On 21-22 October 2021, Treatment Action Group (TAG), The Kirby Institute, UNSW Sydney, FIND, the global alliance for diagnostics, and the International Network of People Who Use Drugs (INPUD) hosted a virtual satellite session at the 2021 International Conference on Health and Hepatitis Care in Substance Users (INHSU 2021) "Innovations in HCV Diagnostics: Real-World Implementation".
Facilitated by Ms Bryn Gay, HCV Project Director at TAG, the session featured global experts on HCV diagnostics including Dr Tanya Applegate (Kirby Institute, UNSW Sydney), Ms Sonjelle Shilton from FIND, Mr Rajkumar Nalinikanta (Community Network for Empowerment – Manipur, India), Ms Olga Denisiuk (Alliance for Public Health – Ukraine), Ms Emi Okamoto (Clinton Health Access Initiative), Ms Caroline Thomas (Peduli Hati Bangsa – Indonesia), Mr Francisco Viegas (Drugs for Neglected Diseases initiative), with additional insights from Professor Margaret Hellard (Burnet Institute), Mx Elizabeth Lovinger and Ms Sara Helena Gaspar (both from TAG).
Via short presentations and collaborative breakout groups, the speakers discussed near-to-patient diagnostic innovations, identified the hurdles and practical solutions to scale up, and how to bring testing closer to the community.
Here are the key takeaways:
1. Scaling up implementation is about more than just the tests themselves
Dr Tanya Applegate, Senior Scientist at the Kirby Institute in Sydney, provided an overview of existing tools in the HCV diagnostics pipeline and discussed how COVID-19 has demonstrated what is possible when it comes to accelerating the delivery of innovative testing strategies nearer to the patient.
“COVID has shown that where there is a will there is a way,” she explained. “It has also created a flurry of new diagnostic tools that we hope will pivot to hepatitis C in the coming years.”
Tanya discussed the importance of maintaining this pivot to patient-centred care – where diagnostic testing takes place where the patient is – but remembering that there is “no one size fits all approach” – every community is different and will require different tests, tools, and approaches.
The one thing that remains the same no matter the environment, is that scaling up implementation of point-of care testing methods is about more than just the tests themselves.
“You also need to consider acceptance, linkage to care, quality management systems, education and training, funding, policy, governance and regulatory frameworks, reporting and connectivity,” she concluded.
2. A one-stop-shop is a team effort
Ms Sonjelle Shilton, Hepatitis Lead at FIND, discussed the emergence of the ‘one-stop-shop’ model which aims to bring hepatitis C diagnosis, treatment and care into the same location to minimise patient drop off. “It’s been proven time and again,” she explained. “If you move them, you lose them.”
Sonjelle shared successful case studies from Georgia and Malaysia which are both moving towards the one-stop-shop model, using existing infrastructure to minimise costs.
For example, in Georgia, 60% of people who were testing positive for HCV at harm reduction sites weren’t making it to the treatment stage of the care cascade. Minimising the movement of patients has seen a significant increase in linkage to care. In Malaysia, a similar story can be seen thanks to the blood samples moving more, meaning the patient moves less, which enhances access to care.
For both of these case studies, Sonjelle emphasised how important it is to bring stakeholders together so that everyone is aligned. “The most important thing was bringing people together and facilitating connections with government, civil society, etc,” she concluded. “It was through this holistic approach that we were able to move forward.”
Another interesting takeaway from Sonjelle’s presentation was Malaysia’s recently introduced trial of HCV self-testing. The small sample so far shows a 60% uptake in testing compared to traditional primary care testing.
3. Advocacy and community networks are central to success
Ms Bryn Gay, HCV Project Director at TAG facilitated a panel discussion at the end of the session, bringing together feedback from the various breakout rooms. The themes were clear across both groups: when it comes to scaling up HCV testing, community groups play an integral role and advocacy is imperative.
Community-led awareness-raising, treatment literacy and anti- stigma trainings, as well as the monitoring of stockouts and available services are examples of meaningful inclusion of communities in the design and implementation of HCV testing strategies, including self-testing, that can generate evidence and inform models of care.
“The centrality and capacity of community is something that is continually underestimated,” said Professor Margaret Hellard from the Burnet Institute. Margaret went on to discuss how it can be difficult to measure the impact of community on HCV diagnostics (and other elements of the care cascade) but how the involvement of community organisations and groups must be included in guidelines.”
In the Ukraine, social networks played an integral role in meeting people where they are, reaching undiagnosed people, and expanding HCV in existing HIV programs. Lessons for other low- and middle- income countries without vertical funding in their national budgets were shared. Advocates noted the importance of building relationships within Ministries of Health and monitoring the unspent HIV funding that could be positioned for HCV as one strategy for building out national programs.
The importance of advocacy was also discussed and the role it plays in forcing governments to act, as well as how activists can lobby for more affordable pricing and non-exclusive licensing of diagnostics, with particular emphasis on those developed with public funding.
The Time for $5 campaign is a powerful example of this – an advocacy effort to persuade industry to lower the price of life-saving TB testing and also utilise it for other infectious diseases, including HBV and HCV. Proposals such as expanding a mechanism, such as the Medicines Patent Pool, to pool patents on diagnostics and reagents were also discussed.
An example that was given in one breakout session, of a broad-scale screening initiative across seven correctional facilities in Jakarta, demonstrated the importance of community involvement to motivate government action. Following project outcomes, an HCV elimination plan has been announced across all Indonesian prisons and a financial strategy informed by project learnings is now in place.
4. Make use of the existing workforce
As part of the breakout sessions, HCV diagnostics in prisons was discussed. Tanya Applegate reported back to the attendees a discussion around the need to ensure that the existing workforce in prison is maximised to ensure successful testing and treatment. Upskilling people already working in the field, and integrating screening into normal duties, is an important solution to overcome workforce challenges in this setting.
“It’s all about increasing the capacity of the existing workforce,” she explained. “And simplifying the process. For example, simplification of the tests themselves (so that they do not need to be performed by a medical professional) and also the simplification of data entry.”
Although the discussion was primarily around prisons, this advice is valuable for any environment or community looking to increase testing and treatment of hepatitis C.