Even in a country like Australia, with a high standard of living and a socialised health system, the battle to eliminate hepatitis can be challenging. So what is it like in a country like India, where poverty, population pressures and lack of health funding and education make every medical challenge so much harder?
Dr Sunil Solomon is Associate Professor of Medicine at the prestigious Johns Hopkins University School of Medicine. He spoke at the Australasian Viral Hepatitis Conference in Adelaide about his work on eliminating HCV among people in India who inject drugs.
“The first thing to remember is that in India itself there are approximately 6.3 million HCV-viremic persons. And across India, primary modes of transmission are contaminated medical injections, which account for the majority of our cases; blood and blood products, which is reducing because of increasing screening efforts; and, of course, injection drug use.
“India is right in the middle of the two largest heroin-producing regions in the world. We have the Golden Crescent on one side, and the Golden Triangle on the other side, and so we really have a lot of drugs coming into India from different parts of the country, and it’s estimated there are as many as 1.1 million injection drug users across the country.
…despite having all this access to free or low-cost hepatitis C treatment, there is still a lot of debate within the Indian government on what is the best way to treat drug users.
“In India it’s predominantly genotype 3. In the north-eastern states of the country we see a lot more genotype 6 because of an influx of drugs from Thailand, and we also have genotype 1 and genotype 4 in some regions, so India is really one of the settings which is perfect for a pan-genotypic medication regimen, a medication that works no matter what type of HCV a person is infected with.”
Dr Solomon noted that until 2015 interferon was the standard method of treatment, but then cheap pan-genotypic direct-acting antiviral generic drugs started being produced by Indian drug companies. But despite having all this access to free or low-cost hepatitis C treatment, there is still a lot of debate within the Indian government on what is the best way to treat drug users.
“The other thing that’s also very critical to know about India is that we have a long-standing tuberculosis program, and our standard strategy for the delivery of TB treatment is directly observed therapy. There are over 1500 directly observed treatment centres for TB across the country, and that’s pretty much how we treat most of our TB.
“So our hypothesis was directly observed therapy will be associated with high rates of frequent completion, and we wanted to try this with hepatitis C in people who inject drugs.”
Dr Solomon’s work focused on people who inject drugs living in Chennai, India. Some clients were active drug users, and some of them had a past history of drug use. Some were homeless, while others were working and couldn’t come into the health centre, so Dr Solomon’s team had field workers who would go and meet them at a venue of their choice—their house, a friend’s home, a bus stop or some other public place which they found was convenient.
“We also used biometrics, so when a field work outreach worker met the participant he actually had to scan his fingerprint. That’s one way of us knowing that they actually saw the participant instead of just telling us they gave the medicine to the participant, because we know people always fudge records to make it look like they’re doing a really good job, and we wanted to be sure that participants were actually getting their medications.
“People who had to come into the clinic were compensated 100 rupees for their travel and their time.”
The study didn’t concern itself with genotypes, and performed relatively few blood tests.
“We did one HCV RNA test at the start and we only did one HCV RNA test at SVR12 (a check to see if the virus is still undetectable 12 weeks after finishing treatment). We did a blood check every four weeks just to check there were no toxic responses to the medication, and liver function tests were done every 12 weeks. And we saw no serious adverse events during the course of the trial.”
Those being treated in the study recorded extremely high levels of success, with the main problems being from a completely unexpected direction: the weather.
“Massive floods happened right after we started our study, right outside our clinic. We had boats going through the city streets, and our airport turned into a harbor. When things like this happen we really can’t get the treatment to those participants. Most people who were on treatment during this flooding in Chennai missed about four to five doses. These are things we don’t plan for, but it is something we should consider when we’re planning strategies.”
Another unexpected aspect was psychological, based on cultural expectations about medicine. “Just to give you an example of what happens in India, patients getting pills only in a study like this were very upset that they were not getting injections. It’s part of the Indian culture that injections are believed to work better, even though if we didn’t have medical injections in India we wouldn’t have so much hep C to begin with. Patients on interferon would tell us, ‘The medicine’s working—I’m having a fever!’ So they actually felt that there was something happening, which those on DAA pills do not.”
Despite the study’s success, Dr Solomon can still see better results in the future. “With poverty, with homelessness and the environment—the floods and so forth—I can say that the shorter the treatment the better our results will get, so that people don’t have the opportunities to miss their pills. So a DAA that takes only eight or even four weeks to work, that’s my dream.”
Here is Dr Solomon presenting some of his work in 2017: