Category: Uncategorized

CONTEXT

Pakistan is the 2nd highest hepatitis C (HCV) burden country in the world, with China having the highest number of people suffering from HCV.

The integrated hepatitis care at the primary health care level in Punjab supported by The Hepatitis Fund (THF), was successfully implemented by the Association for Social Development (ASD) with excellent results and outcomes. It was adapted and expanded through THF support for integrated care at rural health centres.

In Multidrug-resistant tuberculosis (MDR-TB) patients, identifying and managing hepatitis comorbidity (if found) is essential for their overall health and well-being. Hepatitis screening and care have theoretically been a part of MDR-TB care. Still, it is not yet happening because of a lack of comorbid care protocols and linkages for offering “test-treat-prevent” care. This leads to the missed opportunity to screen around 3,000 MDR-TB patients and manage comorbid hepatitis accordingly.

In PLHIV and key populations (i.e., sex workers, people who inject drugs, transgender people, men who have sex with men,  etc.), identifying and treating comorbid chronic HCV/ HBV is a known priority. The Global Fund to Fight AIDS, Tuberculosis, and Malaria has recently created a window for assisting the programmes to implement integrated comorbid hepatitis test-treat-prevent care for known PLHIVs and key populations.

ACTION

ASD will assist the three programmes (Hepatitis, TB and HIV/ AIDS) to adapt and pilot the integrated hepatitis comorbid care of MDR-TB patients and PLHIV/ key populations in Punjab.

ASD will also provide technical assistance and capacity building to a non-governmental organization in Malawi to adapt and pilot an integrated hepatitis comorbid care of PLHIV in primary settings in Malawi.

EXPECTED RESULTS

An adapted package for integrated comorbid hepatitis care (of DR-TB patients and PLHIV/ key populations) will be created. It will include adapted care products and care linkages for the patients to access ongoing public-funded HCV/HBV care at the ongoing Hepatitis Clinics.

Implementation of the comorbid hepatitis care of ≥1,300 MDR-TB patients at 13 MDR-TB sites and ≥1,000 PLHIV/ key populations in a selected district of Punjab

Expansion of the integrated comorbid hepatitis care of MDR-TB patients at the GFATM-supported MDR-TB sites in Punjab and other provinces of Pakistan.

Partner and programme enabling the implementation of integrated comorbid hepatitis care of PLHIV in other parts of Malawi (preferably through GFATM forthcoming work plans)

The results and the products will be shared with potential stakeholders within and outside Pakistan for the potential application of the pilot model in other settings.

EXPECTED RESULTS

The project will provide a hepatitis-free future to newborn babies in Nghe An, which is Vietnam’s largest province, located in the North Central Coast region of the country, with 3,547,247 people living in 21 districts. 

The project will aim to screen 90% of pregnant women receiving antenatal care, treat 80% of eligible pregnant women with Tenofovir (TDF) prophylaxis or treatment, and vaccinate up to 98% of newborns with the HBV birth dose vaccine at the project sites by the end of the project life. 

Evidence generated from implementing the triple EMTCT model in Nghe An will be used to establish a comprehensive evidence base to advocate for financing and programming toward universal access to HBV, HIV, and syphilis screening and care. This includes integrating HBV, HIV, and syphilis screening as a core part of Vietnam’s MNCH and primary health care services and ensuring its coverage in social health insurance structures.

Grant USD 327,000 for three years.

The project aims to scale hepatitis B (HBV) screening, diagnosis, and antiviral treatment among pregnant women and demonstrate that the implementation of a timely targeted hepatitis B birth-dose vaccine can prevent mother-to-child transmission (PMTCT) of hepatitis B.

CONTEXT

In Rwanda, roughly 10,000 newborns are at risk of being exposed to hepatitis B at birth every year. Transmission risk can be decreased to almost 0% through antenatal HBV screening, a combination approach using antiviral treatment in pregnant women and HBV vaccination for infants. However, service gaps and implementation challenges to delivering prevention of MTCT (PMTCT) services exist at antenatal clinics, and they must be addressed to halt the transmission of HBV between mothers and their newborns.

Rwanda has high-performing antenatal care (ANC) platform. Around 93% of Rwanda’s 350,000 pregnant women per year attend ANC facilities for delivery. Despite this, recent data indicates that only 20% of pregnant women are currently screened for HBV during pregnancy.

Rwanda has achieved 96% HBV vaccination coverage by age 5 for children and has successfully rolled out routine HBV vaccination in adults, but HepB-BD given within 24 hours of birth, a key intervention to eliminate mother-to-child transmission, has yet to be introduced.

To advance HBV eMTCT, Rwanda will build upon existing health system infrastructure established for HCV elimination (human resources, diagnostics and treatment platforms, capacity building and procurement systems) established for HCV elimination, a strong vaccination program and a strong ANC platform to advance the elimination of HBV MTCT. 

ACTION

CHAI will work with the Rwandan government to address critical barriers to scale HBV screening, diagnosis, and antiviral treatment among pregnant women and demonstrate implementation of timely targeted HepB-BD. Specifically, CHAI will support the Rwandan Government to build upon the backbone of its HIV and HCV programmes to:

• assess and develop strategies to address HBV PMTCT service implementation challenges in Rwanda;
• increase uptake, availability and quality of HBV PMTCT services among pregnant women;
• implement a demonstration project for targeted HepB-BD for infants of high-risk mothers;
• generate evidence to inform a sustainability plan for HBV services for pregnant women in Rwanda, and inform policies in other AFRO countries.

• ≥90% of pregnant women presenting at antenatal care receive HBsAg screening  

• ≥90% of pregnant women with high viral load receive antiviral treatment   
• ≥90% of infants of high-risk mothers receive targeted timely HepB-BD 
• ≥90% of all newborns receive a complete HBV vaccine schedule (HepB3 vaccine) 

CATALYTIC IMPACT

During the project period, the successful demonstration of HBV BD among newborns of mothers who have high HBV VL levels will be used to advocate for increased government funding to scale HBV BD to all newborns. The implementation of this demonstration project will inform future introduction strategies, generate and leverage evidence to inform the sustainability plan of services in Rwanda and inform policies in AFRO countries. 

The purpose of this project is to demonstrate the impact of introducing screening & treatment of hepatitis B in pregnant women within the Maternal & Child Healthcare system as part of Vietnam’s 2030 triple elimination goal (HIV, Syphilis & HBV).

In the Asia-Pacific Region, mother-to-child transmission (MTCT) at birth plays a very important role in hepatitis B epidemiology. Approximately 3% to 5% of infants born in this region will acquire chronic hepatitis B infection at birth if not immunized immediately after the delivery. Each year, over 180,000 new-born babies in the region  are newly infected by hepatitis B through mother-to-child transmission.

According to the World Health Organization, Vietnam has one of the highest HBV prevalence in the world at more than 10%. Viral hepatitis is the third cause of death in the country and HBV claims over 25,000 lives annually (Polaris Observatory, 2016). Chronic carriers of hepatitis B are at risk of developing liver diseases such as cirrhosis and liver cancer. 45% of all liver cancer cases are caused by HBV.

To prevent MTCT of HBV, WHO recommends that all children be vaccinated against hepatitis B as soon as possible after birth, including a first dose of the vaccine within 24 hours after birth. Timely diagnosis and treatment of women living with chronic hepatitis B during pregnancy and hepatitis B vaccination for newborns can reduce and prevent MTCT of HBV by more than 95% and thus break the cycle of transmission across generations. While national birth dose of hepatitis B vaccination rate is at 82.2%, the proportion of pregnant women screened for HBV is very low (55%) and the prophylactic treatment for pregnant women is not yet dispensed in district hospitals in Vietnam.

The project aims to implement a scalable pilot model towards a hepatitis-free future for newborn babies in Nghe An Province through the following objectives:

• Provide testing for hepatitis B in pregnant women receiving antenatal care (ANC) or delivery services at district health facilities in Dien Chau and Thai Hoa, Nghe An.
• Facilitate linkage to HBV prophylaxis or treatment for pregnant women living with hepatitis B to prevent mother-to-child transmission of HBV.
• Promote newborn HBV birth dose vaccination.
• Provide clinical and operational evidence for policy formulation at both the provincial and national levels

Nghe An is Vietnam’s largest province, located in North Central Coast region of the country, with 3,547,247 people living in 21 districts.

The project aims to screen 90% of pregnant women receiving antenatal care, treat 80% of eligible pregnant women with Tenofovir (TDF) prophylaxis or treatment, and vaccinate up to 98% of newborns with a birth dose HBV vaccine at the project sites.

This project was made possible by support from City of Geneva.

South America has a population of 422 million people and is comprised of 13 countries. Between 2016 and 2018, PAHO, together with the Ministries of Health, estimated there to be approximately two million people living with hepatitis B and two million people living with hepatitis C in South America. Approximately half of this burden is found in countries of the Andean sub-region: Bolivia, Colombia, Ecuador, Peru, Venezuela and Chile.

While HBV immunization impact has been strong, efforts beyond immunization – diagnosis and treatment of HBV and HCV – remain insufficient to reach elimination. For example, in 2017, just 2,500 people in this region were treated for HCV, around 0.3% of the total.

While national plans for viral hepatitis are now numerous, they are often unfocused, and most of them do not contain an adequate monitoring and evaluation log frame, precise targets, workforce needs, costing, budgeting and financing.

In August 2019, in Kathmandu, Nepal, the WHO Regional Office for the South East Asia Region (SEARO), in collaboration with the WHO Secretariat, conducted a workshop with 11 countries of the region to facilitate the development of an outline of national plans that would include quantifications for indicators, targets and costing as well as other resource needs. The workshop was successful and led to the development of planning tools.

CATALYTIC IMPACT       

The plans will be highly beneficial in supporting funding and donor engagement approaches. The project is particularly timely: Bangladesh, Nigeria, Sudan and Uganda will be able to use the updated NSP and costing and cost-effectiveness projections for building the next round of funding requests to the Global Fund, focusing on co-infection, triple elimination of vertical transmission and key populations.  

Bangladesh will be able to use the costed operational plans for upcoming negotiations of its next five-year health budget plan in 2023-2024. Each country’s extensive strategic and planning work has allowed for a renewed focus on a robust viral hepatitis response.  

The project has supported and accelerated the national response beyond the direct outcomes of the grant, notably by further supporting and highlighting the introduction and extension of timely birth dose in Uganda and Nigeria while developing and updating clinical guidelines and monitoring and evaluation frameworks, as well as trainings of healthcare workers, in Vanuatu, Sudan and Nigeria. 

Thanks to this project, Vanuatu included HIV and STIs as part of one consolidated National Action Plan, including triple elimination of vertical transmission. The country created a task force for viral hepatitis, HIV and STIs, which included national stakeholders and international technical partners.   

The WHO Regional Office and WHO HQ will continue to support Vanuatu as the COVID-19 response and epidemic interrupted some of the work in 2021 and early 2022 on the island. 

The project also catalysed the creation of the new WHO/ECHO-webinar series, “Dialogues for Viral Hepatitis Elimination”, which was designed as a platform to facilitate the country-country exchange to accelerate the viral hepatitis response. It will attract more than 36 WHO Member State participants, with a strong focus on national planning and costing.           

Our grantee started a “training of trainers” programme on hepatitis as Zambia had very few public health or clinical leaders prepared to train other health workers on viral hepatitis.  

UTH-HAP has also worked with hospital leadership to ensure the decentralization of testing to various points and the orientation of nurses to offering tests. More service delivery points, such as antenatal, sexually transmitted infection (STI) and antiretroviral therapy (ART) clinics and sites doing HIV testing, are now integrating hepatitis into their routine services. When kits are available, hepatitis testing can now be offered at any service delivery point by a trained provider. 

The ACCELERATE programme estimates that a total of 222,000 people are eligible for HBV treatment in Zambia, including 72,000 people for co-infection (HIV and HBV) and 150,000 for HBV mono-infection. The programme estimates, however, that 30.3% of the treatment need is being met. The gap is primarily among people with HBV only and not living with HIV, where only 1.7% of the need is being completed compared with 90% among people with both HIV and HBV. This poses a severe challenge to health equity, which global health donors must address together.  

CATALYTIC IMPACT 

At the end of this project, 31 doctors were certified as hepatitis expert trainers. Before this programme, there were only five doctor experts in hepatitis in Zambia. This group will spearhead advocacy at the Ministry of Health (MoH) and its facilities. The expert trainers will also be assigned to HIV technical working groups where HBV integration is planned, including by building hepatitis components in Zambia’s application to the Global Fund. As a catalytic result, five project team members have been assigned to lead the national responses, and the MoH recognized hepatitis as a vital area that needs attention. The programme has empowered 81 HIV mentors to drive hepatitis care at hundreds of outlying facilities. 

Leveraging existing healthcare workforce programmes such as the ECHO model and HIV/TB mentorship programme to scale up hepatitis B education and training promises to catalyze strides toward hepatitis B elimination in the entire country.