Feasibility and challenges of implementing hepatitis C testing and treatment services in community-based opioid substitution therapy programs in four South African cities.


Author: Yolaan Andrews, Memory Mahaso, Andrew Scheibe, Kalvanya Padayachee

Theme: Models of Care Year: 2023

Background:
One in two people who inject drugs (PWID) in South Africa has been exposed to hepatitis C virus (HCV). Despite the high burden, access to HCV testing and treatment services are limited. Service decentralisation is likely to enhance HCV elimination efforts.

Description of model of care/intervention:
We assessed the feasibility and challenges of integrating HCV testing and treatment into community-based OST services in four South African cities. PWID on OST were screened using rapid diagnostic tests. Budget limitations restricted the number of laboratory-based confirmatory tests and direct acting antivirals (DAAs) available. Nurses led counselling and testing procedures and general practitioners prescribed DAAs. Implementing partners met monthly to review progress and address challenges.

Effectiveness:
Overall, 672 PWID screened (August 2021 to March 2023) for HCV (146 in Cape Town; 143 in Durban; 370 in Johannesburg and 13 in Sedibeng). Overall HCV prevalence was 78% (522/672); 84% were males (439/522) and 64% were 25-35 years old (333/522). In total, 162 PWID received confirmatory testing and 84% (136/162) with confirmed infections (74% in Durban (34/46), 80% in Johannesburg (36/45), 93% in Cape Town (66/71). No confirmatory done in Sedibeng (0/0). 108 people started and 76% completed treatment (82/108). Twenty-four people received SVR12 testing, with a 79% cure rate (19/24). Key challenges: cost and inaccessibility of confirmatory testing; expensive DAAs; homelessness affecting adherence; treatment fatigue among PWID co-infected with HIV (29%, 39/136); adherence to post-treatment testing protocol, and high staff turnover.

Conclusion and next steps:
HCV burden is high among PWID on OST in these cities. HCV testing and treatment can be feasibly implemented in community-based OST services, with good treatment completion and cure rates. The costs of confirmatory testing and DAAs need to be reduced and psychosocial support and clinician capacity enhanced to enable efficient decentralized HCV service scale-up in South Africa.

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