Initiation of hepatitis C treatment in two rural Rwandan districts: a mobile clinic approach

Abstract

Background To eliminate hepatitis C, Rwanda is conducting national mass screenings and providing to people with chronic hepatitis C free access to Direct Acting Antivirals (DAAs). Until 2020, prescribers trained and authorized to initiate DAA treatment were based at district hospitals, and access to DAAs remains expensive and geographically difficult for rural patients. We implemented a mobile clinic to provide DAA treatment initiation at primary-level health facilities among people with chronic hepatitis C identified through mass screening campaigns in rural Kirehe and Kayonza districts. Methods The mobile clinic team was composed of one clinician authorized to manage hepatitis, one lab technician, and one driver. Eligible patients received same-day clinical consultations, counselling, laboratory tests and DAA initiation. Using clinical databases, registers, and program records, we compared the number of patients who initiated DAA treatment before and during the mobile clinic campaign. We assessed linkage to care during the mobile clinical campaign and assessed predictors of linkage to care. We also estimated the cost per patient of providing mobile services and the reduction in out-of-pocket costs associated with accessing DAA treatment through the mobile clinic rather than the standard of care. Results Prior to the mobile clinic, only 408 patients in Kirehe and Kayonza had been initiated on DAAs over a 25-month period. Between November 2019 and January 2020, out of 661 eligible patients with hepatitis C, 429 (64.9%) were linked to care through the mobile clinic. Having a telephone number and complete address recorded at screening were strongly associated with linkage to care. The cost per patient of the mobile clinic program was 29.36 USD, excluding government-provided DAAs. Providing patients with same-day laboratory tests and clinical consultation at primary-level health facilities reduced out-of-pocket expenses by 9.88 USD. Conclusion The mobile clinic was a feasible strategy for providing rapid treatment initiation among people chronically infected by hepatitis C, identified through a mass screening campaign. Compared to the standard of care, mobile clinics reached more patients in a much shorter time. This low-cost strategy also reduced out-of-pocket expenditures among patients. However, long-term, sustainable care would require decentralization to the primary health-centre level.

Time to complete hepatitis C cascade of care among patients identified during mass screening campaigns in rural Rwanda: a retrospective cohort study

“…Critically, we did not observe that patients from the lower ubudehe categories, reflecting a lower socioeconomic status, were less likely to progress through the treatment cascade. As previously noted, the mobile clinic approach used to link our patients to care has been estimated to reduce patients’ costs to accessing treatment by almost 10 USD, which is a meaningful reduction in rural Rwanda and may have removed economic barriers to accessing care for some patients [ 14 ].…”

“…To facilitate patients’ access to care during the period of the screening and linkage to care activities described in this study, PIH/IMB organized a mobile clinic where clinicians and lab technicians from district hospitals met with patients at their nearest health facilities. This approach allowed patients to attend their local primary-level health centres for same-day clinical consultations, lab exams and treatment initiation, as has been described in detail elsewhere [ 14 ].…”

Knowledge among patients with Hepatitis C initiating on direct-acting antiviral treatment in rural Rwanda: A prospective cohort study

“…Because increased age is a strong risk factor for hepatitis C in Rwanda, our study population was largely composed of older individuals who would have been most affected by this educational disparity. We believe that the predominance of women in our study primarily reflects a structural gender imbalance in the Rwandan population, which is pronounced in older age groups [ 27 ], because previous research in this setting has demonstrated similar linkage to care rates among men and women [ 21 ].…”

“…However, this inverse association could also reflect that quality of care was rated very highly overall and we may not have observed enough variation in satisfaction to observe the expected association. Because the novel mobile clinic approach used by our team is associated with substantial time and cost savings for patients [ 21 ], high self-reported satisfaction could also primarily reflect high patient satisfaction with the overall approach used by our team rather than specifically reflecting patient-provider communication.…”

“…These screening campaigns were open to all Rwandans aged 15 years and above. In particular, PIH/IMB in partnership with Ministry of Health facility staff, supported linkage to care for patients with chronic hepatitis C who were eligible for DAA treatment, defined as having a detectable viral load (hepatitis C RNA ≥15 IU/mL) by implementing a novel mobile hepatitis clinic as described in detail elsewhere [ 21 ]. Briefly, this mobile clinic approach was designed to facilitate access to hepatitis treatment by decentralizing hepatitis care to primary-level health centers.…”