New campaign eyes a Hepatitis C-free Chennai

It is not one of those killers that are widely discussed or feared by the masses, but an estimated 80,000 people in Chennai currently live with the insidious Hepatitis C Virus (HCV), one of the leading causes of liver cancer. What is even more alarming is that a majority do not even know that they have it. The good news, however, is that it may not be long before the city witnesses a new programme in action, that could well set an example for the world in how to effectively rid geographies of the deadly infection. YRG Care, a Chennai-based organisation plans to launch a campaign titled “Hepatitis C Free Chennai 2022”.

Click to view full size. Understanding Hepatitis C. Graphic: Rifa Khan.

The C word has been in the news for over two decades; different kinds of it too. Cancer of the breast, lung and colon have our curiosity and attention. Today, Hepatitis B and C virus are the leading causes of liver cancer. They are both spread by blood. Hepatitis B is a chronic infection, it alters the DNA and leads to cancer even while one waits for jaundice to raise a yellow flag.

There is a vaccine for Hepatitis B but the cure remains elusive. Hepatitis C, on the other hand, has direct and indirect pathways that lead to a severely diseased liver (called cirrhosis) beyond the point of damage control and leads to cancer. (See graphic)

According to WHO statistics, 135 million people globally live with the HCV, which has direct and indirect pathways leading to a severely diseased liver beyond the point of damage control (a condition called cirrhosis), ultimately causing cancer in the organ. This silent pandemic has claimed more lives than AIDS and TB in 2014 even as 95% of those infected remain completely unaware.  Historically, not only was the detection of the virus expensive, its cure too was a lavish trial by fire. But in 2016, the medical fraternity is armed with better preventive and curative measures. Now, then is as good a time as ever to extend the circle of care to the apparently healthy as well.

The “Hepatitis C Free Chennai 2022” campaign is led by Dr. Sunil Solomon, Managing Trustee, YRG Care. An Epidemiologist, and Faculty of Medicine in the Department of Infectious Diseases at Johns­ Hopkins University, Dr. Solomon has worked extensively with populations that are vulnerable to Hepatitis C and HIV across the country over the past decade.

The campaign will link testing, treatment and counselling under one roof at one-tenth of the cost, within a public-­private­-partnership model (explained in Dr. Solomon’s interview below) that underlines the role of a proactive community and the corporate sector in ensuring a medical safety net for increasing numbers of people.  YRG has already tied up with three companies — First Flight Couriers, SPI Cinemas and TT Group — for implementing its plans of testing and treatment, and hopes to sign up at least two corporates per month till 2022.

To a young doctor like me in India, who has worked in a clinical and research setup, it seemed like the greatest barrier to better health was the lack of access. Equitable healthcare is within reach if clinicians, researchers and proactive communities come together. It has been an incredible experience to be at YRG Care in Chennai to see this notion in practice. Personally, it has been an interesting journey for me in Chennai from a medical student to a doctor and now a prospective researcher.

Dr Sunil Solomon

My work for the Hepatitis C Free Chennai Campaign is just gratitude for everything this city and the wonderful people here have taught me. The past few months of working and interacting with Dr. Solomon have opened up several crucial facts about this mission and how it proposes to achieve its end, and here are some answers that I would like to share.

Dr. Solomon, you’ve worked with Hepatitis C over the past decade with vulnerable pockets of society. So what is your rationale for the timing of the Hepatitis C Free Chennai campaign now?

Until about two years ago, there really were no cost ­effective and safe treatment options for Hepatitis C and so most of our management of the disease revolved around education and trying to prevent HCV transmission. We restricted treatment only to those in advanced disease stages. However, in 2015, generic versions of three different medications (Sofosbuvir, Ledipasvir and Daclatasvir) have become available in India dropping the price of medications from about 1.5 lakhs to about 30,000 rupees.

Most importantly, these new medications are tablets that need to be taken only once daily and are associated with almost no side effects and have cure rates 95% or more, compared to the previous treatments which were associated with several side effects and were not very efficacious at curing HCV either.

There are currently no cities that have completely eliminated HCV globally but there are several countries and other states in India that have embarked on such a strategy. In HIV, Chennai set an example for the rest of India to follow ­ in the case of HCV, I believe we can set an example for the rest of the world to follow.

How do you intend to extend the circle of care to the corporate sector and communities as a whole?

We hope to achieve our dream of a Hepatitis free Chennai by implementing a public-­private- partnership. There are several large corporates in Chennai that employ thousands of residents of Chennai. As a first step, we propose to offer extending testing to these employees. (see infographic below for further detail)

Click to view full image

The thing about HCV is almost anyone is at risk ­ the most common mode of transmission is medical injections. It could have happened sometime in your childhood and you could be living with it. The first step to eliminating HCV is knowing your status. These corporates could, as a staff welfare initiative, offer testing to their employees and provide treatment to those who are infected. Investing in your employees, besides buying you their goodwill, also ensures higher productivity levels especially as they age. Several studies from Europe have estimated the costs of lost productivity and health care costs due to HCV-related complications to run into millions of dollars.

The government of Tamil Nadu provides treatment for HCV for free, via the government hospitals for below poverty line populations. However, one of the greatest challenges to these programmes is the identification of people living with HCV. In this regard, the corporate sector could set aside a proportion of their CSR funds to establish a “HCV Free Chennai Fund” ­ this fund will be used to run screening camps for low ­income populations.

Once identified, we will ensure these individuals are linked to the government programme and are cured of their HCV. I believe with a strong commitment from the corporate sector to fund this programme, we can make Chennai HCV free in the next five years and set an example for the rest of the world to follow.

How could one prevent reinfection?

The key to the success of any programme is the scaling up of the entire programme as a whole. It is possible for someone who is cured of HCV to get re­infected with HCV. So, while we scale up treatment, it is critical that we also scale up measures to prevent re­infection. This involves a lot around the need for medical injections ­ several members of community, particularly low ­income groups, feel that injections are the only answer to any ailments. Consequently, they seek medical injections for all conditions and often visit the informal health care sector and “quacks”. Campaigns should educate the communities that tablets are just as effective as injections in most cases and if they do visit such health practitioners to always insist on disposable syringes.

In the case of drug using populations, it is essential to increase access to harm reduction services to minimise reinfection. Aside from these, it is essential that blood is routinely screened for HCV in blood banks and dialysis centres as well as adequate sterilisation of equipment during surgical and dental procedures.

Globally, there is talk of linking HIV and Hepatitis C care. Do you think this is wise given that ignorance and social stigma claim more lives than HIV?

In some countries this may be an acceptable strategy, but in a country like India where there is still widespread HIV stigma, this may not be an optimal strategy. However, in populations like drug users who bear a high burden of both HIV and HCV, such a strategy may be cost­ effective. Prior to implementing these models, we need detailed epidemiological studies to examine the overlap between HIV and HCV infection. Our data in India and most other LMICs are scarce ­ if we do see a significant overlap between HIV and HCV, then such a strategy may be feasible. If not, it might make better sense to keep them separated. HIV in India is primarily transmitted heterosexually and HCV is rarely transmitted sexually and so, I would guess that we may not see a significant overlap. For example, in our clinic that caters to HIV infected persons who acquired HIV heterosexually, the prevalence of HCV was less than 1% similar to what is estimated in the general population. So, this would imply that there will be a significant proportion of HCV infected persons who are not co­infected with HIV. Whether these individuals will be willing to come to a centre where HIV infected persons come will define whether or not an integrated care model for HIV and HCV will work.

At the recent World AIDS Conference 2016 (Durban), you spoke of financing and scale up of HCV treatment. What is the role of generics?

Generic HCV treatments have given hope to the millions of people living with HCV in low­ and middle ­income countries. For example, Sofobuvir which costs about 30,000 rupees for a course of 12 weeks costs 84,000 dollars in the US. We have used these generics to treat people living with HCV in Chennai and seen same outcomes as has been reported in the US and Europe. Therefore, similar to how generic HIV medicines revolutionized HIV disease management transforming it from a fatal disease to a chronic infection, I believe generic HCV medications have transformed HCV to a disease that could be eliminated with strong political commitment and support from the private sector.

YRG has been synonymous with HIV/AIDS for over two decades. Will the coming decade notice a more inclusive organisation for infectious diseases?

Yes, I do believe we have established ourselves as a leader in the field of HIV. But over the next few years, we intend to extend our expertise to hepatitis viruses, TB and other infections that continue to emerge and re­emerge. There are no specialty hospitals that focus on infectious diseases, ­ we would like to establish ourselves as an infectious disease specialty centre in the next 5­ to 7 years.

You currently serve as faculty at Johns Hopkins University, but your work is India centric. What drives you to bring your best ideas to this country?

I was born in India and grew up here, and so, India will always be home. I have a commitment to India…I want to do work in India that showcases this country to the rest of the world. Therefore, I am always looking for ways to build upon the existing health systems by engaging vulnerable communities to improve the quality of medical care in India particularly for the populations that do not have access to these services but need them the most.

Indeed a changemaker