In high burden areas, limited access to screening, diagnosis and treatment for hepatitis C continues to be a barrier. In these areas, the virus goes largely undetected and for the cases that are detected, a number of individuals are lost at different stages of the care pathway. This case study will explore how the team at The Aga Khan University used a same day test and treat approach to close the gap between hepatitis C diagnosis and treatment to tackle loss to follow up care in underserved communities.
Traditional care pathways for hepatitis C follow a structed approach. Individuals are screened using rapid antibody tests and those who test positive are referred for a confirmatory polymerase chain reaction (PCR) test alongside baseline assessments. Treatment is then initiated only after the PCR confirmation. Cirrhotic individuals receive 24 weeks of treatment and non-cirrhotic individuals receive 12 weeks.
Whilst traditional pathways are effective in identifying cases, it allows delays and opportunities for individuals to disengage.
“When we would go back to give treatment to people, we couldn’t find a few of them, they were either not at home, moved or gone somewhere.”
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To address these challenges, a team at The Aga Khan University designed an innovative same-day treatment initiative. Instead of waiting for PCR confirmation before starting treatment, individuals who tested positive on the rapid diagnostic test (RDT) were given a starter pack of 7 to 10 days of direct acting antivirals (DAAs) on the dame day, whilst their PCR and liver function tests were being processed.
Once the PCR test became available, the team would follow up with the individuals. Those who were confirmed PCR positive would receive the remainder of their treatment to complete the full course. Those who were PCR negative were advised to stop the treatment they originally received.
“This was an alternative that we thought might be a solution”
This model drew inspiration from successful same-day treatment approaches used in other programmes such as HIV, where early initiation of treatment has been successful. Even without equipment such as GeneXpert machines, this initiative demonstrated that even in resource limited settings, same day treatment could be achieved.
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A total of 534 individuals participated in this initiative and were split across two groups with 267 in each. One group followed the traditional route for testing and treatment and the other group followed the same day test and treat model.
Treatment acceptance was high across both groups. In the traditional group, all 267 participants agreed to begin treatment upon a positive PCR test. In the same day group, two participants declined treatment, highlighting that this approach was well received and only a small number of individuals needed time to process their diagnosis before committing to treatment.
Retention differed in each group. At four weeks post screening, the dropout rate in the traditional group was 5.2% compared to the 11.4% in the same day group.
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An important lesson learnt from this initiative was the emotional and psychological aspect of a new hepatitis C diagnosis. The team realised that individuals that disengaged and stopped treatment were often those who had not had enough time to understand their diagnosis and what that meant for them and their families.
The team realised early on that in a fast paced, door to door outreach settings, there was not enough time to give individuals pre-treatment counselling and education. To address this, they decided to engage with senior family members during the visits. Speaking with senior family members and using them as advocates to encourage their family members to accept treatment was valuable in a lot of cases.
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“This has to be a very active campaign. We can’t take a retroactive manner, we just have to be very proactive to get as many people onto treatment as quickly as possible”
This micro elimination initiative shows that the use of same day DAA’s is feasible, safe and viable in a high burden, resource limited community settings. This initiative reduced patient visits to healthcare facilities, shortened lead times between testing and treatment and achieved meaningful uptake.
To further reduce future dropout rates whilst using this model, the team want to focus on prioritising pre-treatment counselling, family engagement and community healthcare worker training. These factors can all contribute to increased uptake of treatment and adherence.
Accelerating access to testing and treatment is not only possible, but essential. By adopting innovative, patient-centred approaches such as same-day test and treat, healthcare systems can move closer to ensuring that every diagnosis leads to a cure.
