Eliminating Hepatitis C
Rwanda's Health System: From Devastation to Hope
Following major progress against infectious diseases such as HIV tuberculosis and malaria, Rwanda is taking on another infectious killer – Hepatitis C.
Twenty-five years ago, this would have been unthinkable. In 1994, Rwanda was devastated by the genocide against the Tutsis, which took more than one million lives, and left the entire country including the health system in tatters.
Over the last two decades, a laser focus on recovery has led this Great Lakes country of twelve million to a health system that is committed to serve every Rwandan. Ninety-five percent of Rwandans are covered under a community-based health insurance scheme costing zero to just a few dollars per year. The health system pyramid is decentralised to the community level, where thousands of community health workers ensure people can access quality, routine services close to their home.
But health challenges remain. Hepatitis C is one of them. The blood-borne virus was only discovered in 1989. There is no vaccine. It can fester, silent in the body for years. And treatment, until very recently, was prohibitively expensive.
Despite all of that, Rwanda is planning to eliminate Hepatitis C.
Hepatitis C: Silent, then deadly
Hepatitis C (HCV) is a virus spread through blood-to-blood contact. People are at risk through unscreened blood transfusions, unsafe injections and other unsafe practices.
A minority of people will clear the virus from their bodies and may never know they were infected. But for most (60-80%) the virus remains in the blood and becomes a chronic infection, which, over many years, can gradually damage the liver, causing cirrhosis, liver cancer and death.
As the liver damage is so gradual, many people will not know they are infected with Hepatitis C and will never be tested.
Often, it’s only when symptoms appear that a person will see a doctor. By then, it can be too late.
Globally, about 71 million people have chronic Hepatitis C infection, which kills about 400,000 people each year. Current data suggests that hepatitis deaths are increasing worldwide, while HIV, tuberculosis and malaria deaths are on the decline.
In Rwanda, Hepatitis C prevalence amongst adults is estimated around 4%. Prevalence is slightly higher in key vulnerable populations, such as people living with HIV. It’s more than 16% in people over 55 years of age.
Someone can live with hepatitis C and not know they have the disease until symptoms start to appear.
Hepatitis C in Rwanda
In Rwanda, people who have been diagnosed with chronic Hepatitis C come from every walk of life. Guillaume is a businessman. Dativa is a farmer. Aimee is a nurse. Laurent is a retired truck driver.
But they all share one thing in common: not so long ago, they did not know they had Hepatitis C. When it was diagnosed, they each thought they were going to die.
When I was diagnosed with Hepatitis C I was so sad. I thought there was no hope for my recovery.
“Being diagnosed with Hepatitis C automatically meant death for my patients,” says Dr. Marie Beata Murekatete. “Because the former treatment was both expensive and not very effective, I felt like a parent watching her children die because she had no food to feed them. Could you imagine this?”
Dativa Mukantawali says she was very strong before she became ill, and was up early every morning to tend her fields for several hours. Then she began to have stomach problems, and went to the doctor. Her Hepatitis C diagnosis was a shock.
"When I was diagnosed with hepatitis C , what worried me most was that I was going to die and leave behind very young children," says Dativa.
“I was tired and had lost weight. For a long time, I thought I had malaria. I'd go to the hospital seeking malaria treatment,” explains Guillaume Rutembesa. Instead, Guillaume was very ill with chronic Hepatitis C.
“I had fatigue, trouble breathing and headaches all the time,” explains Aimee Vivine Uwimana. “Doctors thought my fatigue was related to work. When I was finally diagnosed with Hepatitis C, it was very hard to accept because I was worried about what was going to happen next.”
Ineffective older treatments
In Rwanda, people diagnosed with Hepatitis C were typically offered a series of interferon injections to try to cure the disease. But these were expensive and ineffective.
Interferon-based treatment sent Aimee Uwimana’s family towards financial ruin. She was prescribed 48 injections. Each cost about 200 USD. That’s a total of around 10,000 USD in a country where an average professional makes about that amount in a year, and most people make a lot less.
Side effects were also a major issue.
“Every Friday I’d have an injection,” explains Aimee. “And I would be sick for the entire next day. I had to plan my work and family schedule around these injections.”
Ultimately Aimee’s treatment didn’t even work. She became sicker.
This was a similar pattern for many Hepatitis C patients. “Only about 40% of my patients responded to the interferon treatment, and almost all had terrible side effects,” explains Dr. Musabeyezu. “We lost a lot of patients.”
A Treatment Revolution
The year 2014 heralded a major breakthrough for Hepatitis C treatment – the approval of the first oral combination of Directly-Acting Antivirals (DAAs), with high cure rates and minimal side effects.
The DAAs are a revolutionary breakthrough,” says Dr. Musabeyezu. “Patients take daily tablets for three to six months. There are almost no side effects. And the cure rate is 95%.”
Dativa Mukantwali, the farmer, says she faithfully followed her one-pill per day prescription for three months. "When I was told I was cured of Hepatitis C, I was so happy, and my family was so relieved!"
“Normally other oral medications would affect me a lot,” recalls Laurent Gahiza, the retired truck driver. “But this one was normal. It was like eating food. I didn’t feel anything at all."
One problem remained – the cost.
“When these drugs were first announced, I remember the cost very clearly: 86,000 USD. That was unaffordable,” recalls Dr. Sabin Nsanzimana, Director General of the Rwanda Biomedical Centre (RBC).
“This was both an ethical and an equity issue. We had the patients, we had the drugs, but we couldn’t afford to get the drugs to the people. We had to change this.”
The Government of Rwanda began to negotiate for a better price. They succeeded, initially securing a price of 1000 USD per cure.
“The President himself was involved to ensure that all Rwandans in need could access Hepatitis C treatment," says Dr. Nsanzimana.
There was an initial treatment plan in 2015, focussed on screening high-risk groups including people living with HIV, prisoners and the elderly. This was very successful.
“We have already treated more than 15,000 people, and we screened more than a million,” says Dr. Nsanzimana. “This was a big step and we showed Hepatitis C detection and treatment was possible. So we knew we had to go even further. We had the political commitment and partnership support to do it.”
In the meantime, the companies that originally developed DAAs began to license their products to generic manufactures to make them available to low- and middle-income countries. The World Health Organization (WHO) prequalified them for use in 2016.
“We continued to negotiate. And we succeeded to secure further price reductions from 1000 USD to 350 USD in 2017," says Dr. Nsanzimana.
Success with implementation and the treatment price reduction meant we could go even further with our Hepatitis C plans. We could aim to eliminate Hepatitis C.
A Bold Elimination Plan
WHO has called for HCV elimination globally by 2030. It defines this as screening 90% of the eligible population and treating 80% of those with chronic infection.
Rwanda is more determined, and plans to achieve Hepatitis C elimination by 2024.
The country formally announced the Hepatitis C elimination goal in December 2018, with a five-year plan.
“We are increasing access to services, finding cases, raising awareness among the population and establishing new partnerships,” says Professor Jeanine Condo, the former Director General of the Rwanda Biomedical Centre.
According to the plan, Rwanda will screen four million people aged 15 and above over five years. Of those, about 120,000 will need Hepatitis C treatment. Fully implemented, this plan should result in a drop of HCV prevalence from 4% to 1% by 2024.
"This is very exciting," says Professor Condo. “Given the social and economic costs of treating liver cirrhosis and cancer later, we believe Hepatitis C elimination is a strategic and humane investment today.”
A Huge Demand for Screening
At the Rwamagana market, about 55 kilometres east of Kigali, people form a huge queue in front of a local building near the market stalls.
One-by one, each person approaches a desk, to register to be tested Hepatitis C. The doctor in charge of the hepatitis screening station calls through a megaphone – explaining that screening and treatment are free. People continue to join the queue. In just a few hours, hundreds of people will be screened at this site. There is more: the Rwanda Ministry of Health is using the Hepatitis C screening opportunity to also screen for Hepatitis B.
One reason screening is successful is due to a new rapid diagnostic test that can be used on-site, costs just 1 USD, and offers results in less than twenty minutes.
It involves a quick finger prick so a nurse can squeeze a drop of blood into the kit sample well. The blood is mixed with drops of an assay diluent. Then, a short wait of up to just twenty minutes to find out one’s hepatitis status.
If positive, blood is collected for a more specialized viral load test at a nearby laboratory to determine if the virus has cleared, or if there is a chronic infection. If the infection is chronic, the person will be referred to a doctor for follow-up including treatment.
Access to treatment is a defining factor in the uptake of screening.
“Before people felt that without treatment, there was no point in screening,” explains Guillaume Rutembesa, who is now in a senior role with a Rwandan association that advocates for diagnostics and treatment for hepatitis.
Now, with treatment there is so much hope. People will come for screening because they know that diagnosis will lead to cure of Hepatitis C. And even better, it can lead to elimination of HCV altogether.
Access and Simplicity - A Public Health Approach
A principle of HCV elimination is to make testing and treatment as simple and accessible as possible for all Rwandans.
For uncomplicated cases of Hepatitis C, general practitioners, and soon, nurses will be able to prescribe and monitor treatment. They’ll refer those with complications including cirrhosis or liver cancer to a specialist.
Rwanda’s Hepatitis C elimination plan includes a major scale-up of sites where people can be screened, laboratories equipped for viral load testing, and critically, of doctors and nurses who can prescribe DAA treatment.
Task-shifting from specialists, to general practitioners and to nurses in primary health care settings was a successful strategy for HIV control in Rwanda, and can work for hepatitis as well.
“We have already trained 158 doctors who can prescribe treatment,” explains Jeanine Condo. “In the next year we will expand that to train a further 96 doctors, and 96 nurses.”
Our goal is for Rwandans in even the most remote areas of the country to access screening and treatment.
Hope to Eliminate
Partnerships: Essential to Success
Rwanda's Ministry of Health has put each of the elements in place to successfully eliminate Hepatitis C by 2024: simple testing and affordable treatment, a large laboratory network, and accessible services made possible by task shifting diagnosis and treatment to primary care doctors, and soon, to nurses in primary care facilities across the country.
The total program cost is now estimated at 43 million USD. This is reduced from an original 113 million USD because of the dramatically reduced cost of treatment and is expected to be reduced even further as the market changes in the years to come.
Rwanda has negotiated treatment down to a record-low for WHO pre-qualified DAAs to just 60 USD per cure.
“It’s a relatively small cost for a huge outcome,” says Dr. Sabin Nsanzimana.
Rwanda is welcoming partners to supplement the country's investments in Hepatitis C elimination.
We as a government welcome everyone’s contribution -development partners, church leaders, the private sector, and Rwandans – we welcome everyone’s contribution to this journey. We believe we can achieve Hepatitis C elimination.
“It is essential that partners act now to support the Hepatitis C elimination plan and save lives. We simply cannot wait until later, when people will suffer liver cirrhosis and liver cancer,” says Sidonie Uwimpuhwe, the Country Director of the Clinton Health Access Initiative (CHAI) in Rwanda.
"The Government has a plan underway including priorities and targets. Treatments are available for a record-low price per cure. Everything is now in place," says Mrs. Uwimpuhwe.
CHAI stands with Rwanda to make Hepatitis C elimination a reality and we invite all partners to join us.
Church leaders, local government and private sector engagement are also critically important.
Robert Bafakulera agrees. He’s the chair of the Private Sector Federation and is appealing to business owners to help support the elimination plan.
“Anyone can suffer from this disease,” says Mr. Bafakulera. “It can be someone you know today, or it can be even you tomorrow. Eliminating Hepatitis C would assure safety to all of us as Rwandans.”
“We are committed and believe Hepatitis C elimination is possible.”
RWANDA: A global model
Those on the front line say they have nothing but joy at the prospect of eliminating Hepatitis C.
Dr. Marie Beata Murekatete is thrilled. She says she used to lose one patient a week to liver disease at her hospital in western Rwanda. Today, she asks that partners help cover the costs of the Hepatitis C elimination program, so that her patients live.
I thank everyone who is making access to treatment possible,” she says. “Though you might not meet them, we receive their gratitude every day on your behalf,” says Dr. Murekatete.
Rwanda intends to become the first country in sub-Saharan Africa to eliminate Hepatitis C.
“This is a country with a painful past,” says Dr. Emmanuel Musabeyezu. “Today, we want to save lives. Our leadership at every level is committed and health care providers are committed to eliminate Hepatitis C.”