30 June 2022
The World Hepatitis Summit is a large-scale global conference organised by the World Hepatitis Alliance and co-sponsored by the World Health Organization. It took place from 7-10 June, with a diverse line up of speakers and topics. The ‘Innovations in technology and service delivery’ session focused on the implementation and scale-up of various point-of-care testing methods and other innovations – such as low dead space syringes – that can help move us towards elimination.
The session was chaired by INHSU board member Professor Margaret Hellard, Deputy Director (Programs) at the Burnet Institute and Head of Hepatitis Services in the Department of Infectious Diseases at The Alfred Hospital.
Sonjelle Shilton, Deputy Director Operational and Implementation Research from FIND, opened the session by discussing hepatitis self-testing, which was officially recommended by the World Health Organization (WHO) in July last year, with the release of its first-ever HCV self-testing guidelines.
With no doubt left about the benefits of self-testing for hepatitis elimination, the question is left about how best to integrate it into services and existing models of care.
Integrate self-testing into existing services (and try incentivisation)
In Georgia, hepatitis C testing of key populations (men who have sex with men and people who use drugs) is being integrated into existing HIV testing services in Tbilisi and Batumi, as part of a study by NCDC and FIND in partnership with local community based organizations – “Tanadgoma”, “Equality Movement”, “New Way” and “Batumi Imedi”.
Dr Ketevan Stvilia, National Center for Disease Control, discussed how – of the 752 people who were tested as part of the program – 26% had used HIV self-test and Covid-19 self-test before, 16% only used HIV self-test before and 17% had only used Covid-19 self-test before.
Despite the newness of the diagnostic method for the study participants, 95% reported understanding the results and 80% would do a self-test again if provided the test and instructions for use.
Of the 5% of people who had trouble understanding the test, the majority (80%), were people who use drugs, a community that Sonjelle Shilton also flagged as potentially needing more support assistance during self-testing models.
The Georgian study included small credits on telephone accounts to encourage completion of online baseline and follow-up surveys to collect their feedback on self-testing process, their attitude and willingness to do self-test again and at what setting.
A door-to-door model of care could help meet people where they are
Pakistan has some of the highest hepatitis C prevalence rates in the world, with an estimated 6% national average. Dr Aliya Hasnain, research coordinator at Aga Khan University shared a unique self-testing study nested in a door-to-door model that includes screening, RNA testing, and treatment.
In the self-testing study, which aims to evaluate uptake of secondary distribution of self-testing in a micro-elimination program, there were two groups. The intervention group had a HCV self-testing kit left for them to use, complete with instructions. The control group had a pamphlet left, explaining about HCV and advising them to visit a clinic for screening.
2,185 participants were recruited with 87% of participants reporting completing the test in the intervention arm, and just 22% in the control arm. The control arm participants were then followed up and provided a self-test, with a further 66% completing the self test. Over 50% of people have not received any formal education, showing the simplicity of the testing process.
The results show that secondary distribution of self-tests within a door-to-door model works, but that it is not without challenges. While self-testing has drastically increased screening in the intervention arm, individuals can still be hard to reach and often not at home due to work commitments. This means linkage to care after a positive result can be difficult.
Consider plasma separation cards as an alternative testing method
Camila Picchio, pre-doctoral fellow and project manager, Barcelona Institute for Global Health (ISGlobal) discussed a recent study in Kampala, Uganda, a country where hepatitis B prevalence is sometimes as high as 15%.
The study evaluated the use of a Plasma Separation Card (PSC) for viral hepatitis and found an HBsAg prevalence of 13% among people living with HIV and nobody was anti-HCV positive.
The PSC is similar to a dried blood test, except a porous membrane only allows the plasma to go through, with a dried plasma spot being the final result rather than whole blood without needing centrifugation or to be kept in cold-chain. This type of test is very sensitive to viral hepatitis. (Martínez-Campreciós J et al. Reflex viral load testing in dried blood spots generated by plasma separation card allows for screening and diagnosis of chronic viral hepatitis. J Virol Meth 2021;114039).
Of 88 participants, 90% would recommend it as a means of testing to their peers, with a mean sample collection time of just 10 minutes, being one reason. It also has a very low level of reported pain, meaning high acceptability.
Consider linking people directly to treatment after a positive point-of-care test result
Sunil Solomon, associate professor of medicine and epidemiology, Johns Hopkins University School of Medicine discussed how self-testing can help people move onto Direct Acting Antiviral treatment quickly, and how the cost of inaction or delays can impact getting people accessing this treatment.
With current models, a positive result from a self-test then means referral for an RNA test to confirm results, followed by a clinical/lab exam. Depending on where you are located, this can take anything from a few hours to a month, with the potential of losing patients to follow up throughout this process.
Sunil posted the question ‘how can this be simplified?’ and ‘do we need the HCV RNA confirmation prior to initiation (of treatment)’?
Some suggestions included moving directly from positive self-test to a clinical exam to rule out decompensated cirrhosis, followed by a two week starter pack of DAAs with the rest provided when results are available.
Switch to Low Dead Space Syringes (LDSS) to help minimise hepatitis C infection from the start
People who use drugs commonly use two types of syringes, one with attached needles (LDSS) and one with detachable needles. Syringes with attached needles have less dead space so carry less blood after injection. Because of this, it has been hypothesised that they are less likely to transmit infections if shared.
The WHO have previously recommended the use of LDSS to reduce the risk of HIV and HCV acquisition, but there has been no evidence to support this. Peter Vickerman, Professor of Infectious Diseases at the University of Bristol, shared a study that aimed to provide evidence of the benefits of LDSS for reducing the risk of HCV incidence.
The study utilised the existing Unlinked Anonymous Monitoring (UAM) survey from England, Wales and Northern Ireland, an annual bio-behavioural survey of about 1,800 people who use drugs from across drug treatment clinics, needle and syringe programs, and outreach services. It includes a survey of behaviours and a DBS test for HCV antibody and RNA, with an RNA positive result among individuals with negative antibody being used as a marker of recent infection.
Of 1,465 people eligible, 63.8% always used fixed LDSS. Of these, fewer were ever incarcerated, fewer were on opioid agonist therapy and fewer injected in the groin. The overall findings was that always using fixed LDSS was associated with a 75% reduced risk of HCV acquisition compared to using any syringes with detachable needles.
Vickerman noted the limitations of the study including the low number of incident infections (33 in total) and the reliability of self-reported data, and called on further incidence studies to confirm their findings and to assess the efficacy of different syringe options.
It was concluded that – given the small cost associated with supplying LDSS only – this could be a cost-effective intervention to minimise HCV transmission. The study is published in Clinical Infectious Diseases.