1. Varghese, Nibi MSN, BSN, RN
  2. Knight, Rodney PhD
  3. Gallagher, Lesley MSN, BSN, RN
  4. Ti, Lianping PhD


NPs should be given a more significant role in this effort.


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A 65-year-old woman visits a primary care provider for a health checkup and discovers she has been living with hepatitis C virus (HCV), possibly for more than 20 years. As HCV treatment prescribing is largely limited to liver specialists, she is referred to a gastroenterologist to start treatment, though finds it difficult to navigate the health referral system and does not make it to her appointment. Left untreated for all this time, her stage 4 liver cirrhosis has progressed to hepatocellular carcinoma and within a year her body fails her.


This story is not a solitary one. According to the World Health Organization (WHO), 71 million people worldwide live with HCV today, with an estimated 87% untreated. Approximately 400,000 people die from HCV-related causes such as liver cirrhosis and liver cancer globally each year and numbers are expected to rise as populations age.


With pharmacological advancements that include interferon-free and pan-genotypic treatment options via the oral direct-acting antivirals (DAAs), shorter treatment durations, limited adverse effects, and cure rates as high as 95%, controlling the HCV epidemic is now a realistic possibility. With the WHO adopting an ambitious goal of HCV elimination by 2030 (Global Hepatitis Report, 2017), now is the time to identify actionable strategies for scaling up evidence-informed health system-level changes to optimize the population-level benefits that DAAs present.


Within health systems worldwide, nurses are uniquely positioned to contribute to these efforts. For example, many countries have adopted nurse-led programs with regard to providing HIV antiretroviral therapy within their national HIV strategy. Nurse-led programs present a cost-effective alternative to a physician-led model of care, with improved access and equitable reach of limited resources by making services available at the community level.


While nurses are already integrated within current models of HCV care, these roles have largely been to support physicians. With a growing shortage of specialists available to treat and care for the increasing number of patients becoming eligible for DAA treatments, and in an era where HCV treatment regimens are as short as eight weeks and do not require extensive monitoring of adverse effects, we suggest there is a critical need to expand HCV treatment prescribing authority specifically to NPs. Indeed, lessons can be learned from Nazareth and colleagues' report on "early adopter" settings such as Australia, where NPs have already been given the authority to prescribe DAA therapy (Australian Journal of Advanced Nursing, 2008). In countries like the United States and Canada where the modern HCV epidemic is largely driven by injection drug use and where NPs have considerable presence in areas such as community care clinics, opioid agonist therapy clinics, corrections, and rural and remote areas, this could be an easily attainable possibility.


Previous research studying the implementation of nurse-led models of care for HCV offers optimistic insights into the feasibility of such initiatives. Kattakuzhy and colleagues, whose community-based ASCEND study in 13 urban health centers reported similar outcomes of HCV care provided by specialists, primary care physicians, and NPs, concluded that HCV treatment and care provided by NPs was as safe and effective as that provided by specialists (Annals of Internal Medicine, 2017).


What first steps can be taken toward implementation of nurse-led management of HCV treatment and inclusion of NPs as DAA prescribers? In Australia, a new title specific to NPs (hepatology NP) was created, with NPs' education also including a clinical internship in this field. In 2003, NPs attained prescribing authority for DAAs as long as they were working under the supervision of a specialist. Of importance, government funding to increase the capacity of health systems to support hepatology nurse positions is critical to ensure the sustainability of providing HCV care.


Without responding to the growing body of evidence indicating positive benefits of nurse-led models of HCV care and integrating nurses into the health service delivery system more comprehensively, it may be very difficult to attain the WHO goal of HCV elimination by 2030.