Simplifying Access to Hepatitis C Virus Care Is Effective in Resource-Constrained Settings

Simplifying access to hepatitis C virus care, including decentralized community-based care and task shifting to non-specialists, could improve testing and treatment for patients in settings with limited resources.

Simplifying hepatitis C virus (HCV) care delivery could be feasible and effective for increasing access to testing and treatment in resource-constrained settings, according to a commentary on recent research.

The commentary, published in The Lancet Gastroenterology & Hepatology, addressed a recent study by Meiwen Zhang, MPH, of Medecins Sans Frontieres in Cambodia and colleagues. That study, also published in The Lancet Gastroenterology & Hepatology, evaluated a simplified service model for HCV care integrated in an existing public health system in rural Cambodia.

“Specialist-oriented hepatitis care is often hard to access and afford in many places, creating structural barriers for service users to efficiently utilize when needed,” Dan Wu, MBBS MSc PhD, assistant professor in the Department of Clinical Research, Faculty of Infectious and Tropical Diseases at the London School of Hygiene and Tropical Medicine, told Contagion®. “Community-based HCV diagnosis and treatment with reduced unnecessary steps during the care-seeking process are essential to improving case identification, treatment, retention, and cure rates.”

Wu, along with Joseph D. Tucker of the University of North Carolina and Philippa Easterbrook of the World Health Organization, wrote that Zhang’s study added data on simplified approaches among the general population and in primary care clinics that was limited in an earlier comprehensive systematic review published in The Lancet Global Health, which provided evidence to support simplified service delivery, including decentralization, integration and task shifting to non-specialists. That review included 142 studies from 34 countries involving 489996 patients, including people who inject drugs, people in prisons, people living with HIV, and the general population.

Zhang’s study involved 10425 residents screened at 13 local health centers between March 12, 2018 and Jan. 18, 2019, identifying 540 who were HCV viraemic. Among those, 533 (98.7%) attended a baseline consultation at the HCV clinic, 530 (99.4%) initiated treatment and 515 (97.2%) completed treatment. Among those who completed treatment, 466 completed follow-up, with 459 of those (98.5%) achieving sustained virological response at 12 weeks. About 90% of patients in the study received all of their care at primary care clinics.

“We are surprised by the success of Zhang and colleagues’ study and that decentralized community-based care can achieve such high uptakes (>95%) of HCV viral load testing, linkage to care, and treatment initiation,” Wu said. “These are remarkable achievements, indicating accessible and affordable simplified community-based HCV care is feasible and likely scalable in many other places.”

The WHO has set a goal for eliminating viral hepatitis as a public health threat by 2030 and its guidelines endorse simplified service delivery, including decentralization, integration and task shifting. Globally, less than 20% of people living with chronic HCV infection had been diagnosed and less than 10% treated as of 2017.

The annual rate of acute hepatitis C infections reported to the US Centers for Disease Control and Prevention tripled 2009 and 2018, leading health officials to call for widespread testing for the disease.

Having access to direct-acting antiviral drugs has been shown to decrease mortality among hepatitis C patients.

“We hope clinicians and health care providers, especially those working in primary care clinics, know that they play a crucial role in providing accessible, affordable and continuous quality care for HCV patients, which is essential to HCV elimination,” Wu said. “Specialists are primarily providing care to those with an advanced stage of liver diseases due to HCV and primary care providers should help coordinate care that is necessary for their HCV patients.”

HCV treatment requires minimal expertise and monitoring, and simplified care delivery practices could be adopted quickly. More research is needed, including on implementation to refine simplified models and screening approaches.

“Our research will further tap into the patient angle and look into strategies to further engage patients or advocates in developing effective interventions,” Wu said. “For instance, our team is currently organizing a global crowdsourcing open call to solicit personal stories from service users and civil society groups as personal stories are sometimes powerful to spur changes and shift paradigms but often neglected. Our crowdsourcing open call will invite people to share their experiences and stories related to viral hepatitis including HCV which will then be used in domestic workshops in three countries with heavy hepatitis burden in 2021 and the World Hepatitis Summit in 2022, aiming to generate interests among policymakers.”