It was only a year ago that the first global study on the harmful extent of HIV and Hepatitis C (HCV) coinfection was revealed by the World Health Organization (WHO). While it was always known that HIV and HVC are two major global health problems with overlapping modes of transmission and affected populations, it was only recently confirmed the extent of coinfection in high-risk population groups. Also known as key populations, these groups are identified as among the world’s most vulnerable individuals at risk for HIV and HCV infection.

The WHO study documented that not only are people with HIV at much higher risk of HCV infection (on average 6 times more likely), but high-risk populations, such as people who inject drugs (PWID), have an extremely high prevalence of HCV infection–over 80%. The WHO HIV/HCV coinfection study established that there is a need for scaling up routine testing to diagnose HCV infection in HIV programs worldwide, especially among high risk populations. The report says this is the first step towards accessing the new, highly curative HCV treatments known as direct acting anti-HCV agents (DAAs).

While there is not yet a cure for HIV, there is for HCV, and investment in key populations, and delivery of technical assistance and services to Ministries of Health and local implementation partners will be fundamental factors towards providing lifesaving treatment to confected individuals and helping countries expedite their UNAIDS 90-90-90 targets.

 

This is where the pioneering EQUIP program comes in

 

EQUIP is the first non-American-led global consortium to deliver rapid scale-up of innovative HIV treatment and preventions solutions across 17 PEPFAR countries. Supported by USAID through PEPFAR, EQUIP applies its model for rapid scale-up and technical assistance across Africa, the Caribbean, Eastern Europe and South East Asia. It coordinates with country stakeholders—Ministries of Health, USAID country missions, and local implementing partners—to strengthen health care systems, roll out Test & Start, scale-up viral load monitoring, HIV self-testing, and evaluate cost-outcomes.

Through technical assistance, direct service delivery and demonstration projects, EQUIP enables countries to expedite their progress toward the UNAIDS 90-90-90 targets using the WHO guidelines to treat people living with and most vulnerable to HIV.

Prevalence of HIV/HCV coinfection in Myanmar

In Myanmar, one of EQUIP’s 17 PEPFAR countries, the HIV epidemic is concentrated among key populations, such as men who have sex with men (MSM), PWID, and female sex workers (FSW) and ranks among the most serious in Asia.

More than 2% of the population in Myanmar, approximately 1.5 million, is infected with HCV. The majority of this burden is concentrated in PWID, where HCV antibody prevalence is estimated at 48.1% and treatment access in the region of under 1%.  In line with the trend of coinfection, around 20% of HCV patients in Myanmar are also infected with HIV.

As with most resource-poor countries, Myanmar has significant health sector challenges. The lack of adequate health facilities–compounded by the high cost of testing and treatment, and the stigma for key populations–means that most individuals who present with HCV and HIV are not on treatment and thus already well advanced in their illness.  

 

The EQUIP Rapid-Response Mechanism comes to Myanmar

Dr. Thembisile Xulu, Chief of Party, EQUIP, announced the launch of EQUIP’s HIV/AIDS Flagship Project in Myanmar, funded by USAID.

EQUIP’s HCV test and treat demonstration project in Ukraine in eastern Europe, a milestone project launched on 28 July 2017, World Hepatitis Day.

Right to Care, a NGO based in South Africa and EQUIP program consortium partner, will be working through the EQUIP mechanism to deliver what is known as the EQUIP Myanmar HCV project.

In Myanmar, a simplified HCV testing and treatment care model is proposed for implementation and will integrate with HIV testing and treatment initiation. The aim is to improve access to care among at-risk populations to HCV treatment and enhance ART initiation and adherence in HIV/HCV co-infected persons. Affected populations will be screened for HCV and HIV and treated with anti-HCV DAAs. Those diagnosed for HIV/HCV coinfection will be referred for antiretroviral treatment (ART). The project will also assess implementation of low cost laboratory monitoring in management of HCV infected individuals.  

The EQUIP Myanmar HCV project is funded by the USAID through PEPRAR, in partnership with the Ministry of Health and Sports in Myanmar, U.S. office of USAID, and local implementing partners.

At least 400 eligible patients will be treated in three provinces across Myanmar, Yangon and Mandalay as well as the Kachin region, through cooperation with Mylan and local implementation partners, Myanmar Ministry of Health’s National Hepatitis Control Program, Community Partners International and the Myanmar Liver Foundation as well as local NGOs working with PWID. With capacity based on funding, the aim is to enroll up to 3,200 patients, with a simplified testing and treatment strategy using the fixed-dose combination of DAA, elbasvir and sofosbuvir, once daily for 12 weeks. This drug combination is important as it works across all 6 genotypes of HCV, minimizing the need for genotype testing.

It is envisaged that the evidence generated from this project may be put forth to develop a national cost and impact model for simplified test and treat strategy, which can then be included in Myanmar’s HCV response strategy.

 

A hidden population and silent epidemic

Globally an estimated 185 million people around the world are infected with hepatitis C virus, and most of them are unaware of it. In 2015, only 7.4% (1.1 million persons) diagnosed with HCV infection had started treatment. In the same year, the number of persons treated for HCV reached 5.5 million, but only about half a million of these individuals had received DAAs, which have a cure rate of approximately 95%. 

Now add to this key populations, such as PWID, who are regarded as the hidden people of a country because they are often isolated and shunned by the health system and society as a whole. Varying degrees of stigma, ignorance, and prejudice that these key populations are subject to exacerbate the challenges in accessing infected individuals to provide treatment and care, fueling the spread of preventable and treatable diseases.

Understanding and accessing key populations is an area of expertise for EQUIP, which has over 50 years combined partner expertise and experience working with key populations and local partners and stakeholders. As a result, EQUIP delivers innovative solutions responsive to local needs, assisting countries to reach their sustainable response in HIV and HCV.

The EQUIP Myanmar HCV project will recruit HCV-infected patients attending charity clinics for those who cannot afford treatment. Other patients will be recruited from districts and civil society groups in Yangon including the General Practitioners Society, and Myanmar Blood Donor Networks.  

EQUIP plans to recruit 400 of the 800 participants from community-based organizations, such as Phoenix Group, HIV positive Self-Help Group, Myanmar Positive Group, Sex Workers in Myanmar, Myanmar MSM Network, and Drug User Network.

The other 400 participants will be selected from those who are already registered in the existing clinics supported by Liver Foundation and receiving or not receiving ART. These candidates will also be screened for HIV, and if positive, enrolled into an HIV treatment program within the project.

Representatives of key populations (predominantly PWID) treated for HCV/HIV will receive social peer support and linked to HIV care and treatment, harm reduction services, such as access to needle, syringes exchange program, opioid substitution treatment.

To date, the EQUIP Right to Care program has begun treatment in over 150 HCV-infected individuals, offering free treatment and extensive follow-up.

Through treatment and linking key populations of HIV patients into sustained ART care, there will be a decreased risk of HIV transmission in clustered PWID communities. This is a prime example of treatment as prevention (TasP), which refers to prescribing ART to people living with HIV (PLHIV) in order to reduce the amount of virus in their blood to undetectable levels. This will ensure there is effectively no risk of transmission of HIV.

 

A scalable model for Myanmar

EQUIP and local implementation partners are committed to reducing the stigma of their patient population through compassionate care tailored for their needs, as well as proving that the EQUIP Myanmar HCV project is a cost-effective and scalable model for low- and middle-income countries to follow in eliminating HCV.

Dr. Thembisile Xulu says the EQUIP message is clear: “we are here to join hands with governments, community leaders, health care organizations and representatives from human rights and key populations networks. We are here to show our humanity, implement our technical expertise, and recommit the journey to see a hepatitis-free generation in our lifetime – while leaving a legacy of sustainable capacity for delivering improved health for all.”