Danielle M. Tholey, MD
Regine Nshimiyimana Maniraho, DNP, PharmB, AOCNP
Of 58 million people worldwide living with hepatitis C virus (HCV), one-sixth of them are found in sub-Saharan Africa.1 Yet, in that region, direct access to diagnostic testing and treatment is limited to less than 5%. HCV carries significant downstream implications including cirrhosis (30%–46%), liver cancer (20%–30%), and liver-related death.2 However, HCV is now curable at rates of 95% to 98% with direct-acting antivirals and can reduce downstream liver-related mortality.3
The World Health Organization (WHO) has advanced an HCV elimination plan with a target of treating 80% of patients with HCV by 2030.2 Unfortunately, worldwide, only 11 high-income countries are on track to meet the WHO’s 2030 goal.4 Rwanda, a low-income country in sub-Saharan Africa, implemented a national elimination plan in 2018 to achieve more rapid HCV eradication by 2024; but recent data show Rwanda is lagging behind that goal. The United States has treated 41% of its eligible patients with HCV, whereas Rwanda is only 20% of the way to its 80% HCV eradication goal.5 In sub-Saharan Africa, HCV eradication may be hampered by barriers to diagnosis, screening, resources, and access to care.
Approach to Treatment
In an effort to refine the 5-year HCV elimination plan, Rwanda is utilizing a centralized government approach to treatment. The Ministry of Health has focused on diagnosis with targeted screening campaigns and the development of a centralized HCV chart that helps track patient data and support clinical decision-making. Testing has been expanded to 13 centers with WHO grade, rapid diagnostic testing and nine centers capable of polymerase chain reaction testing.6
“Lack of patient knowledge is a barrier to staying engaged in treatment, and a 2017 study revealed that 75% of Rwandan patients [with HCV] either didn’t finish treatment or never got tested for cure.”— DANIELLE M. THOLEY, MD, AND REGINE NSHIMIYIMANA MANIRAHO, DNP, PharmB, AOCNP
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Rwandan HCV treatment guidelines were published to aid with provider knowledge gaps. The fixed-dose combination of sofosbuvir and velpatasvir and the three-drug fixed-dose combination of sofosbuvir, velpatasvir, and voxilaprevir are the preferred direct-acting antivirals, based on the 2018 SHARED-3 clinical trial results showing high cure rates and safety in both treatment-naive and previously treated Rwandan patients.7,8 HCV treatment is available via centralized government agencies, and manufacturing license agreements have significantly reduced direct-acting antiviral costs.
The national HCV treatment plan is projected to prevent 10,638 new infections and over 35,000 premature deaths.9 Thus far, HCV prevalence in Rwanda has decreased from 4% to 1%.5 Additional targeted interventions could help Rwanda reach its eradication goal.
Barriers to Treatment
Nevertheless, barriers to HCV treatment persist. Serumondo et al conducted public health surveys to identify HCV treatment barriers among Rwandan providers and patients. Participants highlighted financial hardships regarding drug, lab, and transportation costs, as well as difficulties navigating the “treatment cascade.” They also cited a lack of patient and provider education on HCV and difficulty accessing diagnostic technologies in remote regions.3
"A system of mobile HCV units—traveling with point-of-care testing and drugs available on demand—could be a solution to improving HCV diagnosis and treatment."— DANIELLE M. THOLEY, MD, AND REGINE NSHIMIYIMANA MANIRAHO, DNP, PharmB, AOCNP
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Although drug costs have improved, the associated treatment costs remain prohibitive, as the average income in sub-Saharan Africa is $5.6 (U.S. dollars) per day, with 75% of the population living on $2 per day.10 Lack of patient knowledge is a barrier to staying engaged in treatment, and a 2017 study revealed that 75% of Rwandan patients either didn’t finish treatment or never got tested for cure.3 Patients were often hampered by the long distances and travel costs necessitated to receive treatment as well as the unpredictability of provider schedules due to heavy workloads and late cancellations.3 Lastly, the need for increased HCV screening and connection with treatment providers was highlighted in a 2022 study, which demonstrated that despite the greater effectiveness of direct-acting antivirals, only 8% of patients receiving those agents have been cured globally vs 1% to 2% of patients who received interferon monotherapy.11
Overcoming Treatment Barriers
To help combat barriers to HCV treatment in Rwanda, we advocate a multitargeted approach. Because most of the HCV treatments and diagnostics are centralized, this creates issues in screening, diagnosis, and treatment for those in remote areas who cannot afford to travel to a centralized care system.
We propose greater emphasis on point-of-care testing with immediate access to treatment at the time of test results. Decentralizing treatment could decrease the number of patients lost to follow-up, provide greater access to treatment, and decrease patient-related medical expenses. A system of mobile HCV units—traveling with point-of-care testing and drugs available on demand—could be a solution to improving HCV diagnosis and treatment. Such a model could ameliorate issues of patient access, travel costs, and coordination.
Both the WHO and Centers for Disease Control and Prevention have highlighted that political investment is the most important predictor in eradicating HCV.2 Hence, the Rwandan government’s prioritization of HCV treatment provides hope, and their investment in such a model could drive effective change in reducing liver cancer and other HCV-related diseases. We strive to implement such a model to improve the equity and effectiveness of HCV treatment and eradication efforts across Rwanda and sub-Saharan Africa. n
REFERENCES
1. World Health Organization: Hepatitis C, 2023. Available at https://www.who.int/news-room/fact-sheets/detail/hepatitis-c. Accessed February 27, 2024.
2. Polaris Observatory HCV Collaborators: Global change in hepatitis C prevalence and cascade of care between 2015 and 2020: A modelling study. Lancet Gastroenterol Hepatol 7:396-415, 2022.
3. Serumondo J, Penkunas M, Niyikora J, et al: Patient and healthcare provider experiences of hepatitis-C treatment with direct acting antivirals in Rwanda: A qualitative exploration of barriers and facilitators. BMC Public Health 20:946-961, 2020.
4. Charuchandra S: Most countries not on track to eliminate hepatitis B and C by 2030. Hep, January 4, 2023. Available at https://www.hepmag.com/article/countries-track-eliminate-hepatitis-b-c-2030. Accessed February 27, 2024.
5. CDA Foundation: Polaris observatory: Countries/territories. Available at https://cdafound.org/polaris-countries-compare. Accessed February 27, 2024.
6. Mbituyumuremyi A, Nuil J, Umuhire J, et al: Controlling hepatitis C in Rwanda: A framework for a national response. Bull World Health Organ 96:51-58, 2018.
7. Kateera F, Shumbusho F, Manirambona L, et al: Safety and efficacy of sofosbuvir-velpatasvir to treat chronic hepatitis C virus infection in treatment-naive patients in Rwanda (SHARED-3): A single-arm trial. Lancet Gastroenterol Hepatol 7:533-541, 2022.
8. Gupta N, Manirambona L, Shumbusho F, et al: Safety and efficacy of sofosbuvir-velpatasvir-voxilaprevir for re-treatment of chronic hepatitis C virus infection in patients with previous direct-acting antiviral treatment failure in Rwanda (SHARED-3): A single-arm trial. Lancet Gastroenterol Hepatol 7:542-551, 2022.
9. Serumondo J, Penkunas MJ, Ngwije A, et al: Effectiveness of direct-acting antivirals for the treatment of viral hepatitis C in Rwanda. Ministry of Health Hepatitis C Plan Launch in Rwanda. Abstract. December 11–12, 2018.
10. Global Living Wage Coalition: Living wage reference value: Rural Rwanda. https://www.globallivingwage.org/living-wage-reference-value%E2%81%A0-rural-rwanda. Accessed February 27, 2024.
11. Manns M, Maasoumy B: Breakthrough in hepatitis C research: From discovery to cure. Nat Rev Gastroenterol Hepatol 19: 533-550, 2022.
Dr. Tholey is a global health advocate and physician in the Division of Gastroenterology and Hepatology at Thomas Jefferson University, Philadelphia. Dr. Nshimiyimana Maniraho is a former pharmacist in Rwanda and currently an oncology nurse practitioner and Country Co-Director for the Jefferson Consortium for African Partnerships at Thomas Jefferson University, Philadelphia.
