hepatitis nurses, health promoters, peers and other health professionals working with people with viral hepatitis. The conference this year attracted 508 attendees. The conference theme was â&#x20AC;&#x2DC;no one left behindâ&#x20AC;&#x2122;. The Australasian Viral Hepatitis Conference is the leading multidisciplinary Viral Hepatitis Conference in Australasia. The Nurseâ&#x20AC;&#x2122;s Forum held at the Grand Chancellor Hotel was a great basis in which to lead up to the conference. The program was well thought out and the mixed bag of speakers were thought provoking, innovative and clearly passionate about the role they played of this shared interest. Upon reflection of the Nurses Forum I believe that at the forefront of the World Health Organisation (WHO) 2030 Hepatitis Elimination Strategy were nurses, who appeared to be in pivotal positions to bring together health providers and all stakeholders by encouraging and supporting innovative strategies to enhance uptake and ongoing care to those with hepatitis. Key highlights of the conference were on the networking and collaborative opportunities going forward. ASHM have done an outstanding job! No stone was left unturned in this well organised Viral Hepatitis Conference 2018 at the Adelaide Conference Centre. I feel truly blessed to have been able to attend a conference to witness the high level of dedication shared among a diverse melting pot of people. It gave me reassurance that with continued networking, information sharing, and the innovative strategies shared at this conference, we will reach the goal of 2030 Elimination Strategy of hepatitis set out by the WHO. With the extensive and varied program, I was lucky to attend as a scholarship winner, I believe it has prepared me well for this position I have recently started as a community hepatitis nurse for the Hepatitis Foundation of New Zealand. I have a passion for this role and given the additional tools I have acquired through this well laid out program I believe I will be able to enhance my role further to meet the needs of those I serve. In addition, I made myself available to openly network among the myriad of people who attended this conference. I made strong connections from all walks of life and will continue to network with these people in which to strengthen the shared vision we all strive towards. Finally, on reflection of the conference I believe I am fortunate to work for the Hepatitis Foundation of New Zealand. From the amazing leaders in our organisation, who are very supportive and forward thinking, to our comprehensive data system for screening and monitoring people, I believe this ensures positive outcomes that No one is Left Behind. I thank the Foundation for supporting me to attend this conference, and the ongoing support in my role.

Alexandra Wade - Clinical Nurse Consultant Hastings Macleay Liver Clinic, Mid North Coast Local Health District, New South Wales Over the three days there was such quality in presentations and presenters. I was moved more than once by the honest reflection of people with lived experience and researchers alike. Anne Mitchells lived experience story indicates the need for health professionals to see a person in their entirety and connect and collaborate with other services to provide optimal care for people who inject drugs. Sunil Soloman’s presentation directly afterwards was a snapshot insight into the viral hepatitis situation in India. His obvious dedication, sense of humour and high reaching ambition for a Tolkien worthy cure, “one injection to heal them all”, pushed the audience to continue to think beyond the plateau we are fast approaching with the existing DAA’s. His snowballing recruitment for treatment was astonishing with what appeared to be a 12 tiered reach – it spread out across the country like life-blood. Link to his research below from The Lancet. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2814%2971045-X/fulltext Deadly Liver Mob, in the same aspiration as Sunil’s research, the Deadly Liver Mob are having great success – this project highlights that ‘yarning’ and ‘community connections’ are an integral part of health in the Aboriginal community and outlined how important it is to have Aboriginal Health Workers involved every step of the way. Mt Druitt also reached 12 layers with their model. https://csrh.arts.unsw.edu.au/research/projects/deadly-liver-mob-nhmrc-partnership-project/ The split sessions in the afternoons fired up all kinds of heated and interesting conversations; especially discussion around accessing public health HCV RNA notification data for clinician follow up. I felt particularly inspired and moved ‘again’ by their passion and dedication to the people we all are aiming to assist. It is, after all, all about the person not the provider. Presentations and discussions around stigma and discrimination continued throughout the conference and it saddens me that we are still failing our clients/patients in this way as health professionals but inspires me to do more – be more – act more.

Jana Van der Jagt – Nurse Practitioner Hepatology Mid North Coast Local Health District, New South Wales The 11th Australasian Viral Hepatitis Conference has had so many highlights so far, it's hard to know where to start. The ASHM Nurse-led Models of Care Satellite Symposium was an opportunity to see the incredible work being done by dynamic nurses from all around Australia and New Zealand. A fertile ground for sharing ideas. There have been lots of lightbulb moments for me so far. A great conversation between Janice Pritchard-Jones and Ben Cowie around strategies for using hepatitis C RNA notification data to link people loving with hepatitis C to care while protecting their privacy has already led to some exciting discussions within my local team. Great debates about the need for testing for SVR 12 weeks after completing hepatitis C treatment ... is it an unnecessary burden and expense? Who are we doing it for? Maybe it's only valuable in populations at risk of reinfection or where we have concerns about adherence? I will be keeping a keen eye out for the online, interactive map being developed for clinicians, so we can see current prevalence of hepatitis C and hepatitis B in different localities as well as treatment rates. I feel inspired and can't wait to apply some of the great ideas I've heard here.

Jillian White Fibroscan and Hepatitis Nurse The Hepatitis Foundation of New Zealand Thanks for welcoming me as a hepatitis nurse raised in New Zealand to again visit my country of birth, Australia, as part of the world-wide network of medical professionals in hepatitis. It was truly amazing to share in the learning and collaborations for the betterment of our world in health, with people who genuinely aim for delivering quality care to patients with viral hepatitis. It was enlightening to be surrounded by medical professionals and people with extensive and understanding of the viral hepatitis condition and who are committed to removing barriers to quality care for all patients. It was great to hear other professional journeys with regards to viral hepatitis, including the successes, challenges that are faced as health professionals when addressing viral hepatitis in Australia. The Australian medical professionals in attendance had a great understanding of their target viral hepatitis populations and were committed to hepatitis study and research to inform evidence-based practice. Medical professionals were also trying to engage with remote Aboriginal communities in a meaningful way. How we engage with Maori, Asian and Pacific Island communities in New Zealand was discussed with regards to hepatitis. A highlight on a professional level was to hear the somewhat similar yet very different engagement successes and challenges when it comes to hepatitis B and C patients. In summary both New Zealand and Australia have much to learn from each other, on the many levels and idiosyncrasies of chronic hepatitis B and C and its management in conjunction with the patient/family/community and other health professionals.

Joanne Teague â&#x20AC;&#x201C; Clinical Nurse Northern Drug and Alcohol Services South Australia As a drug and alcohol and mental health nurse, listening to Anne's story and her experiences from first being diagnosed with hepatitis C in the 1990â&#x20AC;&#x2122;s, up to and including her treatment and how it affected not only her but her family, as well as the emotional, mental, financial, legal, relationship and her extended community. It gave me the opportunity to reflect upon my current work practices and the barriers I face daily with Aboriginal and Torres Strait Islander and non-Indigenous clients, in keeping them engaged, whether they are on maintenance treatment for opiate dependence (MATOD), or counselling only clients; whether they attend for onsite dosing, collect interim scripts, needing blood and urine testing, or attend referred appointments to have fibroscans etc. This is a challenge I and we face daily. I feel that one barrier in retaining these clients, maybe a lack of cultural insight, even though we were all mandated to attend training. This is certainly something I will discuss with my colleagues and address any areas that could possibly be amended, to increase clients continued engagement, treatment, our increased support for them, better understanding of their needs and wants and ultimately their positive health outcomes. Working as a clinical nurse, within the Alcohol and Other Drugs public sector in Adelaide, I have heard throughout this discussion, the barriers to people receiving optimal testing, treatment and especially follow up, whilst incarcerated and when released into the community. I feel many clients I have seen who are hepatitis C positive and been through the revolving door of our justice system, have still not been treated and or followed up and I am curious as to why this is still happening. Many of the clients have contracted hepatitis C from prison and have slipped through the system to follow up care, all the while they've been in and out prison, since confirmed with the virus. I am

aware our clients continuing to use illicit drugs in prison and some have heard “horror" stories of past treatments and are hesitant to commence treatment. Why? This is not a priority for them at the time. Getting money from Centrelink, finding somewhere to live, reconnecting with family, attending parole, corrections, drug court, job providers and giving clean urines, so they don't go back to jail are their priorities. I respect this and discuss with them a time frame to take up this discussion or at least grab their bloods when they come in over the next few days, as a start. I would love to see our correctional facilities, work more closely with our service, to better coordinate clients on MATOD, and new clients wanting to commence MATOD who have a diagnosis of hepatitis B or hepatitis C, to provide an optimal treatment service delivery system, where our mutual clients have regular contact with both services. We need to address the current illicit drug use within our correctional facilities and seriously think about having a clean needle program to reduce the incidence of blood borne virus (BBV), in particular hepatitis C and hepatitis B infections. Preventative measures are more cost effective and accessible than the cure!! Katherine McQuillan – Nurse Specialist Bathurst Liver Clinic, Victoria The ASHM Models of Care Nursing Forum and the 11th Australasian Viral Hepatitis conference showcased the exemplary work of the passionate and committed workforce that are tirelessly working towards elimination of hepatitis. A strong focus on how to maximise services to make treatment and care an equitable undertaking for all with an emphasis on human rights, was the backbone theme to the conference. Building relationships with GPs, practice nurses, drug and alcohol workers, peer driven education, engaging Aboriginal Health Workers and utilising our NGO sector, were key enablers to achieve this. Prison population work also reinforced micro elimination successes, that can be upscaled, even in the constraints of a restricted environment with many barriers to work with along the way. Dr Sunil Soloman summed up nicely a ‘Wish list’ that resonates universally; to have availability of rapid testing, short drug regimes, advocacy, activism and political commitment for funding to continue the fight against viral hepatitis. We are so fortunate to have access to mapping and modelling data to guide our efforts and transfer this information into practical utility on the ground. Knowing what data can and can’t tell us, and using it appropriately, can influence health services and local government to provide equitable access to care, as Dr Ben Cowie states “it’s a human rights issue!” Presentations covered many aspects in the disparity of care given to our priority populations, but with many innovative solutions being implemented to overcome this. These diverse models of care continue to address the theme of ‘no one left behind’. Personal and powerful messages from people with the lived experience of viral hepatitis, proudly took the stage and reminded us all, that sadly, stigma and discrimination is still very much a part of community and healthcare settings. Multicultural advocacy groups, hepatitis organisations, and peer workers are all adding to the arsenal against this fight. Alarming mental health statistics and hepatitis C, also highlighted more work to be done in this marginalised group, especially for inpatient care. Last but not least the opportunity to network within this event allows likeminded people to build, feed and grow the passion it takes to continue the work against elimination efforts. Also, to acknowledge the sponsors of the event, that support this to happen. The overwhelming

Australasian passion and commitment amongst delegates, leaves me feeling optimistic that no one will be left behind. Ken Murray - GP Liaison Nurse Consultant South Eastern Sydney Local Health District I began the conference a day early at the Nurses Forum, which provided an opportunity to see how nurses were driving treatment outcomes for people living with hepatitis.  It was an opportunity to see that NP positions are proving their worth by combining a nursing approach along with prescribing.   Aboriginal and Torres Strait Islander peoples are over-represented for many chronic illnesses, including hepatitis B and C.  The conference had various presentations which showed how this population in remote Australia need thoughtful and targeted care provision.  It was re-assuring to see that so much effort is going into this group and led me to hope that this may be one inequality in health that will be at least partially, addressed. It was shocking to hear that Northern Territory has only 1 fibroscan machine, and it would seem that should be a priority for the healthcare system there. Another hard to reach population, people who are incarcerated, a captive population with a very high sero-incidence would seem to be relatively easy to treat.  However, various presentations illustrated the very real barriers presented by various factors, including the unpredictable mobility of the prison population. It was very gratifying to see that many speakers also touched on the ongoing unrealistic, expensive and counterproductive culture of prohibition which means the further marginalisation of drug users who are very over-represented in the hepatitis positive cohort. The conference was well run, easy to navigate to get to particular presentations, and gave enough time for breaks for poster viewing and networking.  A bonus for me was environmental responsibility, with little paper and/or plastic based resources/promo items etc. to send to landfill.

Lisa Clements – Clinical Practice Nurse Companion House Medical Centre, Canberra “I was so angry I wasn’t told.” The conference provided a great breadth of information about viral hepatitis and the demands of living with such a condition. A great quote on of the sessions was a nurse that had said her client was angry that she, the patient wasn’t told how much better she would feel after taking her DAAs and clearing hepatitis C. This really made me think about how much we presume the clients know. I mean what a great hook that is to encourage someone to undergo treatment. That brings me to thinking, that as a nurse providing care for clients living with chronic hepatitis B (CHB) a big concern is that I think the clients who are living with CHB still don’t really understand how deadly it can be. As a result, I was really hoping to get some different resources and the following resources will be useful in my service. The Hep b side by side YouTube is a good plain English language quick explanation https://www.youtube.com/watch?v=IZyvYSRv14c (I will certainly be showing that to the clients. Especially as it is also in Karen, a common ethnicity of many of the clients living with CHB at my service) and another clip with Sudanese Hip Hop artists Malesh P See: https://screeningresources.cancervic.org.au/malesh-p-hep-b

Lynnaire Matthews - Hepatitis Community Nurse The Hepatitis Foundation of New Zealand The strong messages that came through for me were the need to continue to breakdown stigma through education of the community and health care workforce about viral hepatitis to enable patients to gain trust for engagement of care in our various health settings through: • The value and benefits of working with peer-based model of care in people who inject drugs (PWID) for an effective hepatitis C service delivery linked to ease of access to treatment • Developing and implementing harm reduction within that service to reduce re-infection rates • Considering the option and benefits of telehealth with our geographically isolated hepatitis C communities to help facilitate them towards treatment • The importance of collaboration with all stakeholders connected to our patients to help expediate the opportunity for treatment and improve health outcomes • Lobbying the ‘Purse string holders’ of the service contracts to adequately fund an appropriate, accessible, affordable and acceptable service to a potential cure • Enabling NPs to prescribe treatment in primary care settings including prison health to reduce some of the financial and time barriers to getting treated. • Continually evaluating service plans and delivery and be prepared to ‘think outside the current square’ if we want to keep working towards viral hepatitis elimination targets and leave no one behind. I agree with Dr Alex Lampen-Smith that their needs to be key performance indicators attached to hepatitis work in the primary care areas if we are to find the undiagnosed and treat and care for those diagnosed with viral hepatitis.

Matthew Maddison Hepatitis C Clinical Nurse Consultant Department of Health, Northern Territory Over the past few days I was fortunate to have attended the ASHM Nurse led Models of Care Forum and the Australasian Viral Hepatitis 2018 Conference in Adelaide. I travelled to Adelaide from Darwin and found both of the meetings to be highly informative and engaging. It was amazing to hear about all of the work that others are doing across Australia and New Zealand. Living in Darwin and working across the Top End is a unique experience and it was great to be able to share my stories as well as hear what others are doing to improve the lives of those affected by viral hepatitis. Thank you to everyone who put in all the hard work to make these events happen and thank you to all the speakers for sharing your work with us all. Take home messages: • Liver cancer is attributable to so many deaths across the world yet does not have the same status or recognition as other forms of cancer. • There is so much great work being done in the field of viral hepatitis, but more work needs to be done to bring Hepatitis B and C to the attention of the community. Nicole Daley Remote Area Nurse Department of Health, Northern Territory A grateful and excited recipient of a scholarship to attend the 11th ASHM Australasian Viral Hepatitis 2018 Conference, I left my remote Indigenous community in the Northern Territory and headed for

Adelaide. Hepatitis is like the poor little cousin that doesn’t get a lot of recognition or resources compared to show stealers like diabetes and cardiovascular disease. My existing knowledge of hepatitis was fairly limited, and I was keen to better understand this disease, the people living with it, and current nurse led models of care in hopes of becoming a hepatitis champion. Although the incidence of viral hepatitis is not particularly high in my community, Indigenous Australians are disproportionately represented as with so many other health care issues. Reaching these marginalised people, urban or remote, requires the same approach. Passionate nurses stood before us and shared their experience in ways to engage notoriously difficult patients. Rethinking standard models of ‘9-5’ care was particularly highlighted by the traveling kombi van. I welcomed the shift in language from an IVDU to a PWID, what a positive step in shutting down stigma. For me, this conference has put viral hepatitis on my radar. The challenge has been set: no one left behind.

Pieter Herbold – Registered Nurse, Mental Health Clinical Care Coordinator Nunkuwarrin Yunti Community Health Centre, South Australia I attended the conference and forum to better understand the barriers to treatment in marginalised communities, to better understand how I could be affective in encouraging my clients into treatment. During the conference, and associated forum there were multiple models of care presented. These ranged from in hospital settings to outreach programs, both multi-disciplined and individual, rural, remote and urban. All of the models presented worked to engage people in testing for viral hepatitis and those found to be hepatitis positive into treatment. All models presented appeared to have a measure of success. There were universal issues around appointment attendances. The need to understand a person's hepatitis status being only one of a competition of individual needs and wants and the need to understand how past engagement with the health sector informs a person's willingness to engage further were both factors in engagement. Staffing was also highlighted as vital to success. Not only have the right skillsets, i.e. proficient phlebotomists, prescribers, infectious disease specialists and fibro scanners, but also people who have the right mindset. Those that can engage effectively, without bias and who let the consumers drive how and when they will engage. The support of individuals was also highlighted for effective engagement. These supports could be as simple as reminder calls, providing transport, incentives such as vouchers to attend or complete treatment, minimising the number of appointments one would have to attend to the possibility of bringing the testing, and treatments to the individual rather than the individual having to come to the provider. At face value, from the presentations, any effort to engage people in this process could have success, and the scale of that success could be limited, or expanded by how individualised the model could become, what supports could be put in place around that individual in need. The message being that one model of care would not suit all people, and the need to be flexible in delivery of care, being client centered, client driven and providing options and choice to the consumer were all highlighted as ways to engage affectively.

Sam Blake – Registered Nurse, Nurse Practitioner Candidate Swan Hill District Health, Victoria I had the fortunate opportunity to attend the 11th Australasian Viral Hepatitis conference in Adelaide recently with the aim of increasing my knowledge and understanding of the screening, treatment, monitoring and aftercare of clients at risk of contracting or who have hepatitis C in particular. I have certainly achieved my goals and have come away with increased confidence in providing information to clients and educating other health care professionals including staff in my counselling team, Swan Hill District Health staff, local GP’s and other external stakeholders. The take home messages were that hepatitis C can be cured and that screening, treatment and monitoring can be simplified by changing the way the delivery of service is provided. Access can be improved by taking the treatment to the hard to reach clients, implementing finger prick testing, and combining NSPs or opiate replacement therapy with hepatitis C treatment are examples of such. The ‘one stop shop’ is an effective approach – combining multiple services in one location. The other message is that unless we change the way screening, treatment and monitoring is currently carried out, the WHO targets of a cure by 2030 will not be reached. The conference had excellent speakers both internationally and locally, also the opportunity to network was fantastic. It was well organised, the catering was great, the seating was comfortable. I would most definitely recommend to anyone who is interested in learning more about viral hepatitis to attend this conference.

Wendy Sue Forder – Registered Nurse Harm Minimisation Program Redfern, Sydney Local Health District Drug Health Services, NSW The Nurse led Models of Care Forum led by the highly engaging Jacqui Richmond was a fabulous highlight. Lots of wonderful interpretive dance was enjoyed by all. The day was full of nurses teaching each other, sharing knowledge, having a laugh and it was just fantastic. I particularly enjoyed hearing NP Leanne Myers experience working with PWID and a peerbased model of care in a harm reduction setting. The complexity of clients and the work she does with a peer worker was inspiring. I’ve made some wonderful contacts. Viral Hepatitis conference 2018 “no one left behind” 11th Australasian conference Each day of the conference I couldn’t wait to bounce out of bed to have a coffee from the gorgeous colourful AbbVie stand then trying to decide which breakout sessions I just couldn’t miss. A bunch of informative, compelling and fascinating presentations were had. Dashing between talks all scheduled in different rooms was challenging. Everything was appealing so it was a matter of eliminating sessions often based on location. Dr Kylie Valentine Deputy Director of the Social Policy Research Centre UNSW, as the first presenter, beautifully set the tone. Her discussion around inequality in Australia was thorough and at times touchingly sad. I particularly enjoyed the Early Career networking lunch. Professor Margaret Hellard, Deputy Director, Burnet Institute Victoria was wonderfully honest and entertaining. Margaret had some very sound and salient advice when talking about career direction and choice. NP Mary Fenech from Queensland Injectors Health Network presentation on the “quiet achievers” a multidisciplinary approach for the marginalised client was heartfelt compassionate care, highlighting what it is that nurses bring to health care treatment landscape.

The “Kombi clinic Boys” (Dr Mathew Young) from Queensland gave a great presentation. It is such an innovative and fun way to engage people for hepatitis treatment. The dedication to the work was quite evident. Suresh Sharma NP from John Hunter Hospital, Gastroenterology Department presented the B-Side, hepatitis B awareness project for clients in the Northern Territory. It is available in several languages and in particular the Kriol language of the Aboriginal community around Darwin. The audio-visual digital resource was jaw droppingly beautiful and clever. The venue, location, accommodation, flights and food were amazing, so nice to have “healthy” food and refreshments. One last highlight was the amazing conference dinner and the dancing. I’d say… Think outside the square. The use of alternative locations such as the use of Physiotherapists rooms to see hard to engage clients is a really great idea that Lynnaire Matthews shared. Otherwise all the important strategies Lynnaire spoke about to engage the hard to engage many of us out there are doing.  Maybe because I’m working with PWID and they are often hard to engage. The take home message from the conference was to be innovative and compassionate with our client group.

Jaclyn Tate-Baker – Registered Nurse Department of Health, Northern Territory Anne Mitchell brought a tear to my eye with her lived experience of hepatitis C and overcoming many hurdles to make it through interferon treatment. Dr Sunil Solomon educated the audience of the devastating hepatitis C/HIV co-infection prevalence in India and discussed some positive outcomes with using incentives and refer-a-friend approach to increasing treatment uptake and reducing the burden of disease. Deadly Liver Mob are also having good results with the incentive approach to engaging Aboriginal Australian’s living with hepatitis C. Overall it was noted by all speakers that more needs to be done to engage hard to reach populations living with viral hepatitis such as: • Prisoners • AOD/PWID • Mental Health • CALD • Aboriginal and Torres Straight Islanders Furthermore, everyone was in support for approving NSP access in Australian prisons and increasing access to OST. Innovative HealthELink is aimed at increase DAA uptake in the prison population. Whilst, artistic media such as Hepatitis B comedy in Mandarin; Hep B song in multiple languages and paintings have also featured as a tool to reach patients and educate about viral hepatitis management, treatment, risk factors and attempt to reduce stigma. Understanding cultural influences and our patients’ lived experience with viral hepatitis will assist at removing barriers to treatment, improve service delivery and patient engagement. Simplifying treatment and monitoring and implementing strategies that are addressing the challenges of reach the above-mentioned populations has been cornerstone in making sure that no one is left behind.