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Changing how we combat hepatitis in low-and middle-income countries

On World Hepatitis Day, Ed Booty shares new ways to transform hepatitis screening, diagnosis and treatment based on our work in LMIC communities…

During a recent visit to our sites with our community teams and healthcare service providers, we explored the challenge of viral hepatitis and what’s getting in the way. Progress on this disease globally is still slow, with a 2019 WHO report calling for a major scale-up in testing and treatment access to achieve its 2030 targets. 9/10 people still live unknowingly with this disease, and low- and middle-income countries account for the largest proportion – 96% of people living with HBV and 72% of those with HCV2.

Misinformation and stigma remain a key barrier. In communities it is shocking to hear the anguish and confusion of normal, decent people who simple can’t fathom how they came to have a disease they associate with drug use or unprotected sex. Adequate screening and diagnostics simply don’t reach these communities – many of the essential machines are expensive and in private facilities, often in urban areas. The chronic nature of Hepatitis B poses financing challenges for health budgets already strained from investment in infrastructure and initiatives to end infectious diseases on the global agenda (such as malaria, TB and AIDS). In 2017, only 58% of the 82 WHO-reported low-and middle-income countries had included domestic funding in their national hepatitis plans.

Robust vaccination programmes should solve the problem eventually and those born today and in future years that are vaccinated will contribute to a declining prevalence rate. But new solutions are also needed now to combat hepatitis, and public-private partnership is essential to solve this challenge. For World Hepatitis Day, I’ve shared 3 ways that we can achieve this in practice based on insights and learnings from our community solutions and programmes.

1-Overcome misinformation to find the missing millions

The World Hepatitis Alliance advocacy campaign focuses on ‘finding the missing millions’ living unknowingly with viral hepatitis. Overcoming misinformation is critical to finding these missing millions.

I am open to admitting that, as a non-clinical professional, I initially got the causes of hepatitis wrong. From our work within communities and with community health workers it becomes apparent that I am not the only one.

This misinformation, creating stigma and isolation in communities, must be tackled directly through awareness campaigns that drive better understanding of the causes, diagnosis and treatment pathways. The campaigns must firstly address emotional barriers to change entrenched attitudes around hepatitis and motivate people to get tested.

For example, at reach52 we have been working on targeted, door-to-door screening campaigns. Based on our initial community health profiling, we can conduct discrete interactions in the home, directly with a community member, with robust content to help them understand what a specific condition means. This has allowed our non-clinical Access Managers to provide better support, access healthcare and extend the reach of government health providers.

2-Make screening and diagnostics go further through technology and people

Screening programmes are woefully inadequate. Infrastructure is lacking and many of the tests required for safe diagnosis according to recommended clinical protocols (such as viral load testing – also used for HIV/AIDS) are missing in lower-income communities. Diagnostic equipment often isn’t available in public rural health facilities, adding additional burden to lower-income residents. Treatment is often expensive, but regardless of the price, it just isn’t available in more rural communities – the pharmacies don’t have stock. To address these healthcare system gaps, we believe it’s essential to both harness new technology and empower the people in the communities to be the solution for their problems.

We have developed offline-first apps that can be used to profile residents, identify at-risk patients, and get them tested at the right time at the right health facilities or through outreach events. Members of the community are equipped as access managers and health workers to run these services on the ground. Additionally, through our e-commerce and distribution platform, we can work with the private sector to ensure affordable treatment is available to those that need it, when they need it. As part of our data collection and community risk profiling, we are collecting hepatitis risk indicators to help targeted screening campaigns where they are needed most.

3-Demonstrate future outcomes to galvanise action now

Many governments simply do not think they have a significant prevalence rate as a comprehensive effort to understand the problem hasn’t been undertaken. Of course, it’s a trade-off: health systems have limited finance, must make choices, and not everything can be funded. Medicines are too expensive for many governments to afford at scale.

Hepatitis will often lead to complex health conditions in the future, so the only way to solve the challenge will be to invest early. We must shift the discussion from short term costs to long term health and economic outcomes. According to WHO, investing in hepatitis testing and treatment services as part of UHC efforts can cut global deaths by 5% and increase healthy life years by about 10% by 2030 – a smart decision for broader health outcomes.

Yet often to galvanise action, government leaders understandably want the data to make decisions and subsequently demonstrate the impact in their communities. This just isn’t available in a rural setting – although the broader healthcare market is moving towards Real World Evidence and outcomes in general. Therefore, it’s critical to both extend health profiling to the undiagnosed and disconnected, and use forecasting to demonstrate downstream cost savings as a result of early interventions.

Existing partnership models aren’t working and a radical new approach to public-private partnership is needed. On World Hepatitis Day, it’s time to change how we’re combatting hepatitis in low-and middle-income countries by fully harnessing the new technologies and opportunities available.