Bridget Louise Draper1,2, Hla Htay3, Alisa Pedrana1,2,4, Win Lei Yee3, Jessica Howell1,2,5,6, Khin Pyone Kyi7, Win Naing7,8, Khin Sanda Aung9, Jessica Markby10, Philippa Easterbrook11, Anna Bowring1, Win Aung7, Yi Yi Sein7, Nwe Nwe10, Kyi Thar Myint3, Sonjelle Shilton10, Margaret Hellard1,2,12,13,14. 1. Disease Elimination Program, Burnet Institute, Melbourne, Australia. 2. School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. 3. Burnet Institute, Yangon, Myanmar. 4. Health Services Research and Implementation, Monash Partners, Melbourne, Australia. 5. St Vincent's Hospital Melbourne, Australia. 6. Department of Medicine, University of Melbourne, Melbourne, Australia. 7. Myanmar Liver Foundation, Myanmar. 8. Yangon Specialty Hospital, Myanmar. 9. National Hepatitis Control Program, Ministry of Health and Sports, Myanmar. 10. Foundation for Innovative New Diagnostics, Geneva, Switzerland. 11. Department of Global HIV, Hepatitis, and STI Programmes, World Health Organization, Geneva, Switzerland. 12. Hepatitis Service, Department of Infectious Diseases, Alfred Hospital, Melbourne, Australia. 13. Doherty Institute, Melbourne, Australia. 14. School of Population and Global Health, University of Melbourne, Melbourne, Australia.
Abstract
BACKGROUND: With the advent of low-cost generic direct-acting antivirals (DAA), hepatitis C (HCV) elimination is now achievable even in low-/middle-income settings. We assessed the feasibility and effectiveness of a simplified clinical pathway using point-of-care diagnostic testing and non-specialist-led care in a decentralized, community-based setting. METHODS: This feasibility study was conducted at two sites in Yangon, Myanmar: one for people who inject drugs (PWID), and the other for people with liver disease. Participants underwent on-site rapid anti-HCV testing and HCV RNA testing using GeneXpert(R) . General practitioners determined whether participants started DAA therapy immediately or required specialist evaluation. Primary outcome measures were progression through the HCV care cascade, including uptake of RNA testing and treatment, and treatment outcomes. FINDINGS: All 633 participants underwent anti-HCV testing; 606 (96%) were anti-HCV positive and had HCV RNA testing. Of 606 tested, 535 (88%) were RNA positive and had pre-treatment assessments; 30 (6%) completed specialist evaluation. Of 535 RNA positive participants, 489 (91%) were eligible to initiate DAAs, 477 (98%) completed DAA therapy and 421 achieved SVR12 (92%; 421/456). Outcomes were similar by site: PWID site: 91% [146/161], and liver disease site: 93% [275/295]). Compensated cirrhotic patients were treated in the community; they achieved an SVR12 of 83% (19/23). Median time from RNA test to DAA initiation was 3 days (IQR 2-5). CONCLUSIONS: Delivering a simplified, non-specialist-led HCV treatment pathway in a decentralized community setting was feasible in Yangon, Myanmar; retention in care and treatment success rates were very high. This care model could be integral in scaling up HCV services in Myanmar and other low- and middle-income settings.
BACKGROUND: With the advent of low-cost generic direct-acting antivirals (DAA), hepatitis C (HCV) elimination is now achievable even in low-/middle-income settings. We assessed the feasibility and effectiveness of a simplified clinical pathway using point-of-care diagnostic testing and non-specialist-led care in a decentralized, community-based setting. METHODS: This feasibility study was conducted at two sites in Yangon, Myanmar: one for people who inject drugs (PWID), and the other for people with liver disease. Participants underwent on-site rapid anti-HCV testing and HCV RNA testing using GeneXpert(R) . General practitioners determined whether participants started DAA therapy immediately or required specialist evaluation. Primary outcome measures were progression through the HCV care cascade, including uptake of RNA testing and treatment, and treatment outcomes. FINDINGS: All 633 participants underwent anti-HCV testing; 606 (96%) were anti-HCV positive and had HCV RNA testing. Of 606 tested, 535 (88%) were RNA positive and had pre-treatment assessments; 30 (6%) completed specialist evaluation. Of 535 RNA positive participants, 489 (91%) were eligible to initiate DAAs, 477 (98%) completed DAA therapy and 421 achieved SVR12 (92%; 421/456). Outcomes were similar by site: PWID site: 91% [146/161], and liver disease site: 93% [275/295]). Compensated cirrhotic patients were treated in the community; they achieved an SVR12 of 83% (19/23). Median time from RNA test to DAA initiation was 3 days (IQR 2-5). CONCLUSIONS: Delivering a simplified, non-specialist-led HCV treatment pathway in a decentralized community setting was feasible in Yangon, Myanmar; retention in care and treatment success rates were very high. This care model could be integral in scaling up HCV services in Myanmar and other low- and middle-income settings.
Keywords:
Myanmar; South East Asia; cirrhosis; general practitioners; hepatitis C; non-specialist; people who inject drugs; point-of-care testing; retention in care