Received: 13 February 2019 Accepted: 14 February 2019

DOI: 10.1002/hpm.2770

RESEARCH ARTICLE

Elements of community‐based models for treating

hepatitis C virus in supporting HCV elimination in
Australia: A Delphi study

Davoud Pourmarzi1 | Andrew Smirnov2 | Julie Hepworth3 |

Tony Rahman4,5 | Gerrard FitzGerald1 | Lisa Hall1,2

1
School of Public Health and Social Work,
Faculty of Health, Institute of Health and
Biomedical Innovation (IHBI), Queensland
University of Technology, Brisbane, Australia
2 virus (HCV) elimination is the provision of its treatment in
School of Public Health, Faculty of Medicine,
The University of Queensland, Brisbane,
Australia
3
Mater Research Institute, The University of
Queensland, Brisbane, Australia
4
School of Nursing, Faculty of Health,
Queensland University of Technology,
Brisbane, Australia
5
Department of Gastroenterology and
Hepatology, The Prince Charles Hospital,
Brisbane, Australia
Correspondence
Davoud Pourmarzi, O Block, Kelvin Grove
Campus, QUT, Victoria Park Road, Kelvin
Grove, QLD 4059, Australia.
Email: d.pourmarzi@qut.edu.au
Summary
Background: A key to achieving the goal of hepatitis C
community settings. This study aimed to identify the impor-
tant organisational and operational elements of community‐
based models for treating HCV and their feasibility in the
Australian context.
Methods: A Delphi study was conducted with 33 experts
from Australia. The questionnaire included 13 elements
drawn from the literature. Participants rated each element
on a five‐point Likert scale for importance and feasibility
and suggested additional elements. Consensus was identi-
fied when the sum of categories 1 and 2 or 4 and 5 of the
five‐point Likert scale reached greater than or equal to 70%.
Results: Eight elements reached consensus in regard to
importance including “Safe and enabling environment,”
“Training and support for healthcare providers,” “Open
referral policy,” “Linkage with or providing outreach ser-
vices,” “Person‐centred approach,” “On‐site screening and
assessment,” “Linkage or co‐location with harm reduction
services,” and “Linkage or co‐location with drug and alcohol
services.” At least 65% of participants agreed implementing
elements of open referral policy, Training and support for
healthcare providers, and Person‐centred approach are usu-
ally or always/very feasible. For the other five elements, this
was agreed to by a range of 15.2%‐57.6% of participants.

Int J Health Plann Mgmt. 2019;1–10. wileyonlinelibrary.com/journal/hpm © 2019 John Wiley & Sons, Ltd. 1
2 POURMARZI ET AL.

Conclusion: Successful community‐based models for

treating HCV in Australia are dependent on the integration
and coordination of care and the support provided for both
patients and healthcare providers. Substantial work is
required across policy and health service planning to inte-
grate these highly rated elements into Australian primary
health care.

KEYWORDS

community based, DAA, hepatitis C, primary health care

1 | I N T R O D U CT I O N

Hepatitis C virus (HCV) infection is one of the main causes of liver related morbidity and mortality worldwide.1,2 On
the basis of the latest estimation, at the end of 2016, 199 412 chronically HCV‐infected individuals were living in
Australia, of whom 81% were diagnosed, 14% had received treatment, and 13.4% had been cured. In 2016,
11 949 new HCV cases were diagnosed.3
People with a history of injecting drug use, incarcerated populations, Aboriginal and Torres Strait Islander people,
immigrants from countries with high HCV prevalence, and men who have sex with men are the priority groups in
HCV management in Australia.4 All target groups for HCV treatment and management may be considered “hard to
reach,” as there are many barriers to engaging them in health services.5,6
The listing in 2016 of highly effective direct‐acting antivirals (DAAs) on the Pharmaceutical Benefits Scheme (PBS)
aims to increase the availability of these agents.4,7 Guidelines also have been changed to allow general practitioners
(GPs) and nurse practitioners in community settings to prescribe DAAs. Consequently, there is an opportunity to
improve the accessibility of treatment through appropriate community‐based models of care to eliminate HCV.4,7
Community‐based models of care include various organisational and operational elements to support patients and
HCV care providers and facilitate service delivery to increase the effectiveness, acceptability, and accessibility of the
services.8 This study aimed to develop a better understanding of key organisational and operational elements of
community‐based models for treating HCV, in the era of DAAs, and their feasibility in Australian primary healthcare
settings.

2 | METHOD

2.1 | Study design

A two‐round online survey using a Delphi method was carried out to achieve a consensus among experts from dif-
ferent sectors in HCV management.

2.2 | Instrument

The first round questionnaire included 13 organisational and operational elements of community‐based models
for treating HCV, which was developed based on a systematic literature review using a qualitative inductive
thematic approach.9,10
POURMARZI ET AL. 3

In each round, the participants were asked to rate each element on a five‐point Likert scale for importance and
feasibility. In the first round, participants also were asked to suggest additional elements, which had not been included
in the questionnaire. The second round questionnaire included these new elements and the findings of round one.

2.3 | Sampling

A list of 138 potential participants including HCV care providers, researchers, policy makers, and members of
advocacy groups working on HCV management in community settings in Australia was developed. The link of the
survey and invitation letter were sent to their email address.

2.4 | Analysis

Data from round 2 were analysed using descriptive statistics. Consensus was identified when the sum of agreement
of categories 1 and 2 or 4 and 5 of the five‐point Likert scale reached 70% or greater. The data analysis was done
using SPSS software version 23.

2.5 | Ethical considerations

This study protocol was approved by the Queensland University of Technology Human Research Ethics Committee
(approval number 1700000974).

3 | RESULTS

Thirty‐three experts participated in both rounds of the Delphi. Approximately 47% of the participants were
healthcare providers, including nurses (n = 4), nurse practitioners (n = 3), GP (n = 1), specialists (n = 8), and others
(n = 5) (Table 1).

TABLE 1 Characteristics of the participants in Delphi study

Characteristics Number (%)

Occupation Health care providers 21 (46.7)

Researchers 12 (26.7)
Policy makers 5 (11.1)
Members of advocacy groups 7 (15.6)*
Gender Male 15 (45.5)
Female 18 (54.5)
Age group 20‐29 3 (9.1)
30‐39 2 (6.1)
40‐49 12 (36.4)
50‐59 11 (33.3)
≤60 5 (15.2)
State and territory ACT 2 (6.1)
NSW 5 (15.2)
NT 1 (3.0)
QLD 15 (45.5)
SA 1 (3.0)
VIC 8 (24.2)
WA 1 (3.0)

*Some participants self‐categorised in more than one category.

4 POURMARZI ET AL.

Analysis of the “round one” comments in relation to possible new elements, resulted in the identification of four
new elements including safe and enabling environment, person‐centred approach, linkage with dispensing pharmacy,
and having peers as champions of treatment. These elements were subsequently included in round 2.

3.1 | Importance and feasibility

Except for the elements “Financial/non‐financial incentives for health care providers” (2.21 ± 1.02) and “Psychological
assessment and support” (2.91 ± 0.80), the mean score for all other elements was higher than 3 (somewhat important)
(Table 2). In terms of feasibility, the mean score for seven elements was lower than 3 (somewhat feasible) (Table 3).

3.2 | Consensus

Eight elements reached consensus in regard to importance, which means that at least 70% of participants agreed they
were of “high importance” or “most important” for inclusion in community‐based models for treating HCV. The eight
elements were (1) safe and enabling environment (93.9%), (2) training and support for healthcare providers (90.9%),

TABLE 2 Importance and feasibility of organisational and operational elements for successful community‐based
models for treating hepatitis C virus (HCV)

No Low Somewhat High Most

Importance Importance Important N Importance important
Elements Mean ± SD N (%) N (%) (%) N (%) N (%)

Safe and enabling environment 4.39 ± 0.61 0 0 2 (6.1) 16 (48.5) 15 (45.5)

Open referral policy 4.33 ± 1.05 2 (6.1) 0 2 (6.1) 10 (30.3) 19 (57.6)
Person‐centred approach 4.30 ± 0.77 0 0 6 (18.2) 11 (33.3) 16 (48.5)
Training and support for healthcare 4.03 ± 0.73 1 (3.03) 0 2 (6.1) 24 (72.7) 6 (18.2)
providers
Linkage with or providing outreach 3.85 ± 0.57 0 1 (3.0) 5 (15.2) 25 (75.8) 2 (6.1)
services
On‐site screening and assessment 3.82 ± 0.68 0 1 (3.0) 8 (24.2) 20 (60.6) 4 (12.1)
Linkage or collocation with harm 3.76 ± 0.71 0 2 (6.1) 7 (21.2) 21 (63.6) 3 (9.1)
reduction services
Linkage or collocation with drug and 3.63 ± 0.78 1 (3.03) 2 (6.1) 6 (18.2) 23 (69.7) 1 (3.0)
alcohol services
Peer support 3.52 ± 0.83 0 5 (15.2) 8 (24.2) 18 (54.6) 2 (6.1)
Treatment adherence support 3.45 ± 0.81 0 6 (18.2) 8 (24.2) 17 (51.5) 2 (6.1)
Linkage with dispending pharmacy 3.42 ± 0.71 0 3 (9.1) 14 (42.4) 15 (45.5) 1 (3.0)
Having peers as champion of 3.42 ± 0.83 1 (3.03) 3 (9.1) 11 (33.3) 17 (51.5) 1 (3.0)
treatment
Multidisciplinary team 3.33 ± 0.96 1 (3.03) 4 (12.1) 15 (45.5) 9 (27.3) 4 (12.1)
Social assessment and support 3.30 ± 0.81 0 6 (18.2) 12 (36.4) 14 (42.4) 1 (3.0)
Linkage with HCV infection tertiary 3.06 ± 0.75 0 8 (24.2) 15 (45.5) 10 (30.3) 0
services and specialists
Psychological assessment and support 2.91 ± 0.80 0 12 (36.4) 12 (36.4) 9 (27.3) 0
Financial or nonfinancial incentives for 2.21 ± 1.02 9 (27.27) 13 (39.4) 6 (18.2) 5 (15.2) 0
healthcare providers
POURMARZI ET AL. 5

TABLE 3 Feasibility of organisational and operational elements for successful community‐based models for treating
hepatitis C virus (HCV)

No Low Somewhat Usually

Feasible Feasibility Feasible Feasible Always/Very
Elements Mean ± SD N (%) N (%) N (%) N (%) Feasible N (%)

Open referral policy 4.36 ± 0.93 0 1 (3.0) 7 (21.2) 4 (12.1) 21 (63.6)

Person‐centred approach 3.97 ± 0.95 0 2 (6.1) 9 (27.3) 10 (30.3) 12 (36.4)
Linkage with HCV infection tertiary 3.91 ± 0.68 0 1 (3.0) 6 (18.2) 21 (63.6) 5 (15.2)
services and specialists
Training and support for healthcare 3.88 ± 0.65 0 1 (3.0) 6 (18.2) 22 (66.7) 4 (12.1)
providers
Safe and enabling environment 3.67 ± 0.82 0 2 (6.1) 12 (36.4) 14 (42.4) 5 (15.2)
Linkage or collocation with harm 3.58 ± 0.80 0 2 (6.1) 14 (42.4) 13 (39.4) 4 (12.1)
reduction services
Treatment adherence support 3.55 ± 0.74 0 3 (9.1) 10 (30.3) 19 (57.6) 1 (3.0)
Linkage with dispending pharmacy 3.48 ± 0.91 2 (6.1) 1 (3.0) 11 (33.3) 17 (51.5) 2 (6.1)
Linkage or collocation with drug and 3.24 ± 0.79 1 (3.0) 2 (6.1) 20 (60.6) 8 (24.2) 2 (6.1)
alcohol services
Social assessment and support 3.12 ± 0.74 0 7 (21.2) 15 (45.5) 11 (33.3) 0
Linkage with or providing outreach 2.97 ± 0.78 1 (3.0) 6 (18.2) 20 (60.6) 5 (15.2) 1 (3.0)
services
Psychological assessment and support 2.94 ± 0.70 0 9 (27.3) 17 (51.5) 7 (21.2) 0
Multidisciplinary team 2.94 ± 0.83 2 (6.1) 6 (18.2) 17 (51.5) 8 (24.2) 0
On‐site screening and assessment 2.88 ± 0.82 2 (6.1) 6 (18.2) 20 (60.6) 4 (12.1) 1 (3.0)
Peer support 2.81 ± 0.81 2 (6.1) 8 (24.2) 17 (51.5) 6 (18.2) 0
Having peers as champion of 2.70 ± 0.88 5 (15.2) 4 (12.1) 20 (60.6) 4 (12.1) 0
treatment
Financial or nonfinancial incentives 2.12 ± 0.96 7 (21.2) 19 (57.6) 5 (15.2) 0 2 (6.1)
for healthcare providers

(3) open referral policy (87.9%), (4) linkage with or providing outreach services (81.8%), (5) person‐centred approach
(81.8%), (6) on‐site screening and assessment (72.7%), (7) linkage or colocation with harm reduction services (72.7%),
and (8) linkage or colocation with drug and alcohol services (72.7%) (Table 2).
For those eight elements in which consensus had been achieved in regard to their importance, only two
elements open referral policy and “Training and support for healthcare providers,” were considered by more
than 70% of participants to be “usually feasible” or “always/very feasible” for implementation in the Australian
primary care setting. On the other hand, less than 19% of participants rated the elements linkage with or
providing outreach services and on‐site screening and assessment as usually feasible or always/very feasible.
The other four elements were rated as usually feasible or always/very feasible by a range of 30.3%‐66.7% of
participants (Table 3).

4 | DISCUSSION

On the basis of the findings of this study, there are several important elements to consider in the development of
successful community‐based models for HCV treatment. These elements relate to the provision of support for
6 POURMARZI ET AL.

patients, support for healthcare providers and facilitating service delivery and can be seen as fundamental for
successful community‐based models for treating HCV in Australia, a setting in which there are no restrictions on
the availability of DAA therapy.
The element of safe and enabling environment was considered the most important element. But only about half
of the participants agreed that this element is feasible in the context of the Australian primary health system. Stigma
and discrimination were highlighted as barriers to engaging HCV patients with HCV services in Australia.11,12 The
target population for HCV treatment in Australia is often socially marginalised and hard to reach or conversely, finds
services hard to access because of illicit drug use, mental health problems, and diverse cultural and linguistic back-
grounds. Therefore, it is important that HCV services be provided in a safe and culturally appropriate environ-
ment.4,11 In Australia, health policy emphasises the importance of building a safe and enabling environment and
ending discrimination against HCV patients in the health system.4 Although this provides the basis for creation of
a safe and enabling environment, there are still many things to be done in relation to health care providers' attitudes,
patients' internalised stigma, and clinic design.11,12 Special training for staff to provide HCV services within a non-
judgmental culture and changes to the clinic's physical design, can be helpful to establish a safe and enabling environ-
ment.11-13
About 90% of participants ranked training and support for healthcare providers as important for community‐
based models for treating HCV, and more than 70% agreed that it is feasible to implement this within the Australian
primary health system. Well‐trained healthcare providers are the fundamental part of a successful service. They also
need to be confident that they can access sufficient professional support when needed.5,14,15
HCV treatment for a long time was based in tertiary centres and was challenging because of the toxicity of the
interferon‐based treatment schedules and the sociodemographic characteristics of patients. To have successful
community‐based models, which are easy to access and directly translatable to routine practice, training needs to
be provided for both the clinical and social aspects of HCV management.5,14,15 In Australia, there are number of
online and face‐to‐face training options available for HCV care providers. Also some tertiary centres have developed
programs to provide support for GPs and to encourage them to prescribe the DAAs. Despite all of these training
options and support, there is inadequate knowledge among Australian GPs in this area, and there are not many
GPs who are willing to initiate the treatment.16,17
Having an open referral policy was another highlighted element, and more than 70% of participants agreed that
implementing this element within the Australian primary health system is feasible. Referral pathways were considered
a barrier to HCV treatment.5,6 The aim of providing HCV treatment in community settings is to remove this barrier
and make HCV services easily accessible to patients. This is more significant for people who inject drugs (PWID),
homeless people, and those from lower socio‐economic backgrounds, as many do not have regular primary care pro-
viders or the financial ability to see someone to get a referral.4-6 As the administration of DAA therapies for HCV has
become less complicated and requires minimal monitoring, in Australia, the guidelines for HCV treatment have been
changed to allow GPs and nurse practitioners in community settings to prescribe DAAs. This policy provides the
opportunity to remove barriers related to the referral pathway.4,7 However, patients do need to be informed of
the location of HCV care providers and possibility of self‐referrals.17
The fourth most important element was linkage with or providing outreach services, but less than 19% of
participants rated this as feasible in the Australian primary care context. Outreach services are aimed at providing
HCV services that are accessible for hard to reach patients and remove barriers related to travelling, when a lack
of appropriate services are available in the patient's locality. Providing HCV treatment through outreach services in
Australia is more significant for patients who live in outlying suburbs and in rural and remote areas, culturally and
linguistically diverse patients, and Aboriginal and Torres Strait Islander people.4,7 Developing linkage with outreach
services also provides an opportunity to perform screening in the community and to refer patients to community‐
based HCV services.4,7,18
Having a person‐centred approach was another element that participants agreed was important and feasible for
inclusion in community‐based models for treating HCV. Person‐centred approaches emphasise the importance of
POURMARZI ET AL. 7

responding to the whole person, not just the disease, including the health and personal issues, which may affect
treatment outcomes.19 To have successful community‐based models for treating HCV, patients' values, desires, social
situations, and life style need to be considered. Involving patients in HCV treatment planning, considering patients as
a central part of the service, and providing comprehensive services are important for addressing individual patients'
care barriers and improving patients' engagement with the services. Providing flexible appointments, appropriate
opening hours, and culturally appropriate environments, helps to ensure a more patient‐centric service.20,21
Experts also identified that the inclusion on‐site screening and assessment are important for community‐based
models for treating HCV. This included point of care testing and access to a portable FibroScan® machine. But only
about 15% of participants considered it to be feasible in the Australian primary care system. This “one‐stop shop”
approach is an attraction of tertiary centres, and so for community‐based models to be successful, patients need
access to all the testing and assessment services on‐site. This immediate access reduces the time to commence treat-
ment, the number of patients lost to follow‐up, the number of visits required and travelling costs. Point of care testing
was also highlighted as a way of making testing easier for PWID with poor venous access. Unavailability of point of
care testing and the capital and training costs associated with the provision of a FibroScan® are barriers to the imple-
mentation of onsite testing and assessment in Australian primary health settings.7,22 Using serum biomarkers such as
aspartate aminotransferase to platelet ratio index as an alternative for assessing the liver fibrosis status is
recommended.7
Linkage to or colocation with harm reduction services and drug and alcohol services were also identified as impor-
tant. But less than 50% of participants agreed that these elements are feasible in Australian primary care system. To
eliminate HCV, a “treatment as prevention” strategy has been widely discussed and to some extent has begun to be
adopted.6,23 In the context of HCV, treatment as prevention involves very active screening and treatment uptake
among those actively engaged in injecting drug use.6,23,24 Linkage or colocation of HCV services with harm reduction
services can provide opportunities to engage with PWID and reduce the risk of reinfection. Colocation or linkage of
HCV services enables the provision of holistic care especially for PWID. It might be difficult for HCV prescribers to
provide specialised advice on harm reduction, thus linkage to dedicated services may ensure that support is provided
for prevention of new infections post‐treatment.6,23,24
In Australia, there is some integration of HCV and drug and alcohol services where HCV services were added to
the existing drug and alcohol services. In some of them, harm reduction services were also provided.18,25,26 Additional
strategies need to be developed, and facilities provided to link HCV care providers especially in rural and remote area
with these dedicated services.
The implementation of other elements in the era of DAA is strongly dependent on the characteristics of the
patients. Extensive support for patients including peer support and social and psychological support was particularly
important to ensure treatment adherence in interferon‐based treatment because of the long duration and toxicity of
the treatment. As the DAA treatment is shorter treatment duration (8‐12 wk) and has fewer side effects, these sup-
port arrangements are more applicable for some patients, particularly PWID, patients who are suffering mental health
problems, and socially complex and isolated patients.27-29
Referring such patients to the existing peer groups in the regions and online peer forums may help to fulfil peer
support needs. Support for treatment adherence also may be needed for some patients based on their psychosocial
characteristics.29 Social and psychological assessment can be helpful to understand patients' situations but should not
be a barrier to accessing treatment, and only a minority of HCV patients may need to access these services in the era
of DAA. The availability of community‐based mental health and social support services in Australia can facilitate the
provision of psychosocial assessment and support for HCV patients.30
Linkage with the dispensing pharmacy, having peers as champions of treatment, multidisciplinary teams, and link-
age with HCV tertiary services and specialists were also more particularly important in interferon‐based treatments.
However, there is still perceived benefits in the era of DAAs.27-29
As not all pharmacies stock the new DAA medicines for HCV, it is important for primary healthcare providers to
be able to inform patients where they can fill a prescription. Peers as champions of treatment can be helpful to
8 POURMARZI ET AL.

increase treatment uptake. Implementing multidisciplinary teams depends on patients' characteristics. For some
patients, especially PWID and psychologically and socially complex patients, a team of healthcare providers may be
needed to maximise health outcomes. Thus developing linkage and collaboration with other relevant services can
be helpful to ensure the availability of healthcare providers from different disciplines to provide additional services.
Although having a linkage with HCV tertiary services and specialists was more important in interferon‐based treat-
ment, nevertheless in the era of DAA, it can be helpful to facilitate referral pathways for cirrhotic and complex
patients, ensure post‐treatment follow‐up and facilitate training and support for HCV care providers.1,2,27-29
Providing financial or nonfinancial incentives was considered to be the least important element. In
Australia, primary healthcare providers are paid largely fee‐for‐service and for the majority of primary healthcare
providers being able to provide HCV services can be seen as an incentive. As registration with a GP or general
practice is not required for individuals, HCV patients can freely choose their HCV care provider in Australia. It
is important for primary healthcare providers to be able to provide services that the patients' needs, to keep them
connected.30
Although these findings are specific to the Australian setting, they may also be increasingly relevant to other
countries as barriers pertaining to the availability of DAA drugs are addressed. Stigma and discrimination toward peo-
ple who have HCV infection or a history of injecting drug use are common problems internationally.1 Further, PWID
are often socially marginalised and face economic and cultural barriers to health service access, regardless of the
country in which they live.24,31 Consequently, our findings that relate to engagement with these target populations
may be especially pertinent.

5 | CO NCLUSIO N

The further implementation of community‐based models for treating HCV in Australia is dependent on evidence‐
based approaches to policy development. This study has identified the key components of community‐based models
for treating HCV and emphasised the requirement for further substantial work across policy and health service plan-
ning so as to integrate highly rated elements into primary health care. Community‐based models for treating HCV in
Australia need to be designed in such a way as to support patients, through adopting patient‐centred approaches and
creating safe and enabling environments. Also, to provide quality care and to achieve the aspiration of HCV elimina-
tion, HCV care providers need to be supported through access to education and training and professional linkages to
expert support. At the same time, such services need to apply open referral policies, develop linkage with other
community‐based services such as harm reduction, drug and alcohol, and outreach services and provide where pos-
sible a “one stop shop” approach to facilitate service delivery.

ACKNOWLEDGEMENTS
The current review is as part of D.P.'s PhD research. The authors gratefully acknowledge the participants in this
study.

DECLARATION OF I NTERESTS

We declare no competing interests.

FINANCIAL SUPPORT

Nothing to report.
POURMARZI ET AL. 9

ORCID
Davoud Pourmarzi https://orcid.org/0000-0002-1970-3609

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How to cite this article: Pourmarzi D, Smirnov A, Hepworth J, Rahman T, FitzGerald G, Hall L. Elements of
community‐based models for treating hepatitis C virus in supporting HCV elimination in Australia: A Delphi
study. Int J Health Plann Mgmt. 2019;1–11. https://doi.org/10.1002/hpm.2770