Feasibility of decentralised, task-shifted hepatitis C testing and treatment services in urban Myanmar: implications for scale-up

Abstract

ObjectivesTo assess the feasibility considerations for a decentralised, one-stop-shop model of care implemented in Yangon, Myanmar.SettingTwo primary care level clinics in urban Yangon, Myanmar.DesignThis is a feasibility study of a highly effective care model. Using Intervention Complexity Framework by Gericke et al, we collated and analysed programmatic data and evaluation data to outline key project implementation requirements and experiences.ParticipantsProgrammatic data were collected from clinical records, GeneXpert device test and maintenance reports, national guidelines, product and device instructions and site monitoring visit reports. Healthcare providers involved in delivering care model contributed interview data.ResultsThe main feasibility considerations are appropriate storage for test kits and treatments (in response to temperature and humidity requirements), installation of a continuous stable electricity supply for the GeneXpert device, air-conditioning for the laboratory room hosting GeneXpert, access to a laboratory for pretreatment assessments and clear referral pathways for specialist consultation when required. Lessons from our project implementation experiences included the extensive time requirements for patient education, the importance of regular error monitoring and stock storage reviews and that flexible appointment scheduling and robust reminder system likely contributed to high retention in care.ConclusionsDetailed documentation and dissemination of feasibility requirements and implementation considerations is vital to assist others to successfully implement a similar model of care elsewhere. We provide 10 recommendations for successful implementation.Trial registration numberThe trial was registered at ClinicalTrials.gov NCT03939013 on May 6, 2019. This manuscript presents post-results data on feasibility.

Cost‐effectiveness of a decentralized, community‐based “one‐stop‐shop” hepatitis C testing and treatment program in Yangon, Myanmar

“…25,26 The CT2 study has already shown that a one-stop-shop model of care with simplified HCV clinical pathway is safe and feasible in Myanmar and acceptable to healthcare providers and patients. 15 High retention in care was also achieved, with cure rates above 90%. 16 Our study adds to the evidence by showing that this model of care is a cost-effective way of providing testing and treatment in Myanmar to people with poor current access.…”

“…The CT2 study has already shown that a one‐stop‐shop model of care with simplified HCV clinical pathway is safe and feasible in Myanmar and acceptable to healthcare providers and patients 15 . High retention in care was also achieved, with cure rates above 90% 16 .…”

“…To understand how these limitations would influence results, we conducted sensitivity analysis around positivity rates and follow‐up rates. Third, care must be taken when generalizing these findings because CT2 was conducted in the business capital of Myanmar where laboratory facilities, electricity, and human resources are more available than in rural and remote areas 15 . Future projects should be conducted in areas with high HCV burden, for example, where National HIV/TB Program sites or NGO branches are situated or at private GP clinics, to understand the cost‐effectiveness of models of care in other decentralized and less well‐served settings.…”

“…The project was implemented in partnership with the Foundation for Innovative New Diagnostics (FIND) as part of the Hepatitis C Elimination through Access to Diagnostics (HEAD‐Start) program led by FIND and supported by Unitaid/WHO. The CT2 Study assessed the feasibility of a decentralized HCV model of care in a resource‐limited country 9,15 . It showed high retention in care, with most participants initiating treatment within two visits (median time from RDT to DAA initiation 3 days [IQR 2–5]) and high cure rates (non‐cirrhotic patients 93%, cirrhotic patients 83%) 16 .…”

Pathway to global elimination of hepatitis B: HBV cure is just the first step

“…Passive national disease surveillance and active sentinel site surveillance systems work synergistically to provide holistic views of progress toward 2030 targets 6 . The WHO Viral Hepatitis Continuum of Care Monitoring and Evaluation Framework provides guidance for surveillance systems investment, 107 while electronic medical record and data collection systems, such as Open MRS (OpenMRS Inc.) supported by WHO, enable local data collection to monitor HBV elimination programs 108 . Guidance on the measurement of impact and validation of WHO HBV elimination targets is provided in the 2021 “Interim guidance and framework for country validation of hepatitis elimination” 109 and can be adapted to the implementation of HBV cure when available.…”