Breaking down the silos: integrating hepatitis C 'test and treat' services into ART clinics is possible

Integrating hepatitis C screening, diagnostics, and treatment into antiretroviral therapy (ART) clinics in Nigeria and Vietnam led to a 98% and 99% hepatitis treatment completion rate for those who initiated treatment in the two countries, the recent 12th International AIDS Society Conference on HIV Science (IAS 2023) heard.

The successes of these interventions demonstrate that integration is critical to achieving hepatitis C virus (HCV) elimination in people living with HIV.

Globally, 2.3 million people with HIV also live with HCV (6.2% of the HIV population). If left untreated, HCV can lead to cirrhosis, liver cancer and death. Although effective oral direct-acting antivirals are available that can cure HCV in 12 weeks with a success rate of over 95%, there are still gaps in HCV care services for key populations and people with HIV.

At the conference, Dr Chukwuemeka Agwuocha of the Clinton Health Access Initiative shared that while Nigeria's national prevalence of HCV was 1.1%, affecting about 2 million people, the states of Nasarawa has a higher burden with positivity rates of 19.6% and 7.5% among hospitalised patients and healthy blood donors, respectively. Over 200,000 people in the state were chronically infected, and 95% were unaware of their status.

A situational assessment conducted by Dr Agwuocha and colleagues in the state showed that healthcare workers lacked knowledge in managing viral hepatitis. Routine screening, diagnostics and treatment services were also unavailable, except in the private sector, where they were offered at exorbitant prices of US$200 and $1500, respectively.

To address this, intervention strategies were developed, which included implementing the public health approach for HCV management, task shifting and decentralisation of care, targeted screening strategies to increase case finding, integrating HCV services into HIV differentiated service delivery models and mobilising lay health workers, known as ART defaulter trackers, in communities.

Between 2020 and 2022, a pilot programme was conducted to integrate HCV services into four high-volume ART sites in Nigeria. The clinics provided antibody rapid and confirmatory tests using HCV RNA and treatment. A baseline assessment was carried out at the ART facilities and community ART engagements, which included home visits, to identify crucial areas for service integration. These areas included HCV screening, confirmatory testing for viral load, and treatment, all without disrupting existing services.

Clients coming for ART visits received HCV screening during their preliminary examinations. Patient navigators and ART defaulter trackers used facility HCV screening and enrollment data to identify individuals with HIV who had not yet been screened. They then contacted these individuals through text messages or phone calls to prompt their return to the facility for HCV services or provided these services in community settings. Patients who tested positive were connected to viral load testing and treatment at the facility or community.

A total of 3831 out of 4042 clients who were receiving ART were screened across various sites. Of those screened, 459 (11%) tested positive. Further testing was conducted on 425 of those who tested positive to confirm the results. Among those who underwent confirmatory testing, 250 (59%) received an HCV viral load test. Two hundred and fifteen clients started treatment with sofosbuvir / daclatasvir, and 211 (98%) completed it.

During the conference, Dr Nhan Do Thi from the Vietnam Administration for HIV/AIDS Control also presented a poster demonstrating HCV treatment's successful integration and expansion in ART clinics in Vietnam. One million people are living with hepatitis C in Vietnam, primarily those living with HIV and those who inject drugs. The national health insurance in Vietnam covers 50% of hepatitis C treatment costs.

Between 2021 and 2022, 16,052 patients (4492 who injected drugs and 11,560 people living with HIV) initiated HCV treatment with direct-acting antivirals at 210 ART clinics in 38 provinces in Vietnam.

Most (84%) of these ART clinics were at district hospitals. The cure rate was defined as undetectable HCV RNA at 12 weeks or more after completion of HCV treatment.

Out of the 16,052 patients who began treatment, almost all (99%) completed the treatment course. As of November 2022, 30% of patients underwent a second HCV RNA test at least 12 weeks after finishing treatment; the rate of undetectability was 97%. However, a large portion (70%) of patients who had completed treatment for at least 12 weeks did not receive a second HCV RNA test. This was mainly due to patients feeling healthy and not wanting to spend the time or money on another test.

While these findings from Vietnam and Nigeria highlight the importance of integrating HCV testing and treatment services with HIV services, both hepatitis B virus (HBV) and HCV are massively under-diagnosed. While 85% of people with HIV have been diagnosed, only 11% and 21% of those with hepatitis B and hepatitis C have.

Dr Natasha Beard from Imperial College London, therefore, conducted a systematic review to determine the prevalence of hepatitis B, hepatitis C, and HIV and to inform testing programmes which test for all three viruses using a combined test.

After analysing 175 studies conducted in 56 countries involving over 14 million people, Dr Beard and colleagues found that the average prevalence of HIV, HBV, and HCV in these studies was 0.2%, 1.1% and 0.7% respectively. This means that for each individual testing positive for HIV, triple testing would identify another five individuals with HBV and three with HCV, resulting in nine individuals with a blood-borne virus.

According to the researchers, the cost for the triple test ranges from $1 to $5. Additionally, tenofovir disoproxil / emtricitabine + dolutegravir treats HIV for $60 per year, while generic tenofovir disoproxil can be used to treat hepatitis B for $32 per year. For hepatitis C, generic sofosbuvir / daclatasvir could be used to cure it for $60, likely making this a cost-effective package that can be adopted in most countries.