The hepatitis C virus (HCV) is an infectious disease that can result in serious liver damage, liver cancer, and death. Many people with HCV have no symptoms until long-term infection gives way to these serious consequences. In Vietnam, up to four percent of the population have been exposed to HCV, with many developing long-term infection.
Similar to HIV, HCV is spread through the blood of an infected person (such as through shared needles), so it is unsurprising that people at higher risk of contracting HCV are often also those who are at increased risk of HIV. In Vietnam, this includes people who inject drugs (PWID) and men who have sex with men (MSM). Studies have estimated that anywhere from 43 to 99 percent of PWID and approximately 29 percent of MSM have HCV in Vietnam.
PATH has been working with these groups to increase demand for and access to HIV services, like HIV self-testing and testing by lay providers, since 2015, through the USAID/PATH Healthy Markets project. So it was a logical next step to partner with Gilead Sciences and expand this approach to also address HCV.
A ‘silent killer’ – raising awareness about HCV
National guidelines for best practice in the prevention, care, and treatment of HCV in Vietnam were developed and released by the Ministry of Health back in 2016, and antiviral medicines are highly effective. But public awareness and understanding of HCV remain low, as do rates of screening.
Hieu is the head of Nu Cuoi, ("Smile"), a community-based organization led by and working to support PWID. Nu Cuoi has been delivering community-based HIV testing since 2016. In 2018, PATH trained and equipped Nu Cuoi staff to provide HCV counseling, rapid testing, and referrals for further diagnosis. Before this, even Hieu didn’t know much about HCV.
“Before Nu Cuoi started participating in PATH’s HCV project, I knew a little bit about HCV—that it is transmitted through blood—but not much else. I know for sure that other people in my community have very limited knowledge about HCV; I think most PWID haven’t been tested.”— Hieu, head of community-based organization, Nu Cuoi (Smile)
Initial studies conducted by PATH found that most people at risk of HCV did not know about the risks and consequences of HCV; where to go for screening, diagnosis, and treatment; or how to prevent HCV. In response, PATH and Gilead worked together with community influencers and groups to develop a dynamic educational and demand creation campaign, called ‘Healthy Liver, Happy Life’. This campaign mobilized social media networks, community-led offline events, and in-clinic counselling (integrated into counseling for HIV testing and other HIV-related services) to raise awareness of HCV, and motivate people to engage in HCV testing.
Minh (not his real name), a 21 year old man living in Ho Chi Minh City, learned that he was a risk of HCV through the Healthy Liver, Happy Life campaign on the Facebook page a PWID and MSM-friendly private clinic that has been supported by PATH to offer HCV testing.
“On Facebook, I learned that HCV is a serious disease and that people who inject drugs, like me, are likely to get it. Thinking about those times I shared syringes with other people, I texted the clinic and was counseled by a member of staff there. I didn’t think I could have it because I felt very healthy, but the counselor showed me that I was still at risk so I agreed to come in for testing. I am especially concerned about HCV because I already have HIV.”— Minh, HCV client
Peer-led services encourage people to get tested
Again, in a similar way for people at risk of HIV, concerns about experiencing discrimination at testing facilities were also a barrier to HCV testing. However, studies conducted by the Healthy Markets project found that PWID and MSM lay providers (members of community-based organizations) in HCMC were significantly more likely to reach people who hadn’t tested before, and that those testing through PWID and MSM-led CBOs and clinics were also more likely to be HIV positive than those tested in public facilities—as people at risk of HIV prefer to receive services from people with they trust. PATH also found that trained non-health professionals were just as skilled as health care workers in delivering HIV tests, which are often very similar to the rapid tests for HCV.
This was certainly true for Tuan (not his real name), a 33 year old man living in Ho Chi Minh City. Tuan was convinced to get tested for HCV by a friend of his who was working for Nu Cuoi and had been trained to deliver HCV testing.
“I had never even heard about HCV before, so I definitely hadn’t sought testing. My friend told me about HCV and the dangers, and also that he could test me himself. It sounded easy and I realized that I was probably at risk of infection, so I agreed to go with him and get tested.”— Tuan, HCV client
Both Minh and Tuan had a reactive result with the rapid test, and were referred for follow up testing. Both were diagnosed with HCV. In total, 3,116 people have been tested for HCV under this project, between April and November 2018. A total of 217 (7 percent) received a reactive result, and 111 of those people went for a follow-up test and were confirmed to have HCV.
Neither Minh nor Tuan would have sought HCV testing if they had not had contact with community-based testers or online information from PWID-friendly clinics. Now that they know their HCV status, they can consider their next steps. However, neither of them have enrolled in HCV treatment yet, as they fear that treatment costs will be prohibitively high.
But, hope is on the horizon. Since Minh and Tuan got tested, Vietnam’s Ministry of Health has approved a new social health insurance policy that will cover 50 percent of the cost of HCV treatment at social health insurance-registered clinics. These clinics are now following up with those clients diagnosed with HCV who have not initiated treatment, to inform them of this change. Moving forward, PATH will go on to support clinics and organizations like Nu Cuoi to provide up to date information about social health insurance entitlements and encourage clients to get their social health insurance card, as well as promoting social health insurance enrollment through Facebook and other channels.
It is hoped that soon Minh, Tuan, and everyone diagnosed with HCV in Vietnam will be able to access appropriate care. The clinics involved in this pilot will continue to provide integrated HIV and HCV counseling, screening, and linkages to care, and community-based organizations will also continue to provide information, counseling, and referrals to HCV services, at the same time as providing HIV services.
“I want to tell people like me that you can get HCV – so to go for counseling and testing soon!”— Minh, HCV client
This project was run between January and December 2018 in direct collaboration with Gilead Sciences. PATH and Gilead each continue to seek opportunities to advocate for the further development of community-based HCV services in HCMC and across Vietnam, including raising awareness and increasing access to care for people with HCV.