Survey of programmatic experiences and challenges in delivery of hepatitis B and C testing in low- and middle-income countries

Abstract

Background: There have been few reports on programmatic experience of viral hepatitis testing and treatment in resource-limited settings. To inform the development of the 2017 World Health Organization (WHO) viral hepatitis testing guidance and in particular the feasibility of proposed recommendations, we undertook a survey across a range of organisations engaged with hepatitis testing in low- and middle-income countries (LMICs). Our objective was to describe current hepatitis B and C testing practices across a range of settings in different countries, as well as key barriers or challenges encountered and proposed solutions to promote testing scale-up.

Methods: Hepatitis testing programmes in predominantly LMICs were identified from the WHO Global Hepatitis Programme contacts database and through WHO regional offices, and invited to participate. The survey comprised a six-part structured questionnaire: general programme information, description of hepatitis testing, treatment and care services, budget and funding, data on programme outcomes, and perceptions on key barriers encountered and strategies to address these.

Results: We interviewed 22 viral hepatitis testing programmes from 19 different countries. Nine were from the African region; 6 from the Western Pacific; 4 from South-East Asia; and 3 from Eastern Europe. All but four of the programmes were based in LMICs, and 10 (45.5%) were supported by non-governmental or international organizations. All but two programmes undertook targeted testing of specific affected populations such as people living with HIV, people who inject drugs, sex workers, health care workers, and pregnant women. Only two programmes focussed on routine testing in the general population. The majority of programmes were testing in hospital-based or other health facilities, particularly HIV clinics, and community-based testing was limited. Nucleic acid testing (NAT) for confirmation of HCV and HBV viraemia was available in only 30% and 18% of programmes, respectively. Around a third of programmes required some patient co-payment for diagnosis. The most commonly identified challenges in scale-up of hepatitis testing were: limited community awareness about viral hepatitis; lack of facilities or services for hepatitis testing; no access to low cost treatment, particularly for HCV; absence of national guidance and policies; no dedicated budget for hepatitis; and lack of trained health care and laboratory workers.

Conclusions: At this early stage in the global scale-up of testing for viral hepatitis, there is a wide variation in testing practices and approaches across different programmes. There remains limited access to NAT to confirm viraemia, and patient self-payment for testing and treatment is common. There was consensus from implementing organizations that scale-up of testing will require increased community awareness, health care worker training, development of national strategies and guidelines, and improved access to low cost NAT virological testing.

Keywords: Feasibility; Hepatitis testing; Low- and middle-income countries; Programme experience; WHO guidelines on hepatitis B and C testing.

Fig. 1

Geographic distribution and characteristics of the 22 testing programmes. Categories of programme: Governmental; NGO/IO (Non-governmental or international organization); Research; Hospital (hospital initiative). Coverage of programme: National; Regional; Local (only the population covered by the site). Number of sites: One; 2 to 5; > 5. Duration of programme (year): ≤1; 2 to 4; ≥5. Testing settings: Hospital; PHC (primary health care site); ANC (antenatal care site); HRS (harm reduction service); Out (outreach); HIV (HIV clinic); G (general population); BD (blood donor); PW (pregnant women); C (child); HCW (health care worker); HIV+ (HIV positive person); PWID (people who inject drugs); SW (sex worker); MSM (mem who have sex with men); P (Prisoner); F (family of HIV/HBV/HCV positive person); ALF (person with abnormal liver function test); STI (sexually transmitted infection); TB+ (tuberculosis positive person); NID (non-injecting drug user); NA (not answered). Assays: RDT (Rapid Diagnostic Test); EIA (Enzyme Immunoassay); NAT (Nucleic Acid Test). ¹: Add NAT within 6 month after the RDT screening to confirm the chronic infection; ²: RDT was also available at the site; ³: Select test approach (RDT standalone, EIA standalone, RDT/EIA + NAT) based on the patient’s financial status; ⁴: RDT and NAT were available but test approach was not answered; ⁵: Apply NAT standalone to assess the eligibility of treatment; ⁶: Applied RDT + NAT standalone for HBV to assess the eligibility of treatment for children; ⁷: Apply RDT + NAT standalone for HCV limited to persons living in the city; ⁸: Offered test only for HBV; ⁹: EIA standalone for HBV and NAT standalone for HCV; ¹⁰: PWID for HCV and SW for HBV; ¹¹: Financial support is available for HCV treatment but not available for HBV treatment; ¹²: The treatment for HBV-HIV co-infected person is covered by the programme. Financial support is available for HCV treatment; ¹³: Financial support is available for HBV testing but not for HCV testing