Volume 6 Issue 2, July 2023, pp. 234-248

Abstract

Few countries have implemented the necessary policy changes to reduce the number of steps in the cascade of care to achieve hepatitis C virus (HCV) elimination, including Canada. The aim of this study was to describe and compare legislation, scope of practice, and policy as it relates to the provision of HCV care in each province.

We reviewed grey literature and regulatory and legislative documents which affect various aspects of the HCV cascade of care. Findings were verified by content experts.

HCV RNA reflex testing ensures those that are antibody positive get an HCV RNA test; however only 80% of provinces have reflex test. Point-of-care antibody testing can be offered in most community non-health care settings, yet many types of health care providers are unable to do this independently. Following a positive test, it may not be feasible to complete venipuncture; however only a single province processes HCV RNA dried blood spot cards. In many provinces, training and verification are required for novice prescribers, and in some provinces prescribing continues to be restricted to specialists. Only a single province has task-shifted treatment to a non-physician non-nurse practitioner model, where pharmacists can prescribe treatment. Finally, 80% of provinces require authorization forms, and 30% require proof of investigations for treatment.

No single province is optimizing the use of diagnostic tools and task shifting and decreasing paperwork to expedite treatment initiation. Collaboration between provinces is needed to streamline practice, update policy, and promote equity in HCV diagnosis, care, and treatment.

In 2016, the World Health Organization (WHO) presented their strategy for eliminating viral hepatitis as a global public health threat by 2030, and Canada agreed to achieve this goal. Despite progress being made in hepatitis C virus (HCV) treatment and diagnostics, multiple system-level barriers continue to impede progress toward elimination. These challenges include structural and geographic barriers, as well as pervasive stigma associated with the disease and the ongoing opioid epidemic. The WHO highlighted significant policy and practice barriers relevant in Canada (1), yet a public and population health approach, rather than a strictly clinical approach, has yet to be operationalized across Canada as recommended by leading organizations (14).

Based on the outline presented by the WHO, the Public Health Agency of Canada developed the Pan-Canadian Framework for Action to Reduce the Health Impact of sexually transmitted and blood-borne infections (STBBIs) in 2018, and CanHepC published a Blueprint specifically for HCV in 2019 (3,4). Innovations in testing and in models of care have been prioritized, and although they are critical, to date the role of legislation, optimization of laboratory workflow, treatment reimbursement, and interactions between and the roles of health care providers have not been leveraged as a major aspect of elimination. Ultimately, implementing novel low-barrier testing and treatment models for HCV is highly dependent on provincial policies. However, to date we do not fully understand which differences exist across Canada, or how these differences lead to equitable or inequitable care. Importantly, there is little communication between provinces to understand why or how a change is made.

Across Canada, decreasing the time to treatment is a priority to reach those most vulnerable. This includes making testing and diagnosis more accessible, task-shifting to providers in diverse and remote settings and eliminating the need for submission forms and laboratory evidence for treatment coverage and initiation. Therefore, the goal of this study was to characterize gaps in policy and practice by each province to better understand key determinants in moving individuals through HCV care with a particular focus on testing and diagnosis including newer testing technology, scope of practice restrictions as they relate to the provision of HCV care, and the funding mechanisms used to initiate individuals on HCV treatment.

Study design

To characterize policies and practices used in each province and territory as they relate to the provision of HCV services, we categorized care into four themes: health promotion – hepatitis A virus (HAV) and hepatitis B virus (HBV) immunizations; testing and diagnosis; scope of practice; and treatment coverage/reimbursement. Considering the rapid change in legislation and provincial modifications to guidance for vaccine eligibility, provider scope of practice, and HCV treatment eligibility, publications in this area for Canada are not up-to-date. Thus, an extensive review of provincial websites and documents, regulatory websites and personal communication with regulatory bodies, and a review of laboratory documents and personal communication with laboratory leads, was conducted. Data were collected between July 1, 2019, and July 10, 2022, from the sources below based on the type of resource used.

Data sources
Immunizations for HAV and HBV among those infected with HCV

The most up-to-date, publicly funded immunization schedules were found on provincial websites. Eligibility for publicly funded HAV and HBV vaccines for anyone living in the province, as well as those living with HCV.

Testing and diagnosis: Point-of-care and laboratory algorithms

The most up-to-date, provincial legislation (i.e., laboratory acts), as well as provincial announcements, laboratory testing requisitions, provincial laboratory websites, and publications were used.

Scope of practice as it relates to the provision of HCV care

In Canada, the scope of practice of Medical Doctors (MDs), as it would relate to HCV care, is consistent between provinces. However, beyond MDs, the scope of practice between types of providers who do or could play a large role in HCV elimination varies. Scope of practice for the health care providers defined below, was found in the most up-to-date legislative documents, provincial announcements and scope of practices documents from regulatory colleges, and/or associations.

Reimbursement of HCV treatment under the public formulary

Since 2018, most provinces have listed at least one pangenotypic treatment for HCV without fibrosis restrictions, or other qualifying criteria. The most up-to-date government documents and announcements, and medication authorization forms or documents, were used to gather data on the requirements for treatment coverage in each province.

Study setting: Jurisdictional health care delivery in Canada

As a result of provincial health care delivery in Canada, HCV testing algorithms, provider scope of practice, and vaccine and medication coverage vary by province. In some provinces prescribing publicly funded medications requires a code, while in others the prescriber must complete appropriate documentation, and await approval. The process may also be medication specific. As it relates to priority populations affected by HCV, medication coverage for those who fall under refugee health (known as Interim Federal Health), and those who identify as Indigenous (Non-Insured Health Benefits) is overseen by the federal government.

Health promotion: Immunizations

All provinces provide HAV and HBV vaccination for those with an HCV diagnosis (Table 1 [526]), Quebec (QC) is the only province that provides publicly funded universal immunization for HAV, with a single dose at 18 months (27). HBV vaccination varies greatly from initiation at birth/infant to adolescence, and inequities exist in which provinces provide universal catch-up vaccination for all children and adults (Table 1).

Table

Table 1: Immunization schedule for hepatitis A and B (HAV and HBV) by Canadian provinces and territories

Table 1: Immunization schedule for hepatitis A and B (HAV and HBV) by Canadian provinces and territories

Vaccine BC AB SK MB ON QC NB NS PEI NL NWT YT NU
HAV for all children/adults NR NR NR NR NR 1 dose at 18 months NR NR NR NR NR NR NR
HAV if an HCV diagnosis
HBV for all children/adults Infant-adults Infant-adults Adolescent Adolescent Adolescent Infant (last dose 18 months) Birth dose Adolescent Infant Adolescent Birth dose-adults Infant-adults Birth dose
HBV if an HCV diagnosis
Sources (5, 6) (7, 8) (9) (10, 11) (12) (13) (14, 15) (16, 17) (18, 19) (20, 21) (22) (23, 24) (25, 26)

AB = Alberta; BC = British Columbia; HCV = Hepatitis C virus; MB = Manitoba; NB = Brunswick; NL = Newfoundland and Labrador; NR = Not routine; NS = Nova Scotia; NU = Nunavut; NWT = Northwest Territories; ON = Ontario; PEI = Prince Edward Island; QC = Quebec; SK = Saskatchewan; YT = Yukon

Testing and diagnosis

Testing algorithms varied widely across Canada with some provinces completing antibody (Ab) testing in non-provincial (community/commercial/hospital) and provincial sites, and some using only provincial facilities (Table 2 [2846]). Reflex testing (using a positive Ab sample for a confirmatory test) using HCV core antigen, occurs in Saskatchewan (SK) and Manitoba (MB) (4750). However, SK requires a second sample for HCV RNA testing (47,48), while MB uses both core Ag and HCV RNA in their algorithm from the same sample (49,50). All other provinces apart from ON and QC reflex test positive HCV Ab samples for RNA testing (Table 2) (5153).

Table

Table 2: Testing practices by the Canadian provinces

Table 2: Testing practices by the Canadian provinces

Testing BC AB SK MB ON QC NB NS PEI NL
Central laboratory Ab
Community/hospital laboratory Ab that is not a provincial central lab X X X X
Reflex antigen testing X X X X X X X X
Reflex RNA testing X X X *
POC testing Not used
POC testing require provincial oversight X X X X X X X N/A
Ab repeated after POC testing before RNA X N/A
DBS testing Pilot provincial or NML Pilot provincial or NML Pilot provincial or NML Pilot provincial or NML X Pilot provincial or NML Pilot provincial or NML Pilot provincial or NML Pilot provincial or NML
Sources (28, 29) (2931) (29, 32, 33) (29, 34, 35) (29, 3638) (29, 39, 40) (29, 41) (29, 42, 43) (44) (29, 45, 46)

*Antibody-positive samples sent to Nova Scotia for RNA testing

NML

Ab = Antibody; AB = Alberta; BC = British Columbia; DBS = Dried blood spots; POC = Point-of-care; MB = Manitoba; NB = Brunswick; NL = Newfoundland and Labrador; NML = National Microbiology Laboratory; NS = Nova Scotia; ON = Ontario; PEI = Prince Edward Island; QC = Québec; SK = Saskatchewan

Point-of-care (POC) Ab testing allows for the utilization of models of care that include non-physician health care providers, peers, and those with lived, and living experience. Yet, while 90% of provinces utilize HCV POC testing, 20% require a laboratory licence or clinic accreditation by a provincial laboratory. For settings in which a POC is followed by venipuncture for HCV antigen or RNA, 70% of provinces repeat the Ab test in their laboratory if there is no history of a positive Ab test (British Columbia [BC], Alberta [AB], Manitoba [MB], Ontario [ON], Quebec [QC], Brunswick [NB], Prince Edward Island [PEI]). HCV RNA testing from dried blood spots (DBS) decreases the number of individuals lost to follow-up between a positive antibody result and RNA testing and is an especially important tool if venous access is poor. ON currently processes DBS provincially with the criteria being a previous positive Ab test (high throughput or POC) (54). All other provinces only offer DBS HCV RNA access as part of pilot projects (including sending to the National Microbiology Laboratory).

Scope of practice

Pharmacists and nurses are well positioned to provide services on site such as vaccination, POC testing, and treatment in some settings. Although there are different types of nurse practitioner (NP) sub-subspecialities, NP is a consistently protected title across Canada, as is Registered Nurse (RN). The designation Registered Psychiatric Nurse (RPN) does not exist in every province (Table 3 [55108]) but refers to a Bachelor’s-prepared nurse who specializes in mental health and addictions. This is distinct from a Registered Practical Nurse (RPN), a designation which exists in Ontario (ON) and refers to a college-prepared nurse designation. All other provinces have licenced practical nurses (LPNs) for this same role.

Table

Table 3: Scope of professions, legislation, and access

Table 3: Scope of professions, legislation, and access

BC AB SK MB ON QC NB NS PEI NL
Procedure
Order HBV vaccine MD, NP, RN, RPh MD, NP, RN, RPN, RPh MD, NP, RN (AAP), RPh MD, NP, RN (AP), RPh MD, NP, RPh MD, NP, RN, RPh MD, NP, RPh MD, NP, RN (P), RPh MD, NP, RPh MD, NP, RPh
Administer HBV vaccine MD, NP, RN, RPN, LPN, RPh MD, NP, RN, RPN, LPN, RPh MD, NP, RN, RN (AAP), RPN, LPN, RPh MD, NP, RN, RN, RPN, LPN, RPh MD, NP, RN, RPN, RPh MD, NP, RN, LPN, RPh MD, NP, RN, LPN, RPh MD, NP, RN, LPN, RPh MD, NP, RN, LPN, RPh MD, NP, RN, LPN, RPh
Labs
Order and interpret HCV labs (including biochemistry) MD, NP MD, NP, RPN, RPh MD, NP MD, NP, RN (AP) MD, NP MD, NP MD, NP MD, NP, RN (P) MD, NP, RN MD, NP
Order and interpret ultrasound MD, NP MD, NP RPN, RPh MD, NP MD, NP MD, NP MD, NP MD, NP MD, NP MD, NP, RN MD, NP
Independently Initiate POC testing MD, NP, RPh** MD, NP, RPN, RN, RPh MD, NP, RN, RN (AAP), RPN, LPN, RPh MD, NP, RN MD, NP, RN, RPN MD, NP MD, NP MD, NP Not used Not used
Prescribing
General MD, NP, RN (CP), RPN MD, NP, RN, RPN, RPh MD, NP, RN(AAP), RPh, MD, NP, RPh, RN (AP) MD, NP, RPh MD, NP, RN, RPh MD, NP, RPh MD, NP, RN (P), RPh MD, NP, RPh MD, NP, RPh
DAA initiation MD, NP MD, NP, RPh MD, NP, RPh Limited specialists only MD, NP MD, NP MD, NP MD, NP MD, NP MD, NP
DAA prescriber list/training* Specialist, non-specialist with training on a restricted prescriber list Specialist, non-specialist with training on a restricted prescriber list Specialist, non-specialist with training on a restricted prescriber list Restricted prescriber list Specialist, non-specialist with training None Specialist, non-specialist with training on a restricted prescriber list Specialist, non-specialist with training on a restricted prescriber list None None
Sources (5563) (55, 57, 6472) (55, 51, 7379) (55, 8083) (55, 8488) (55, 8991) (55, 9296) (55, 57, 9799) (55, 57, 100104) (55, 57, 105108)

Notes: In some cases, a health care professional may need to undergo additional training beyond entry to practice competencies to complete the act, however, does not require a change in designation.

*Differentiation not made between when new prescribers require a letter of endorsement to be added onto the list, and when they do not

Limited

If in a collaborative practice agreement

NP practice has extensive sub-specialities in Quebec, and this may impact prescribing ability

**No clear guidance from legislative documents or regulatory college

AB = Alberta; BC = British Columbia; HBV = Hepatitis B virus; MB = Manitoba; MD = Medical doctor; NB = Brunswick; NL = Newfoundland and Labrador; NP = Nurse practitioner; NS = Nova Scotia; ON = Ontario; PEI = Prince Edward Island; QC = Quebec; SK = Saskatchewan; RN = Registered nurse; RPN (BC, AB, SK, MB) = Registered psychiatric nurse; RPN (ON) = Registered practical nurse; LPN (BC, AB, SK, MB, QC, NB, NS) = Licensed practical nurse; RPh = Registered pharmacist; RN (CP) = Registered Nurse Certified Practice; RN(AAP) = Registered Nurse Additional Authorized Practice; RN(AP) = Registered Nurse Authorized Prescriber; RN(P) = Registered Nurse Prescriber.

NPs and MDs in all provinces can prescribe and administer vaccinations. Pharmacists can prescribe and administer vaccinations in all provinces (109), although some nuances exist in the ability to utilize vaccines under the public formulary without an order from a prescriber or the requirement for additional training (Table 3). RNs can prescribe vaccinations in 60% of provinces, also often with additional training (Table 3). All professional designations evaluated were able to independently administer vaccines with an order.

NPs and MDs can order laboratory investigations and ultrasounds in all provinces. Pharmacists and RNs with specialized training can order laboratory testing and interpret the results required for an HCV treatment work-up in 10% and 40% of provinces respectively, and RNs or registered psychiatric nurses can order and interpret diagnostic imaging in 20% of provinces. Ordering an abdominal ultrasound is important in cases where a patient has compensated cirrhosis and may require screening for hepatocellular carcinoma (110). Although POC testing is often completed under medical directives within a program, most provinces have not fully leveraged the ability of different types of professionals to do this independently. AB, SK, and ON are provinces where most providers evaluated were able to do this (Table 3).

NPs and MDs in all provinces can prescribe generally. Pharmacists, RNs and/or registered psychiatric nurses can each prescribe a limited list of medications in 90% and 60% of provinces. Pharmacists can prescribe direct acting antiviral (DAAs) in a single province, whereas RNs and other types of nurses (excluding NPs) do not have this ability in any province. MB likely has the fewest HCV treatment prescribers, where there is a very limited list of specialists who can prescribe DAAs, and neither non-specialist physicians nor NPs can prescribe DAAs. In most other provinces, specialists can prescribe, while non-specialists require proof of training/collaboration. Only 30% of provinces do not have a prescriber list that is checked prior to authorization (Table 3).

Treatment coverage

Two provinces have processes in place for expedited treatment under the public formulary. Both ON and Nova Scotia (NS) use a code which is added to the prescription for immediate processing (111113). In NS, the guidance is that the provincial pharmacare request form, follows the code (111). All other provinces require an authorization form to be sent to the provincial pharmacare program for approval (Table 4); however, in QC providers can submit online, and in MB the details can be called into the governing organization. Multiple provinces (BC, AB, Newfoundland (NL)) require that in addition to the completed form, proof of laboratory investigations be included (113115), for example, RNA results in a specific time frame, genotype, or components of the liver assessment (Table 4).

Table

Table 4: Treatment initiation and coverage

Table 4: Treatment initiation and coverage

Treatment BC AB SK MB ON QC NB NS PEI NL
Code required N/A N/A N/A N/A Chronicity N/A N/A Chronicity N/A N/A
Form required (online, faxed, phone) ✓ (faxed) ✓ (faxed) ✓ (faxed) ✓ (faxed/phone) X ✓ (faxed) ✓ (faxed) ✓ (faxed, following code) X ✓ (faxed)
Form and proof of investigations required RNA within 12 months, GT, APRI/transient elastography /biopsy, biochemistry RNA last 6 months, F-score (only RNA required) Chronic infection, GT* Viral load, GT* X X Viral load in the last 6-month, GT, fibrosis staging, cirrhotic, treatment experience* Form after, GT, viral load last 6 months, cirrhosis status* X RNA in the last 6 months, GT, F-score
Private coverage must be used before public X X X X N/A
Universal public coverage
DAA dispensing centralized X X X X X X X X X X
Sources (116, 117) (118) (119) (36) (120) (121123) (124126) (127) (104, 128) (129)

*No proof needed

No differences between treatment-naïve and treatment-experienced, apart from GT requirements in some provinces for re-treatment

DAAs = Direct acting antivirals; GT = Genotype; FIB-4 = Fibrosis-4; APRI = AST to platelet ratio; AB = Alberta; BC = British Columbia; MB = Manitoba; NB = Brunswick; NL = Newfoundland and Labrador; NS = Nova Scotia; ON = Ontario; PEI = Prince Edward Island; QC = Quebec; SK = Saskatchewan

The scope of practice for HCV service provision, and requirements for treatment initiation were highly varied (Figure 1). These differences likely result in gaps in the consistency of care across Canada and highlight a need for the streamlining of policies and practices.

Figure 1: Trends in HCV testing and diagnosis, provider scope of practice, and treatment initiation requirements

Simplifying the diagnostic process is likely to improve an individual initiating treatment. Yet not all provinces reflexively test HCV Ab-positive samples and returning for an additional blood draw can be a major barrier for patients (115,130). Reflex testing has been validated by several provinces in Canada, and at major diagnostics organizations in the United States and elsewhere (131133), and greatly improved diagnosis rates (134,135), especially among populations who were more likely to be lost to follow-up (136), with good diagnostic correlation (137). As it pertains to workflow, interestingly, because of pangenotypic treatment, when AB adopted reflex testing, they removed reflex genotype testing to offset some of these costs (138).

To avoid a blood draw, the second method is to use POC testing for Ab screening (139). POC testing has major advantages. The blood sample can be collected by a finger prick and requires a single drop of blood, and recent studies have shown that rapid time to positivity of this POC testing can differentiate active infection from exposure (140). Here we show that some provinces require provincial laboratory oversight for POC testing, and some laboratories also repeat Ab testing after a POC Ab test. These added processes are likely not required and have not been the standard for other types of non-microbiological testing. The ability to complete POC testing independently varied greatly across provinces, at times related to a provider not being able to order other diagnostic tests and thus not being able to do POC testing or related to outdated laboratory acts. Fortunately, many provincial laws were revised to increase the scope for providers to complete COVID-19 testing, even when that type of provider was not able to routinely order another laboratory testing (141).

Following a positive POC test, in every province except ON, a trained health care provider or phlebotomist would then need to draw blood. However, since 2017 in ON, providers have been able to follow a positive POC Ab test with an immediate DBS sample collection. The inaccessibility of DBS RNA testing across Canada inhibits continued engagement along the cascade of care for patients and removes a tool that providers may use to promote this engagement.

The most striking finding was the varied scope of practice of health professionals across Canada, and the resulting underutilization of health professionals, especially RNs, NPs, and non-specialist physicians. Modifications to scope often require legislative changes, followed by guidance by the regulatory body as to how these changes will be reflected in practice, and how safety and competency will be ensured. Community need most often drives these changes, amidst physician shortages, and rural and remote communities with at times only a single provider. We show that there are major differences in scope of practice across provider type, with little rationale (Figure 1). Increasing training and provider scope of practice would likely lead to the decentralization of care and greatly improve access to low-barrier models (142145).

In many provinces, RNs, registered psychiatric nurses, and pharmacists could prescribe a limited list of medications. With respect to DAA prescribing, we determined that there is an underutilization of providers who are in the right spaces to see HCV patients for other reasons and could be co-localizing HCV care with primary care, harm reduction services, and in other environments. Leading examples include recent changes to the scope of registered psychiatric nurses, who are now able to prescribe opioid agonist therapy, RN-led STBBI clinics, and community pharmacies with expertise in serving those with HCV. NPs have only very recently been able to prescribe DAAs, and in some provinces, this is also true of non-specialist physicians. Many provinces limit DAA prescribers to a specified list. Comparing the number of prescribers on these lists and the regions they serve with estimated numbers of prescriptions required to reach elimination would provide an evaluation of this method of regulating HCV prescribing. Although many types of high-cost medications require specialist designation to manage the course of treatment, the perception of specialization required to treat HCV must shift to align with the simplicity of treatment with DAAs (47). With respect to treatment coverage, only two provinces utilize codes that would be required if someone is to start treatment immediately following their work-up. The need to understand the processes and systems in place for reimbursement, as well as the additional paperwork, could be a barrier to increasing the number of prescribers who are interested in treating HCV.

Limitations

In evaluating treatment initiation, we did not include federal reimbursement programs (i.e., Interim Federal Health or Non-Insured Health Benefits). Modifications to these formats are not under provincial jurisdictions, and thus there is uniformity across the provinces.

Globally, Canada is a leader in the provision of universal health care. However, to date, widespread political or public buy-in has not occurred for the elimination of HCV. Other countries that have made significant advancements towards HCV elimination have had widespread political support, an emphasis on increasing the number of practitioners in the field, and non-specialist prescribing. Making simpler diagnostic tools available widely, increasing provider scope, and decreasing paperwork to expedite treatment initiation have the potential for a combined impact. Our findings show that there are areas in which provinces have already optimized processes, while others have not. Rather than re-exploring and validating new approaches used elsewhere, Canadian provinces should collaborate and learn from one another to streamline practice and modify out-dated policy barriers that hinder widespread HCV diagnosis, care, and treatment.

Acknowledgements:

The authors would also like to thank the following content experts representing multiple types of providers and scientific areas for helpful discussion (West to East): Sofia Bartlett, Leo Yamamoto, Jackie Foreman, Mark Swain, Shannon Brown, Amber Ly, Lauren Tastad, Dennaye Fuchs, Pam Ford, Amanda Lang, Carolyn Blackner, Derek Stein, Kamran Kadkhoda, Steve Gregg, Kelly Killpartick, Valérie Martel-Laferrière, Isabelle Thibeault, Isabelle Savard, Nadine Kronfli, Camille Dussault, Duncan Webster, Kate Harland, Jac Atkinson, Sarah DeCoutere, and Robert Taylor. This work would not have been possible without the market expertise of treatment coverage experts at AbbVie and Gilead Sciences.

Conceptualization and Study Design, M Biondi, E Mandel, K Underwood, JJ Feld; Data Retrieval, MJ Biondi, E Mandel, K Underwood, C Masterman, RA Kozak; Writing – Original Draft & Editing, MJ Biondi, E Mandel, C Masterman, R Kozak, CH Dale, M Hassall, JJ Feld; Resources, E Mandel, K Underwood, C Masterman, RA Kozak, CH Dale, M Hassall, C Capraru, H Shah, HLA Janssen, JJ Feld, MJ Biondi; Manuscript Review, E Mandel, K Underwood, C Masterman, RA Kozak, CH Dale, M Hassall, C Capraru, H Shah, HLA Janssen, JJ Feld, MJ Biondi; Approval of Final Version, E Mandel, K Underwood, C Masterman, RA Kozak, CH Dale, M Hassall, C Capraru, H Shah, HLA Janssen, JJ Feld, MJ Biondi; Accountability, E Mandel, K Underwood, C Masterman, RA Kozak, CH Dale, M Hassall, C Capraru, H Shah, HLA Janssen, JJ Feld, MJ Biondi.

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All data will not be made publicly available. Researchers who require access to the study data can contact the corresponding author for further information.

This study was funded by the Viral Hepatitis Care Network.

MJ Biondi reports receiving research support and consulting fees from AbbVie, Gilead, and Specialty Rx Solutions. CH Dale is a paid employee of McKesson Canada, and receives consulting fees from AbbVie and Gilead. H Shah reports receiving consulting fees and research support from AbbVie and Gilead. JJ Feld reports receiving research support and consulting fees from AbbVie and Gilead. HLA Janssen reports receiving research support from AbbVie and Gilead. The other authors have nothing to disclose.

This article has been peer reviewed.

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